Based on observation, interview, and record review, the facility failed to have the interdisciplinary team (IDT) determine and document whether self-administration of medications was clinically appropriate for 1 of 8 residents observed during medication administrations. (Resident 52) Findings include: The clinical record for Resident 52 was reviewed on 5/21/25 at 9:00 a.m. The diagnoses included, but were not limited to, hypertension. A Quarterly Minimum Data Set (MDS) assessment, dated 2/26/25, indicated the resident was cognitively intact. A physician's order, dated 1/7/25, indicated the resident was to receive 400 milligrams (mg) of magnesium oxide twice a day. A physician's order, dated 11/5/21, indicated the resident was to receive 240 mg of diltiazem (blood pressure medication) once a day. A physician's order, dated 4/13/22, indicated the resident was to receive a calcium supplement once a day. A physician's order, dated 9/13/24, indicated the resident was to receive carboxymethylcellulose sodium eye drops once a day. A physician's order, dated 5/6/25, indicated the resident was to receive 12.5 mg of metoprolol (blood pressure medication) twice a day. The staff was to obtain resident's heart rate and ordered to hold the medication if her heart rate was less than 60 beats per minute. An observation was conducted of a medication administration for Resident 52 with Qualified Medication Aide (QMA) 2 on 5/21/25 at 9:10 a.m. QMA 2 was observed preparing Resident 52's medications at the medication cart. She had pulled the following tablets: 400 mg of magnesium, 12.5 mg of metoprolol, oyster shell calcium supplement, and 240 mg of diltiazem. She then went to the resident's room to administer the medications. QMA 2 was observed obtaining the resident's heart rate and administering the resident's eye drops. The resident's cup of medications was placed on the bedside table. After, QMA 2 walked to the doorway prior to the resident picking up the medication cup of pill medications. The resident was not observed taking the pill medications. An interview was conducted with QMA 2 on 5/21/25 at 9:35 a.m. She indicated Resident 52 was able to take her medications without supervision. An interview was conducted with the Director of Nursing (DON) on 5/22/25 at 9:22 a.m. She indicated Resident 52 had not been assessed to determine if she could safely administer her medications herself. A bedside medication and self-administration of medications policy was provided by the DON on 5/22/25 at 9:44 a.m. It indicated, .Each resident who desires to self-administer medication will be permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility. Procedure. 1. Each resident is offered the opportunity to self-administer his/her medications during the routine assessment by the facility's interdisciplinary team (IDT). 2 .If the resident desires to self-administer medication, an assessment is conducted by the IDT of the resident's cognitive, physical and visual ability to carry out this responsibility .3. Cognitive ability should be the initial assessment to determine if a resident is capable of self-medicating. It is recommended that the Mini-Mental Status Examination or similar screening tool be used. Once cognitive status is established, the resident requires a skills assessment. 4. The IDT determines the residents ability to self-administer medications by means of a skill assessment as follows: a) The resident's medications are obtained from the pharmacy by usual means. b) The resident is instructed in the use of the package, purpose of the medication, reading of the label and scheduling of medication doses. c) The resident is then requested to read the label on each package and indicate at what time the medication should be taken, and any other special instructions for use. d) The resident is asked to demonstrate the removal of the medication from the package 3.1-11(a)

Based on observation and interview, the facility failed to ensure a resident's call light was within reach for 1 of 1 resident reviewed for environment. (Resident 11) Findings include: On 5/20/25 11:18 a.m., an observation of Resident 11's room revealed as the resident sat in her wheelchair, her call light was not within reach as it laid across her bed. During an observation of Resident 11 in her room on 5/21/25 10:37 a.m., the resident's call light was between the wall and the resident's bed, not within reach, as she sat in her wheelchair. During an interview on 5/21/25 10:39 a.m., the Social Services Director (SSD) indicated Resident 11's call light should be within her reach. On 5/22/25 at 3:44 p.m., the Director of Nursing (DON) indicated the facility did not have a policy specific to the use of call lights. 3.1-3(v)(1)

Based on interview and record review, the facility failed to timely update a care plan with new interventions for behavior management for 1 of 3 residents reviewed for dementia care (Resident 69). Findings include: The clinical record for Resident 69 was reviewed on 5/21/25 at 10:36 a.m. The diagnoses included, but were not limited to, dementia with mood disturbance and paranoid mood disorder. A care plan, with a start date of 9/6/24 and last revised 5/6/25, indicated she had physically abusive behavioral symptoms and violent behaviors such as grabbing another resident's shirt and arm, and hitting staff during care. The goal was for her not to be physically abusive to other residents, visitors, and/or staff. The interventions, which were initiated on 9/6/24, included but were not limited to, administering medications as ordered by the physicians, avoid over-stimulation, convey an attitude of acceptance towards her, and divert her behavior by offering an activity. A Quarterly Minimum Data Set (MDS) assessment, completed 3/10/25, indicated she was moderately cognitively impaired and had displayed verbal behaviors toward others and wandering behaviors for one to three days during the assessment period. A progress note, dated 3/9/25 at 7:50 p.m., indicated Resident 69 seemed mad at the staff and was making comments towards staff as if they had said something to her and argued with staff. Resident 69 had indicated she was leaving and attempted to leave the building through the dining room door. A staff member had been able to redirect her to her room. A social service progress note, dated 3/10/25 at 6:22 a.m., indicated Resident 69 had exhibited cursing, screaming, exit seeking, and false beliefs on 3/9/25. Staff attempted to redirect, provide one on one attention, offered food and fluids, provided a calm environment, and ensured Resident 69's safety. Staff had attempted meaningful activities and a back rub. The interventions were not effective. The Intradisciplinary Team (IDT) had met and reviewed behaviors. Staff were to continue to redirect Resident 69 as needed, offer reassurance and validation, and provide walks for Resident 69 if needed. The behavior care plan had not been updated to reflect the attempt to exit the facility or new interventions to address the behavior. A social service progress note, dated 3/12/25 at 6:17 a.m., indicated, on 3/12/25 at 2:05 a.m., Resident 69 was wandering about the unit. The staff had tried to redirect but it was not effective. The IDT team had met and reviewed the behavior. Staff were to redirect Resident 69 as needed and the resident was placed on fifteen-minute checks. The behavior care plan had not been updated with the new intervention of fifteen-minute checks. A progress note, dated 3/20/25 at 4:57 p.m., indicated Resident 69 had displayed increased aggressive behaviors and exit seeking. The Nurse Practitioner (NP) was informed and a new order for medication changes had been received. A social service progress note, dated 3/21/25 at 6:06 a.m., indicated Resident 69 had been wandering on 3/20/25 at 3:42 p.m. Staff had redirected with food and fluids, and the intervention was effective. On 3/20/25 at 4:30 p.m., Resident 69 began pacing and threatening staff. Resident 69 had displayed false beliefs and misperceptions and threatened to hit staff. Staff had attempted redirection, and it was not effective. The IDT team had met and reviewed behaviors. Staff would continue to redirect Resident 69 as needed. Resident 69's Depakote (anti-convulsant medication used to stabilize mood) was increased. A progress note, dated 4/10/25 at 1:13 p.m., indicated the Psychiatric NP and Proactive NP had been made aware of the urinalysis results and possible room move to the secured unit. A social services progress note, dated 4/11/25 at 2:36 p.m., indicated the nursing staff had spoken with Resident 69's daughter about moving Resident 69 to the secured dementia unit. Verbal consent had been received to move Resident 69. A progress note, dated 4/11/25 at 3:22 p.m., indicated Resident 69 has been relocated to the secured dementia unit. The behavior care plan had not been updated with the new intervention of relocating Resident 69 to the secured dementia unit. During an interview on 5/22/25 at 1:54 p.m., Social Service Director 1 indicated staff had tried many non-pharmalogical interventions with Resident 69 such as walking with her, back rubs, validating her feelings, and offering snacks. During an interview on 5/22/25 at 1:54 p.m., the Director of Nursing indicated Resident 69 had displayed exit seeking behavior and had begun wandering more. There had been a change in Resident 69's cognition, and she had become very focused on leaving the building. She was not always able to communicate her wants or feelings and could become agitated very quickly with little warning. There had been labs done and many attempts to redirect and calm Resident 69. There was another resident in the facility who seemed to exacerbate Resident 69's behavior. The facility had somewhat generalized care plans and Resident 69's care plans could be more individualized. During an interview on 5/22/25 at 3:13 p.m., the Director of Nursing indicated the facility did not have a specific care plan policy but followed the Resident Assessment Instrument Manual. On 5/22/25 at 8:42 a.m., the Director of Nursing provided the Behavioral Health Management Program Policy, dated January 2024, which indicated .[Name of Facility Corporation] believes in a person-centered care approach and tailors all considerations for the individual affected, including physical and psychosocial aspects of wellbeing when it comes to managing maladies that manifest behavioral disturbances . 3.1-35(b)(1)

Based on interview and record review, the facility failed to monitor the use of a non-invasive ventilator (NIV) for 1 of 1 resident reviewed for respiratory care. (Resident 11) Findings include: The clinical record for Resident 11 was reviewed on 5/21/25 11:10 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) and hypoxemia (low levels of oxygen in the blood). A Quarterly Minimum Data Set (MDS) assessment, completed 2/11/25, indicated Resident 11 was cognitively intact. A care plan, initiated on 11/18/2020, indicated Resident 11 had a diagnosis of sleep apnea and was at risk for respiratory difficulties or distress. The goal was for the resident to have no related complications through the next review related to sleep apnea diagnosis. Interventions included, but were not limited to, apply the NIV machine as ordered and to list settings, monitor oxygen saturation levels and apply oxygen as ordered, and contact physician as needed. A physician's order, dated 4/14/25, indicated the NIV to be applied at bedtime and instructed the use of specific settings of the machine. Staff were to monitor and document respiratory rate, minute volume, exhaled tidal volume, and resident tolerance. A review of the Medication Administration Records (MARs) and the Treatment Administration Records (TARs) was conducted on 5/21/25 11:21 a.m. The MARs and TARs did not contain documentation of monitoring with the use of the NIV, as ordered. An interview was conducted, on 5/21/25 at 2:10 p.m., with the Director of Nursing (DON). She indicated the order set was put in on the respiratory flowsheet, which was unseen by nursing. Therefore, there was no documentation of the treatment recorded. On 5/22/25 at 3:31 p.m. the DON provided the Non-Invasive Ventilation Policy, last revised 12/2022, which indicated .Respiratory and/or nursing personnel trained to perform and care for the Non-Invasive Ventilation dependent resident will perform equipment setup, monitoring, and troubleshooting as per physician order .24. Document procedure in resident's medical record (date and time, concerns and action taken, resident's tolerance of procedure, respiratory assessment (breath sounds, oxygen saturation, pulse rate and respiratory rate) and type of Non-Invasive ventilation . 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure infection control was maintained by utilizing hand hygiene during medication administrations for 3 of 8 residents observed during medication administrations. (Resident 50, Resident 52, and Resident 85) Findings include: 1. The clinical record for Resident 50 was reviewed on 5/21/25 at 8:40 a.m. The diagnoses included, but were not limited to, vascular dementia. An observation was conducted of a medication administration for Resident 50 with Qualified Medication Aide (QMA) 2 on 5/21/25 at 8:40 a.m. QMA 2 was observed preparing the resident's medications at the medication cart. She had pulled all pill medications from the drawers and utilized scissors to cut the storage packaging of the pill medications. She then dropped the pill medications in a medication cup. During that time, she had donned gloves to touch a pill medication. After doffing her gloves, she crushed the pill medications; grabbed a spoon from a plastic storage bag and mixed the pill medications in pudding. She then administered the medications to the resident in the dining room. During the preparation of the pill medications, QMA 2 was observed touching scissors, storage bag of unwrapped spoons, drawers of the medication cart, and computer mouse. There was no observation of QMA 2 utilizing hand hygiene prior to donning and doffing gloves or prior to the administration of the medication to the resident. 2. The clinical record for Resident 52 was reviewed on 5/21/25 at 9:00 a.m. The diagnoses included, but were not limited to, hypertension. An observation was conducted of a medication administration for Resident 52 with QMA 2 on 5/21/25 at 9:10 a.m. QMA 2 was observed preparing Resident 52's medications at the medication cart. During that time, she touched the computer mouse, pill packets, a pill medication, scissors, medication drawers, and a storage bag of unwrapped spoons. She then went to the resident's room to administer the medications. QMA 2 was observed donning on gloves, administering eye drops, and touching the resident's face. She then doffed her gloves and left the room. There was no observation of hand hygiene prior to leaving the medication cart and donning her gloves. 3. The clinical record for Resident 85 was reviewed on 5/21/25 at 9:26 a.m. The diagnoses included, but were not limited to, vascular dementia. An observation was conducted of a medication administration for Resident 85 with QMA 2 on 5/21/25 at 9:26 a.m. QMA 2 was observed preparing the pill medications at the medication cart. She pulled all medications including a medication patch. During that time, she was observed touching pill packets, the computer mouse, medication drawers, pen, and medication patch. After, she entered the resident's room. QMA 2 was observed donning gloves and applied a new medication patch on the resident's back. After the administration of the pill medications and medication patch, she left the room. There was no observation of hand hygiene prior to administration of the medication patch and donning gloves. An interview was conducted with QMA 2 on 5/21/25 at 9:35 a.m. She indicated she utilized hand hygiene prior to pulling the medications and after the administration to the resident. She should have utilized hand hygiene prior to donning gloves. An interview was conducted with the Infection Preventionist on 5/22/25 at 10:17 a.m. She indicated the staff should utilize hand hygiene before the preparation of the medications and prior to leaving the medication cart to administer the medication to the resident. A medication administration policy was provided by the Director of Nursing on 5/22/25 at 9:03 a.m. It indicated, .5. Bring medication cart to an area adjacent to resident room .7. Wash hands before medication pass .8. Remove medication from drawer, read label when taking from drawer and before putting in medication cup or pouring liquids .19. Cart was locked .Gel hands 21. Knock on resident's door before entering residents room . 3.1-18(l)

Based on observation, interview and record review, the facility failed to ensure proper medication administration procedures were followed by preparing medications for more that one resident at a time during medication administration for 2 of 2 medications carts reviewed for the prepping of medications for multiple residents. (Facility) Findings include: An observation of the Pine and Juniper units medication carts was conducted on 4/18/24 at 7 p.m. The following was observed: 1. The Pine unit's medication cart was reviewed with QMA (Qualified Medication Assistant) 2. QMA 2 unlocked the medication cart and in the top drawer there two medication cups with medications in them. QMA 2 indicated, one of the medication cups contained medications for Resident Q but when she went to administer the resident her medications she was not available to take her medications. QMA 2 also indicated, the other medication cup with medications inside it were for Resident R. When asked how many residents at a time can they prepare medications ahead of time for she indicated, none. QMA 2 then identified the medications inside each cup for the respective residents. a. Resident Q's medication cup contained the following medications: Tramadol (pain medication), gabatentin (nerve pain medication), acetaminophen, atorvastatin (cholesterol- reducing medication), Lasix (diuretic), melatonin (sleep aid), pramipexole (Parkinsons and/or restless leg medication) and Xarelto (anti-coagulant). b. Resident R's medication cup contained the following medications: Aptiom (seizure medication), Lasix, oyster shell calcium (supplement), lamotrigine (mood stabilizer). 2. Immediately following the Pine unit's medication cart, the Juniper unit's medication cart was reviewed with LPN (Licensed Practical Nurse) 3. LPN 3 unlocked the medication cart and in the top drawer were 5 medication cups containing medications for multiple residents. LPN 3 then identified who the prepared medications belonged to and what medications were in each cup as follows: a. Resident S's medication cup contained: buspirone (anti-anxiety medication), diltiazem (blood pressure medication), Trazadone, Xanax (anti-anxiety medication) b. Resident T's medication cup contained: depakote (anti-seizure, bipolar medication), and senna (laxative) c. Resident U's medication cup contained: atorvastatin, buspirone, carvedilol (blood pressure medication), Lasix, melatonin, oyster shell calcium, and acetaminophen d. Resident V's medication cup contained: buspirone, coreg (blood pressure medication), Cymbalta (antidepressant/nerve pain medication) and Norco (pain medication) e. Resident X's medication cup contained: buspirone and tramadol A QMA Responsibilities policy was received on 4/19/24 at 12:01 p.m. from DON (Director of Nursing). It indicated, Other considerations and Reminders .NO presetting of medication The facility did not have an Administration of Medication policy per DON but instead followed the Licensed Nurse Med Pass Clinical Skills Validation. This Federal tag relates to Complaint IN00431737. 3.1-25(b)(5)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure controlled medications stored in the facility's locked medication storage drawer in the medication refrigerator inside the main medication room were labeled with an opened date and a label which at a minimum includes the medication name (generic and/or brand), prescribed dose, strength, the expiration date when applicable, the resident's name, and route of administration for 2 of 4 resident's medications reviewed for medication storage. (Resident C and P) Findings include: A medication storage observation of the facility's main nursing station medication room was conducted on 4/18/24 at 7:23 p.m. with DON (Director of Nursing). With the medication room was a medication refrigerator which contained a locked metal box which held controlled medications. Inside the locked controlled medication drawer the following was observed: 1. An opened box containing a multi-dose bottle of lorazepam (anti-anxiety medication) which had also been previously opened. On the medication box was a handwritten name in black marker. DON indicated the name written on the box was the last name of Resident C. Neither the box nor the opened bottle of medication inside the box had a pharmacy label affixed with the resident's full name, the prescribed dose, or the route of administration. 2. An opened box containing an opened multi-dose bottle of lorazepam liquid. On the medication box was Resident P's name handwritten in black marker. Neither the box nor the opened bottle of medication inside the box had a pharmacy label affixed with the resident's full name, the prescribed dose, or the route of administration. An interview with DON conducted at the same time as the observation indicated, the medications mentioned above were obtained from the facility's medication management machine and not from the pharmacy. A Medication Labeling policy received on 4/19/24 at 9:59 a.m. from DON indicated, All labeling of prescriptions filled by [pharmacy's name] will be the responsibility of the dispensing pharmacist and will be consistent with State and Federal requirements. Labeling of prescription for outside pharmacies will also be according to State and Federal regulations. Labeling of over the counter drugs NOT dispensed by [pharmacy's name] are the responsibility of the outside pharmacy or the facility Medications Administered by Authorized Staff .shall be labeled as follows . a. Name of Drug b. Route of administration, if other than oral c. The strength and volume . d. The control number and expiration date e. Identification of the manufacturer, [NAME] or pharmacy f. Prescription number g. Special storage conditions . 2. Multiple dose drug distribution systems that dispense single unit packages require the label to contain the following a. Identification of the pharmacy b. Resident's name c. Date of dispensing d. Non-proprietary and/or proprietary name of the drug e. Strength expressed in the metric system whenever possible . 3.1-25(j) 3.1-25(k)

Based on interview and record review, the facility failed to protect a resident's right to be free from physical abuse by another resident for 1 of 4 residents reviewed for abuse. (Resident D) Findings include: The clinical record for Resident D was reviewed on 3/22/24 at 10:40 a.m. Resident D's diagnoses included, but not limited to, dementia and mood (affective) disorder (marked disruption in emotions; extreme highs/severe lows). An interview with Resident D conducted on 3/22/24 at 10:40 a.m. indicated she was going to be discharged from the facility on April 1, 2024. When asked why she was going to be discharged , she indicated she had been abusive to another resident. An interview with SSD (Social Services Director) conducted on 3/26/24 at 3:55 p.m. indicated Resident D was being discharged to another facility once her granddaughter had chosen one that is closer to her. When asked if Resident D's discharge was related to abuse, SSD indicated yes and Resident D had body slammed another resident to the floor then tried to deny that she knew anything about how the other resident came to be resting on the floor. An Indiana State Department of Health reportable incident report was received on 3/27/24 at 1:56 p.m. The report indicated, Resident D and Resident P, who both resided on the memory care unit, had a resident-to-resident altercation on 11/7/23. The Brief Description of Incident indicated, 11/7/23 [Resident P's first name] claimed [Resident D's first name] pushed her but there were no witnesses. It was in a common area, so we were able to access a camera and verify the incident. The type of injury added indicated, [Resident P's first name] has a knot to the back of her head and a skin tear. The immediate actions included: separation of the two residents; Resident D was placed on one-on-one supervision; pain and skin assessments were completed; social services was to provide 72 hours of psychosocial support; and families, doctors and the administrator were notified. Resident D was sent to a psychiatric facility for evaluation and treatment. The follow-up dated 11/13/23 indicated, no signs/symptoms of distress were noted for Resident P and Resident D had gone to a psychiatric facility. The investigation file for the resident-to-resident altercation between Resident D and P was received on 3/27/24 10:10 a.m. from CS (Clinical Specialist). Within the file, was a typed statement which indicated, There was not witness to the actual incident. The resident [sic, Resident P's full name] was found on the floor and she stated she was pushed. The camera footage was pulled and the entire incident was viewed. [sic, name of Resident P] was attempting to sit at the empty seat at the dining room table. [sic, Resident D's name] grabbed the chair not allowing [sic, Resident P's name] to sit down. Then [sic, Resident D's name] stood up, threw a metal drinking cut at [sic, Resident P] hitting her in the abdomen area. Then [sic, Resident D's name] came around the side of the table and forcefully shoved [sic, Resident P] onto the floor. [sic, Resident D] picked up her cup and quickly sat back down in her spot at the table. The staff within approx.[sic, approximately] 30 seconds who were in the pantry of the dining area came to [sic, Resident P] who was on the floor to assess and care for her. The video footage was viewed by the DON [sic, Director of Nursing], SSD [sic, Social Services Director], and the clinical specialist. 11/7/23 A nursing note in Resident D's clinical record dated 11/7/23 at 12:27 p.m. indicated Resident was seen on the video footage shoving another resident. Resident P indicated she was shoved onto the floor by Resident D. Resident D stated, she didn't do anything. A nursing note in Resident P's clinical record dated 11/7/23 at 2:34 p.m. indicated Resident P was shoved down in the dining room and sustained a skin tear to her right hand and a hematoma to the back of her head. A Social Services note dated, 11/7/2023 at 3:17 p.m. indicated social services had spoken to Resident D who indicated, she had pushed Resident P because she did not want that lady to sit with her at the table. When Resident D was told she would be going to a psychiatric facility, she replied, I don't give a f***, send me the f*** anywhere. A nursing note dated, 11/8/2023 at 10:01 a.m. indicated, IDT [sic, Interdisciplinary Team] met and reviewed recent aggressive behaviors from 11/07/2023. resident [sic, Resident D] was not triggered or instigated by any other residents. behaviors[sic] were very aggressive that resulted in injuries to other resident. Resident[sic, Resident D] was removed from situation and immediately placed on 1 on 1 supervision until resident left for [sic, name of psychiatric facility] for in patient psych stay. no [sic] further behaviors once 1 on 1 initiated. resident [sic] did leave this am [sic, a.m.] for hospital. A Social Services note dated, 1/29/2024 at 12:08 p.m. in Resident D's clinical record indicated, a care plan meeting with Resident D, Resident D's family, SSD (Social Services Director), IP (Infection Preventionist) and ED (Executive Director) had occurred, and they discussed Resident D's behaviors and stated, we are not able met her needs here at this facility. [sic, Resident D] is physically and verbally aggressive towards others, hiding knifes [sic] and scissors in her bra and under her bed. An Abuse, Neglect, and Misappropriation Prohibition and Prevention policy was received on 3/22/24 at 3:38 p.m. from ED. The policy indicated, it is the policy of the facility to provide each resident with an environment that is free from verbal, sexual, physical, and mental abuse .Reporting to the Administrator .Our facility will not condone resident abuse by anyone, including .other residents .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish Physical abuse is defined as hitting, slapping, pinching, kicking, etc . 3.1-27(a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely report a reportable incident for 2 of 4 residents reviewed for abuse. (Resident 94 and Resident E) Findings include: 1. The clinical record for Resident 94 was reviewed on 3/25/24 at 10:30 a.m. The diagnoses for the resident included, but were not limited to, dementia with psychotic disturbance and hallucinations. The resident was admitted on [DATE]. The 2/9/24 admission Minimum Data Set (MDS) Assessment for Resident 94 indicated she was severely impaired. 2. The clinical record for Resident E was reviewed on 3/22/24 at 3:11 p.m. The diagnoses for the resident included, but were not limited to, dementia with psychotic disturbance and hallucinations. The 1/8/24 Quarterly Minimum Data Set (MDS) Assessment for Resident E indicated he was severely impaired. A reportable incident that was reported to the Indiana Department of Health was provided by the Clinical Specialist on 3/25/24 at 9:00 a.m. It indicated .Incident date: 2/27/24 Incident Time: 3:01 p.m Brief Description of Incident .[Resident 94] touched [Resident E] on the outside of his pants in his lap area . An event for Resident 94 dated 2/26/24 indicated the resident on 2/26/24 at 10:00 a.m., had touched male resident in private area. A Social Services note for Resident E dated 2/26/24 at 2:41 p.m., indicated Visited with [Resident E] and asked if anything happened this morning. He said he couldn't remember. I asked if a female resident touched his private area. [Resident E] stated [NAME] (sic). I asked if that bothered him, he said no it was fine with me. A Social Services note dated 2/26/24 at 2:54 p.m., indicated spoke with [Resident 94] today regarding this morning incident. [Resident 94] did not recall doing that. I explained to her that she cannot go up to another resident and touch them. She replied okay. An interview was conducted with the Executive Director on 3/26/24 at 3:46 p.m. He indicated when the incident between Resident E and Resident 94 was first reported to him; it was not presented to him as something he thought at that time needed to be reported. After realizing the incident did need to be reported; he reported on 2/27/24. An abuse policy was provided by the Executive Director on 3/22/24 at 3:38 p.m. It indicated .It is the policy of [NAME] & Associates, Inc. and its member Communities to provide each resident with an environment that is free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion and misappropriation of their property .Policy Interpretation and Implementation .C. Reporting to State Agencies .1. Allegations of abuse and any neglect, mistreatment or injury of unknown source that results in serious injury will be reported immediately to the State licensing/certification agency through that agency's approved method of incident reporting .2. Allegations of mistreatment, neglect, or injury of unknown source that do not result in serious injury will be reported within a reasonable amount of time not to exceed 24 hours to the State licensing/certification agency through the approved method of reporting . 3.1-28(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly investigate a reportable incident for 2 of 4 residents reviewed for abuse. (Resident E and Resident 94) Findings include: 1. The clinical record for Resident 94 was reviewed on 3/25/24 at 10:30 a.m. The diagnoses for the resident included, but were not limited to, dementia with psychotic disturbance and hallucinations. The resident was admitted on [DATE]. The 2/9/24 admission Minimum Data Set (MDS) Assessment for Resident 94 indicated she was severely impaired. 2. The clinical record for Resident E was reviewed on 3/22/24 at 3:11 p.m. The diagnoses for the resident included, but were not limited to, dementia with psychotic disturbance and hallucinations. The 1/8/24 Quarterly Minimum Data Set (MDS) Assessment for Resident E indicated he was severely impaired. A reportable incident that was reported to the Indiana Department of Health was provided by the Clinical Specialist on 3/25/24 at 9:00 a.m. It indicated .Incident date: 2/27/24 Incident Time: 3:01 p.m Brief Description of Incident .[Resident 94] touched [Resident E] on the outside of his pants in his lap area . An investigation involving Resident 94 and Resident E was provided by the Clinical Specialist on 3/27/24 at 10:30 a.m. The investigation included but was not limited to: a written statement by Certified Nursing Assistant (CNA) 5. It indicated the following: To Whom This May Concern: I walked out of a Resident's room, and there was [Resident 94], in the hallway in front of the nurse's station holding another resident's private area. I quickly asked her to stop, saying you can not do that, and I asked the nurse to help because she's (sic) wouldn't let go so the nurse grabbed her, and I grabbed him, and took him to his room immediately!!! . The investigation did not include any additional statements from the staff that were present during the incident between Resident 94 and Resident E. An interview was conducted with CNA 5 on 3/27/24 at 11:55 a.m. She indicated Resident E was clothed and standing in the hallway. Resident 94 had ambulated up to Resident E and grabbed his genitalia through his clothing. CNA 5 had intervened to separate the residents, but Resident 94 would not let go of Resident E's private area. She hollered for assistance from Registered Nurse (RN) 10. RN 10 had assisted with separating the residents. Resident E did not voice any pain during that time. An interview was conducted with the Clinical Specialist on 3/27/24 at 1:33 p.m. She indicated the investigation between Resident 94 and Resident E provided was complete. An interview was conducted with RN 10 on 3/28/24 at 9:29 a.m. She indicated she was at the nurse's station and Resident 94 and Resident E were in the hallway. CNA 5 had hollered for her assistance. She had assisted CNA 5 with the separating of the two residents, but when she approached them Resident 94 was not touching Resident E's private area at that time. She had provided assistance with removing Resident E away from Resident 94 by taking him to his room. She then performed an assessment on Resident E and did not observe any injuries to him. RN 10 indicated she could not recall being asked for a written statement about the incident. She works PRN (as needed) and did not return to the facility for approximately a week after the incident. An abuse policy was provided by the Executive Director on 3/22/24 at 3:38 p.m. It indicated .It is the policy of [NAME] & Associates, Inc. and its member Communities to provide each resident with an environment that is free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion and misappropriation of their property .Policy Interpretation and Implementation .V. Abuse Investigations. 1. Should an incident or suspected incident of resident abuse, neglect, injury of an unknown source or misappropriation of resident property be reported, the Administrator or designee ensure the immediately protection and safety of the involved resident(s) and then will appoint a member of management to investigate the alleged incident while retaining ultimate responsibility for ensuring a timely and thorough investigation. 2. The Administrator or designee will provide to the person in charge of the investigation a complete copy of any supporting documents relative to the alleged incident. 3. The individual conducting the investigation will, at a minimum .g. Interview staff (on all shifts) who have had contact with the resident before, during, and immediately after the period of the alleged incident . 3.1-28(d)

Based on interview and record review, the facility failed to accurately complete the cognitive assessment portion of the MDS (Minimum Data Set) Assessment for 3 of 5 residents reviewed for Resident Assessment (Resident 28, 54, and 78). Findings include: 1a. The clinical record for Resident 28 was reviewed on 3/27/24 at 1:30 p.m. The Resident's diagnosis included, but was not limited to, dementia. A Quarterly MDS Assessment, completed 1/29/24, indicated that Resident 28 was usually able to make herself understood and was able to understand others. The BIMS (Brief Interview for Mental Status) of the MDS was not completed. 1b. The clinical record for Resident 54 was reviewed on 3/27/24 at 1:40 p.m. The Resident's diagnosis included, but was not limited to, dementia. A Quarterly MDS Assessment, completed 1/29/24, indicated that Resident 54 was usually able to make herself understood and was able to understand others. The BIMS (Brief Interview for Mental Status) of the MDS was not completed. 1c. The clinical record for Resident 78 was reviewed on 3/27/24 at 1:50 p.m. The Resident's diagnosis included, but was not limited to, dementia. A Significant Change of Status MDS Assessment, completed 2/29/24, indicated he was usually able to make himself understood and was usually able to understand others. The BIMS (Brief Interview for Mental Status) of the MDS was not completed. During an interview on 3/27/24 at 2:40 p.m., the SSD (Social Services Director) indicated that Residents 28, 54, and 78 were capable of answering questions for the BIMS Assessment, and that the assessments should have been completed for them. During an interview on 3/27/25 at 2:51 p.m., the MDSC (Minimum Data Set Coordinator) indicated the BIMS Assessment should have been completed on the MDS for Residents 28, 54, and 78. The facility used the RAI (Resident Assessment Instrument) as the policy for completing the MDS Assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident with an indwelling urinary catheter received appropriate treatment and services to prevent urinary tract infections and to monitor the urine characteristics of a resident being evaluated for a urinary tract infection for 2 of 3 residents reviewed for urinary catheter. (Resident H and Resident L). Findings include: 1. The clinical record for Resident H was reviewed on 3/26/24 at 10:06 a.m. Resident H's diagnoses included, but not limited to, urinary tract infection, acute pyelonephritis (infection of the kidneys), extended spectrum beta lactamase resistance (ESBL, a multi-drug resistant organism), and neuromuscular dysfunction of the bladder (lack of bladder control). A nursing note dated 1/14/2024 at 11:39 p.m. indicated Resident H had an anchored catheter for urinary drainage. The urine was very foul smelling and dark. His urine was tested in-house with a urine analyzer and had numerous abnormal values. Resident H's urine was to be sent to the lab in the morning for a urinalysis with culture and sensitivity. A physician's note dated 1/15/24 indicated, Resident H was seen in follow up rounds to review/discuss recent urinalysis with culture and sensitivity lab/diagnostic testing from 1/15/24 due to malodorous urine. The results noted the urine was positive for leukocytes, nitrites and bacteria while the culture was still pending. A new order for Keflex (an antibiotic) 500 mg (milligrams) twice a day for 7 days was to be started and possibly adjusted once the culture came back. A physician's note dated, 1/18/2024 indicated, Resident H's urine culture showed mixed flora which indicated, a contaminated sample and the lab recommended a repeat sample. The antibiotic did not meet McGreer's criteria but was continued as his urine was reported as cloudy with large sediment and a foul odor. Resident H was also noted to have had increased behaviors recently. No repeat urinalysis with culture and sensitivity labs were to be completed at that time as Resident H was currently on oral antibiotics, and this could have resulted in a false negative urine culture. A physician's order dated 9/28/23 indicated, to provide urinary catheter care every day and night shift. Resident H's care plan dated 4/3/23 and last revised on 2/17/24 indicated; he had an indwelling urinary catheter related to a neuromuscular dysfunction of bladder. Interventions included, but not limited to, provide catheter care every shift and as needed (start date 5/17/23). An interview with CS (Clinical Specialist) conducted on 3/26/24 at 4:14 p.m. indicated, a review of Resident H's MAR (medication administration report) and TAR (treatment administration report) for January and February 2024 did not contain verification documentation that indwelling urinary catheter care had been performed every shift from 1/15/24 to 2/5/24. A Bed Bath/Perineal procedure was provided by CS on 3/27/24 at 10:19 a.m. CS indicated, the facility does not have an indwelling urinary catheter care policy. The Bed Bath/Perineal care procedure indicated, Catheter care: 22. If resident has catheter, check for leakage, secretions or irritation. Gently wipe four inches of catheter from meatus out .Perineal Care .For Males .Pull back foreskin if male is uncircumcised. Wash and rinse the tip of penis using circular motion beginning with urethra. Continue washing down the penis to the scrotum and inner thighs. Rinse off soap and dry. Return foreskin over the tip of the penis.2. The clinical record for Resident L was reviewed on 3/22/24 at 10:52 a.m. The Resident's diagnosis included, but were not limited to, cerebral infarct (stroke) and dysuria (painful urination). She was admitted to the facility on [DATE]. An admission Assessment, dated 3/11/24, indicated Resident L was occasionally incontinent at night and had no symptoms of burning, frequency, pain with urination, or urgency. She wore incontinent pads or briefs to assist with controlling incontinence. A care plan, initiated 3/12/24, indicated Resident L had urinary incontinence. She required staff to assist with toileting and toilet hygiene. The goal was for her not to develop skin breakdown related to incontinence. The interventions included, but were not limited to, assist with toileting and personal hygiene as needed, provide incontinent care after each episode, and weekly skin assessments. A BIMS (Brief Interview for Mental Status) Assessment, completed 3/19/24, indicated she was cognitively intact. A Nurse Practitioner Progress Note, dated 3/20/24, indicated that Resident L had complaints of dysuria on exam. A UA C&S (Urinary Analysis with Culture and Sensitivity) was ordered. During an interview on 3/22/24 at 10:52 a.m., Resident L indicated she thought she was getting a urinary tract infection. She had told the facility, and they were testing her. It took a long time for the staff to take her to the bathroom and she was having urinary accidents. A Nursing Progress Note, dated 3/22/2024, indicated urine was collected for UA C&S and sent to the lab. A Nursing Progress Note, dated 3/25/2024, indicated that the urine sample previously sent to the lab was reported as possibly contaminated. The Nurse Practitioner had been made aware. During an interview on 3/26/24 at 3:19 p.m., Resident L indicated she was beginning to have burning with urination and that it seems to run every 15 minutes. During an interview on 3/26/24 at 3:57 p.m., the Director of Nursing indicated the Nurse Practitioner had been informed of possible contamination of the previous urine sample and had ordered to repeat the UA. A Nursing Progress Note, dated 3/27/2024, indicated that urine had been obtained and sent to the lab that morning. A urine culture was pending at that time and the nurse practitioner was aware. During an interview on 3/27/24 at 11:11 a.m., the Director of Nursing indicated a urine sample that had been sent to the lab that morning had been collected by using an in and out catheter. The Nursing Progress notes did not contain any assessment of Resident L's urine color, characteristics, any odor present in the urine, or how the urinary sample was obtained. On 3/28/24 at 12:16 p.m., the Clinical Specialist provided the current Catheterizing the Urinary Bladder with an In and Out Straight Catheter Skills Validation which read .Document .Document the procedure: Documentation should include a detail of the procedure, the resident's tolerance of the procedure, the color, character and amount of the urine noted in the drainage bag . This citation relates to Complaint IN00425957. 3.1-41(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adequate supervision for an ambulatory cognitively impaired resident that resided on the memory care unit for 3 of 4 residents reviewed for abuse. (Resident 15 and Resident 94, and Resident E) Findings include: 1a. The clinical record for Resident E was reviewed on 3/22/24 at 3:11 p.m. The diagnoses for the resident included, but were not limited to, dementia with psychotic disturbance and hallucinations. The 1/8/24 Quarterly Minimum Data Set (MDS) Assessment for Resident E indicated he was severely cognitively impaired. 1b. The clinical record for Resident 94 was reviewed on 3/25/24 at 10:30 a.m. The diagnoses for the resident included, but were not limited to, dementia with psychotic disturbance and hallucinations. The resident was admitted on [DATE]. The 2/9/24 admission Minimum Data Set (MDS) Assessment for Resident 94 indicated she was severely cognitively impaired. A care plan for Resident 94 dated 2/7/24 indicated .[Resident 94] has a diagnosis of dementia with behaviors and at times exhibits the following signs and symptoms attempting to hit staff, yelling out. [Resident 94] also has a current dx [diagnosis] of hallucinations and is at risk of experiencing certain behaviors regarding .Approach .New or worsening behaviors will be monitored and new interventions will be considered in order to promote the highest level of quality of life for this resident .Allow for hoarding or wandering in a controlled environment with acceptable limits . A care plan dated 2/27/24 indicated .Resident touching another resident inappropriately. Increased interest in touching self, masturbation .Approach .Give resident privacy in own room when desires to masturbate or touch self .Resident on 15 min [minutes] check until deemed necessary to remove per IDT [Interdisciplinary Team.] . A care plan dated 3/6/24 indicated Entering another residents room and taking their belongings .Approach .Goal. Resident will not go into other residents rooms and take their belongings .Approach. Encourage resident to join in scheduled activities to keep her busy .See [Psych Provider] as needed .Stop sign placed on other residents door, 15 min checks to continue until deemed appropriate to remove by IDT .Try self directed activities to help keep resident busy, walk with resident in hallway . A care plan dated 3/6/24 indicated .Resident is at risk for psychosocial distress from physical contact from another resident .Approach .Monitor for any signs of distress, withdraw, change in mood A care plan for Resident 94 dated 3/14/24 indicated Behavioral symptoms. Resident is at risk wandering, exit seeking, history of elopement from home, expresses the need to go home or leave, , and/or expresses anger or frustration about being in the community. wander guard to L [left] ankle. Resident cuts off wanderguard at times .Approach .3/14/24 Increase staff monitoring as needed .Redirect resident if wandering in unsupervised areas .When resident begins to wander, provide comfort measures for basic needs . A physician order dated 2/6/24 indicated Resident 94 was to receive 10 milligrams of memantine daily for a diagnosis of dementia with psychotic disturbances that included hallucinations. A physician order dated 2/6/24 indicated the resident was to receive 2 milligrams of diazepam in the morning daily for combative behavior. The medication was discontinued on 2/7/24. A physician order dated 2/6/24 indicated the resident was to receive 2 milligrams of diazepam at bedtime daily for combative behavior. A nursing progress note for Resident 94 dated 2/6/24 indicated Unable to complete admission PPD [Purified Protein Derivative] testing at this time. Patient is being extremely combative, yelling, swinging arms/attempting to strike nursing staff, screaming and unable to redirect. Will continue w/ [with] plan of care. A Social Services note for Resident 94 dated 2/7/24 indicated Nursing staff did report that on the evening of 2/6/24, resident was combative with nursing staff during admission process/care; attempting to hit nursing staff, verbal aggression. Staff also report that on the morning of 2/7/24, resident was yelling out/screaming at others during care. Staff will continue to reassure resident of her safety during care, and will continue to cue and assist resident as necessary. A physician note dated 2/7/24 indicated .behaviors in hospital requiring prn [as needed] zyprexa. Consult psych if needed. Cont [continue] memantine, diazepam reports of anxiety and behaviors. Add hydroxyzine 25 mg [milligrams] bid [twice a day] prn x 14 days. May need to increase diazepam dosage . A physician order dated 2/8/24 indicated the resident was to receive 25 milligrams of hydroxyzine twice a day as needed. A physician note dated 2/9/24 indicated Resident 94 was confused, but mood was stable. A nursing progress note for Resident 94 dated 2/23/24 indicated Resident wandering throughout the entire morning. She had to be redirected from 3 other resident rooms. In the last room she was found unclothed in another residents bed and had ripped her brief off. She does not take direction well and is not able to understand what you're asking d/t [due to] dementia. Will continue to redirect. An event for Resident 94 dated 2/26/24 indicated the resident on 2/26/24 at 10:00 a.m., had touched male resident in private area. Interventions that were put in place after the incident was one on one interaction, reassurance from staff, 15-minute monitor checks, and psych provider was notified. A reportable incident that was reported to the Indiana Department of Health was provided by the Clinical Specialist on 3/25/24 at 9:00 a.m. It indicated .Incident date: 2/27/24 Incident Time: 3:01 p.m Brief Description of Incident .[Resident 94] touched [Resident E] on the outside of his pants in his lap area .Follow up: 3/5/24 [Resident 94] was seen by psych and new med [medication] added to help with behavior. 15-minute checks continue for [Resident 94]. Interdisciplinary team will evaluate circumstances to decide when they can be discontinued. Neither resident is showing any s/s [signs and symptoms] of psychosocial distress from incident. An investigation involving Resident 94 and Resident E was provided by the Clinical Specialist on 3/27/24 at 10:30 a.m. The investigation included but was not limited to: a written statement by Certified Nursing Assistant (CNA) 5. It indicated the following: To Whom This May Concern: I walked out of a Resident's room, and there was [Resident 94], in the hallway in front of the nurse's station holding another resident's private area. I quickly asked her to stop, saying you cannot do that, and I asked the nurse to help because she's (sic) wouldn't let go so the nurse grabbed her, and I grabbed him, and took him to his room immediately!!! . An interview was conducted with CNA 5 on 3/27/24 at 11:55 a.m. She indicated she was the staff present during the incident on 2/26/24 between Resident E and Resident 94. Resident E was clothed and standing in the hallway. Resident 94 had ambulated up to Resident E and grabbed his genitalia through his clothing. CNA 5 had intervened to separate the residents, but Resident 94 would not let go of Resident E's private area. She hollered for assistance from Registered Nurse (RN) 10. RN 10 had assisted with separating the residents. Resident E did not voice any pain during that time. Resident 94 was then placed on every 15-minute checks. An interview was conducted with RN 10 on 3/28/24 at 9:29 a.m. She indicated she was at the nurse's station and Resident 94 and Resident E were in the hallway. CNA 5 had hollered for her assistance. She had assisted CNA 5 with the separating of the two residents, but when she approached them Resident 94 was not touching Resident E's private area at that time. She had provided assistance with removing Resident E away from Resident 94 by taking him to his room. She then performed an assessment on Resident E and did not observe any injuries to him. A Post Behavioral/Emotional IDT Form dated 2/26/24 indicated .resident went to common area and touch a male resident in his private area .New interventions that will be added to prevent a reoccurrence; make sure resident does not sit next to male resident in common area . A 2/28/24 Behavior IDT follow up for Resident 94 indicated resident was on 15-minute monitoring checks and psych provider ordered 10 milligrams of Paxil (antidepressant) daily. A physician order dated 2/28/24 indicated the resident was to receive 10 milligrams of Paxil daily. A Social Services note dated 3/6/24 at 7:49 a.m., indicated On 3-5-24 at 11:12 p.m., [Resident 94] was having trouble sleeping, up walking and going in/out of other residents rooms taking their personal belongings. Staff did try the following redirection, one-on-one, toileted, provided a calm environment, given food/fluids, was not effective. IDT team reviewed behaviors. Staff will continue to redirect resident as needed. 1c. The clinical record for Resident 15 was reviewed on 3/25/24 at 1:11 p.m. The diagnosis for the resident included, but was not limited to, dementia. The 1/29/24 Admissions Minimum Data Set (MDS) Assessment for Resident 15 indicated she was severely cognitively impaired. A nursing progress note dated 3/6/24 at 8:13 a.m., indicated Res [resident] 94 in [Resident 15]'s room trying to take res in room belongings. Res [94] was struck in the back with a closed fist before staff could intervene. Res was not injured by this contact. Res skin was assessed and found to have no redness or bruising to area Res does not seem to have any memory of this incident and continues to try and go into others rooms and take things out of rooms that are not hers. Res redirected several times without effectiveness. A reportable incident that was reported to the Indiana Department of Health was provided by the Clinical Specialist on 3/25/24 at 9:01 a.m. It indicated .Incident date: 3/6/24 Incident Time: 9:01 a.m Brief Description of Incident .[Resident 94] wandered into [Resident 15]'s room and before staff could reach [Resident 94] and redirect her [Resident 15] touched her back with her hand .Immediate Action taken .Residents were immediately separated. Skin and pain assessment has been initiated .Stop sign was placed at [Resident 15]'s door .Follow up .[Resident 94] was seen by psych [provider] and new order added to care. 15 - minute checks continue with [Resident 94] IDT team met and reviewed behaviors. Staff will continue to redirect as needed. They will try and engage her in self-directed activities along with scheduled activities. An investigation involving Resident 94 and Resident 15 was provided by the Clinical Specialist on 3/27/24 at 10:30 a.m. The investigation included but was not limited to: a written statement by License Practical Nurse (LPN) 2. It indicated, 3/6/24 at 8:05 a.m. Res [94] was in [Resident 15's room] and had taken some belongings from res [15]. Res in [Resident 15's room] was distressed about [Resident 94] in her room. Res [94] had belongings in her hand. Retrieved res belongings and got her to head to the door. As were coming through the door [Resident 15] hit her in the back. Removed res [94] from [Resident 15's room] & assessed for injury. Res in [Resident 15's room] went back to her chair and was upset about her being in her room . A Social Services progress note dated 3/7/24 at 7:37 a.m., indicated On 3-6-24 at 8:00 a.m., [Resident 94] was rummaging through other residents's belongings. Staff did try the following redirection, one-on-one, offered food/fluids was not effective. On 3-6-24 at 9:47 p.m., [Resident 94] was having trouble sleeping, wondering into other residents rooms, taking their belongings, waking them up and yelling at them about her husband. Staff did try the following redirection, one-on-one, food/fluids, toileted, returned to her room, position change, was not effective. On 3-7-24 at 2:56 a.m., [Resident 94] was having trouble sleeping and wandering. Staff did try the following redirection, one-on-one, toileted, returned to her room, position change, was not effective. IDT team met and reviewed behaviors. Staff will continue to redirect resident as needed. Resident just had a recent increase in her Paxil. A physician order dated 3/6/24 indicated Resident 94 was to be increased to 20 milligrams of Paxil daily. An observation behavior note for Resident 94 dated 3/8/24 indicated .follow up behavior and resident altercation/contact .Root cause: Resident with altercation with other female resident and also previously touched male resident in hallway in his lap area on outside of his pants/increased pleasing self-masturbation. Current status: resident conts [continues] to wander however no aggression or physical contact with others. Resident has had no psychosocial distress from physical contact to back when she roamed into other residents room to take her items. Intervention(s): Paxil was increased by psych earlier this week, and it does seem to be helping. Psych evaluated resident this week. This resident is on 15 min checks, and a stop sign is on the door for the female resident whos room she entered and that is effective at this time. Staff gives redirection as needed and engages in appropriate activities . A psych visit note dated 3/8/24 indicated .The patient reports no difficulty with sleeping at night. Staff notes she is having trouble with some difficulty with being up wandering at times. If she continues to have difficulty we will add melatonin She denies difficulty with anxiety and no symptoms are observed. She is more restless than anxious, probably due to her confusion .She is having difficulty with behaviors, including stealing belongings from peers and going in their room. She also has had some sexual behaviors. She was started on Paxil for these, and her dose was increased recently .Staff are obtaining UA on her today. Her recent one was negative for UTI [Urinary Tract Infection]. The patient's cognition is significantly declined. She is currently receiving memantine for cognition decline, which we will probably discontinue once her behavior issues are stabilized Follow up 1 month . An observation behavior note for Resident 94 dated 3/15/24 indicated follow up behaviors .Root cause: resident with behaviors, wandering into others rooms, taking belongings, recently having hypersexual behaviors, such as masturbating. Current status: residents sexual behaviors have decreased, no touching others, conts to roam in to others rooms, and is taking down stop signs. They are not effective. Intervention(s): psych is following resident, and [Medical Provider]. U/A [Urinalysis] ordered. Paxil was started and also increased which has helped resident some . A Social Services note for Resident 94 dated 3/18/24 indicated On 3/15/24 at 9:16 p.m., [Resident 94] was repetitive asking questions. Staff did try to redirect, was not effective. On 3/16/24 at 1:00 a.m., [Resident 94] was having trouble sleeping and going into other residents rooms while they were sleeping. She would uncover them and tell them it was time to get up. She also pulled their clothing out of the closet and put them on top of them. Staff did try the following redirection, offered food/fluids, toileted and returned to her room, was not effective. On 3/17/24 at 7:31 p.m., [Resident 94] was wondering about the unit. Staff did try the following redirection, backrub and provided calm environment, was not effective. IDT team met and reviewed behaviors. Staff will continue to redirect resident as needed through out her daily routine. They will also try to have her do self directed activities and join in scheduled activities. A medical provider note dated 3/19/24 indicated .Resident with pacing and restlessness at night .Start low dose melatonin 3 mg q hs [every night. A physician order dated 3/20/24 indicated the resident was to receive 3 milligrams of melatonin daily at bedtime. A behavior follow up note dated 3/22/24 indicated Root cause: resident with ongoing behaviors. sexual behaviors have decreased some, not touching others. Conts to wander into other areas. Current status: stable. Conts to wander into others space, non pharm [nonpharmacological] interventions attempted. Staff attempting to engage in activities and keep resident busy. Staff reported to NP [Nurse Practitioner] resident not sleeping well. Intervention(s): Melatonin started, cont ss [social services] follow up, psych, and NP to follow .no further IDT monitoring needed at this time . Resident's 94 staff monitoring documents were provided by the Clinical Specialist on 3/26/24 at 12:55 p.m. The monitoring documents indicated Resident 94 was on staff 15-minute monitoring checks on 2/26/24, 2/27/24, 2/28/24, 2/29/24, 3/1/24, 3/2/24, 3/3/24, 3/5/24, 3/6/24, 3/7/24, 3/8/24, 3/9/24 and 3/10/24. An observation was made of Resident 94 on 3/25/24 at 10:55 a.m. During a scheduled activity on the memory care unit, Resident 94 was observed wandering. The resident had wandered into Residents' 68 and 79's room. The residents that reside in the room were not present in the room at that time. Resident 94 was observed going to one of the resident's bed and messing up blankets; rummaging through the closet, and the bathroom. There was no observation of staff redirecting the resident at that time. The resident then left the room and ambulated to the nurse's station. Resident 94 indicated at that time; she needed her, dirty white clothes. During an interview with CNA 5 on 3/27/24 at 11:55 a.m., she indicated Resident 94 wanders in and out of residents' rooms, and it upsets other residents. A stop sign was placed on Resident 15's door after the incident occurred on 3/6/24, with Resident 15. Resident 15 gets upset when Resident 94 takes her belongings. Resident 94 goes into other residents' rooms; messes up their covers and belongings. The stop signs do not help. The resident removes the stops signs. The resident does like her room to be set at a warmer temperature. She will occupy her time in her room at times if the temperature in her room was set to her liking. During an interview with RN 10 on 3/28/24 at 9:29 a.m., she indicated Resident 94 does wander in and out of other residents' rooms. They utilize stop signs on the doors to detour her from entering. An interview was conducted with LPN 2 on 3/28/24 at 11:06 a.m. She indicated she was the staff person present during the incident on 3/6/24 with Resident 94 and Resident 15. She was assisting a resident; assuring that resident was not going to fall and had observed Resident 15 getting aggravated with Resident 94 in her room taking her belongings. She heard Resident 15 yelling get out! Then, LPN 2 entered the room to intervene and redirect. LPN 2 was able to get Resident 94 to head to the doorway of the room. During that time, Resident 15 hit Resident 94 in the back prior to getting Resident 94 to exit the room. LPN 2 indicated stops signs do not stop Resident 94 from entering other residents' rooms. She removes them. Does not help at all; nothing works. She wanders everywhere. A Behavioral Health Management Program was provided by the Director of Nursing on 3/28/24 at 11:50 a.m. It indicated, Behavior policy .[NAME] communities provide services to our residents with specific diseases and disorders. Some of our residents have medical disabilities that can lead to disruptive behaviors and these behaviors have the potential to create a negative effect on the resident, other residents, visitors, and the staff. It is [NAME]'s policy that each community will have a behavior program that: identifies, monitors, manages, and disseminates (whenever possible) all behavioral events by utilizing the least invasive approach based on the individual resident affected. Our goal is to provide the highest level of functioning and well being for each resident we serve. [NAME] believes in a person-centered care approach and tailors all considerations for the individual affected, including physical and psychosocial aspects of well being when it comes to managing maladies that manifest behavioral disturbances . 3.1-37(a)

Based on interview and record review, the facility failed to ensure transmission-based precautions (TBP) were initiated timely for a resident with COVID-19 for 1 of 3 residents reviewed for TBP. (Resident 255) Findings include: The clinical record for Resident 255 was reviewed on 3/25/24 at 1:55 p.m. The diagnoses included, but were not limited to, COVID-19, cough, and hypertension. A progress note, dated 3/16/24 at 12:54 p.m., indicated Resident 255 admitted to the facility from the hospital and admitted with COVID-19. A physician order, dated 3/18/24, indicated the following, .droplet/contact isolation, with no roommate. All meals, activities, therapy and services must be provided in room with isolation precautions followed There was no indication in the progress notes or the physician orders that the resident was in TBP until 3/18/24. A policy titled COVID-19 Policy and Procedure, dated 8/6/23, was provided by Clinical Specialist on 3/26/24 at 12:55 p.m. The policy indicated the following, .Additional PPE [personal protective equipment] and Other Precautions .A. Face Shield/Goggles, N95 Respirator, and a Gown must be worn by healthcare personnel (HCP) who provide essential direct care within 6 feet of the resident when .1. Caring for a Resident in a Red Zone 3.1-18(b)(2)

Based on interview and record review, the facility failed to ensure annual influenza immunization was administered per physician orders for 1 of 5 residents reviewed for immunizations. (Resident 82) Findings include: The clinical record for Resident 82 was reviewed on 3/25/24 at 1:50 p.m. The diagnoses included, but were not limited to, heart failure, diabetes mellitus, and weakness. An immunization consent form, undated, indicated consent was given to administer the influenza vaccine. A physician order, dated 11/3/23, was noted for Fluzone Quad 2023-2024 (flu vaccine) intramuscular injection. The electronic medication administration record (EMAR), dated November of 2023, indicated the dose of Fluzone Quad was not signed off, as administered, on 11/3/23. An interview conducted with the Infection Preventionist (IP), on 3/26/24 at 4:50 p.m., indicated she reached out to the physician and obtained an order to administer the influenza vaccine since it was still within the window to receive the annual influenza vaccine. A policy titled Influenza Immunization Policy - Residents, revised 9/23/20, was provided by the Executive Director on 3/22/24 at 1:30 p.m. The policy indicated the following, .All residents will be offered an influenza vaccination as appropriate when residing in a [name of Corporation] Community. Annually [name of Corporation] will offer the influenza vaccination beginning on October 1 unless the vaccinations have not yet been received in stock by [name of pharmacy] and continue through the influenza season .This policy is created with the intention to follow current CDC [Centers for Disease Control and Prevention] recommendations for influenza vaccination A document from the Centers for Disease Control and Prevention (CDC) titled Key Facts About Flu Vaccines, last reviewed March 22, 2024, indicated the following, .When should I get vaccinated .For most people who need only one dose of influenza vaccine for the season, September and October are generally good times to be vaccinated against influenza. Ideally, everyone should be vaccinated by the end of October

Based on interview and record review, the facility failed to accurately reflect the resident's fall status, related to the Minimum Data Set (MDS) assessment, for 1 of 3 residents reviewed for falls. (Resident E) Findings include: The clinical record of Resident E was reviewed on 8-30-23 at 12:09 p.m. His diagnoses included, but were not limited to, dementia, history of falls, muscle weakness, congestive heart failure and atrial fibrillation (irregular heart rhythm). He resided on a secured dementia care unit. A review of his most recent MDS assessment, a quarterly assessment, dated 8-5-23, indicated he had no falls since the most recent prior MDS assessment, a significant change assessment on 6-20-23. A review of Resident E's progress notes from 7-30-23 to 8-30-23 identified 3 falls that should have been identified for the look back period of 6-20-23 to 8-5-23, with 2 falls on 7-30-23 and 1 fall on 8-2-23. In an interview with the MDS Coordinator on 8-30-23 at 2:05 p.m., she indicated she would need to review Resident E's falls for the appropriate time period. In a second interview on 8-30-23 at 2:10 p.m., with the MDS Coordinator, she indicated she had counted a total of 5 falls for the time period, with 2 or more falls without injury and 2 or more falls with non-major injury. Looks like one of the company's traveling MDS people completed the 8-5-23 MDS assessment. Any number of reasons it could have been put in incorrectly. She stipulated the facility does not have a particular policy or procedure for MDS assessments, but uses the most current Resident Assessment Instrument (RAI) manual. The Centers for Medicare and Medicaid Services' Long Term Care Facilities Resident Assessment Instrument 3.0, version 1.16, October, 2018 manual, section J-1800 indicated, Falls are a leading cause of morbidity and mortality among nursing home residents. Falls result in serious injury, especially hip fractures. Fear of falling can limit an individual ' s activity and negatively impact quality of life .Identification of residents who are at high risk of falling is a top priority for care planning. A previous fall is the most important predictor of risk for future falls. Falls may be an indicator of functional decline and development of other serious conditions such as delirium, adverse drug reactions, dehydration, and infections. External risk factors include medication side effects, use of appliances and restraints, and environmental conditions. A fall should stimulate evaluation of the resident ' s need for rehabilitation, ambulation aids, modification of the physical environment, or additional monitoring (e.g., toileting, to avoid incontinence). Coding for the documentation of falls, section J-1900, should reflect any falls that have occurred since the previous assessment period. Coding for the number of falls and any injuries should reflect any injuries received as a result of the fall, specific to the terms of no falls, injury or major injury. Definitions of those injuries are as follows: Injury (except Major includes skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains; or any fall-related injury that causes the resident to complain of pain. Major Injury includes bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma. Coding for the number of falls utilizes the codes of none (0), one (1) or two or more (2). This Federal tag relates to Complaint IN00415226. 3.1-31(a) 3.1-31(c)(3) 3.1-31(c)(4)

Based on observation, interview, and record review, the facility failed to perform a self-administration of medication assessment prior to allowing a resident to self-administer medications for 1 resident randomly observed for self-administration of medications (Resident 104). Findings include: The clinical record for Resident 104 was reviewed on 1/20/23 at 9:22 a.m. The Resident's diagnosis included, but were not limited to, chronic congestive heart failure. On 1/20/23 at 9:22 a.m., LPN (Licensed Practical Nurse) 1 was observed standing at the medication cart in the hallway outside of the unit dining room. Dietary Aide 17 approached the medication cart and informed LPN 1 that Resident 104's medications were sitting on his breakfast tray in the dining room. LPN 1 locked her medication cart and went to the dining room table where Resident 104 had been setting. She picked up a plastic medication cup which contained several pills and brought it back to the medications cart. During an interview on 1/20/23 at 9:23 a.m., LPN 1 indicated that she had given Resident 104 his medications while he was sitting at the table. He had brought them to his mouth, and she had thought that he had swallowed them. He must not have taken them, or he possible spit them back into the cup. During an interview on 1/20/23 at 3:14 p.m., the Nurse Consultant indicated Resident 104 did not have a self-medication assessment. On 1/20/23 at 3:14 p.m., the Nurse Consultant provided the current Licensed Nurse Med Pass Clinical Skills Validation which read .24. Remained with the resident to ensure that the medication was swallowed . 3.1-11(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect a resident's right to be free from abuse related to a resident getting intentionally pushed out of her room by her roommate and threatening them with clinched fists (Resident 53 and 73) and intentionally pushing another resident into their walker (Resident 53 and 14) for 2 of 2 residents reviewed for abuse. Findings include: The clinical record for Resident 53 was reviewed on 1/23/23 at 9:52 a.m. Resident 53's diagnoses included, but not limited to, cognitive social or emotional deficit following cerebral infarction (stroke), vascular dementia with behavioral disturbance, generalized anxiety disorder, and delusional disorder. Resident 53's quarterly MDS (minimum data set) dated 8/12/22 indicated, she had moderate cognitive impairment. Resident 53's quarterly MDS dated [DATE] indicated, she had no behaviors. 1. An event note dated 10/29/22 indicated, Resident 53 had aggressively pushed her roommate, Resident 73, while in her wheelchair, out of their room and into the hallway, then shook her fist in Resident 73's face, and Resident 73 screamed. A nursing note dated 10/29/22 at 6:58 p.m. indicated, Resident 53 was moved to another room. A nursing note dated 10/31/2022 at 3:30 p.m. indicated, new orders were received to send Resident 53 to a psychiatric facility related to aggressive behaviors towards Resident 73. A nursing note dated 10/29/2022 at 4:36 p.m. and recorded as a Late Entry on 10/31/2022 at 3:41 p.m. indicated, Resident [sic, Resident 53] was physically aggressive towards roommate [sic, Resident 73] by pushing roommate out of room aggressively while roommate was in her wheelchair[sic] out into hallway then roommate screamed out and this resident shook her fist in roommates face.[sic] resident did not make contact with fist. Resident walked away from roommate . A nursing note from Resident 73's electronic health record (EHR) dated, 10/29/2022 at 4:49 p.m. indicated, QMA [sic, qualified medication assistant] reported to writer that resident stated her roommate pushed her out of her room by her w/c[sic, wheelchair]. Resident stated her finger did get pinched when her w/c[sic] moved. Head to toe shows only a small bruise on 4th finger of her right hand .Resident stated roommate threatens her to beat her up in the middle of the night. Resident stated once that she drew her fist at her and the nurse came in just in time to stop it. ED[sic, Executive Director] and DON [sic, Director of nursing] notified of incident . A Social services note from Resident 73's EHR dated 11/2/2022 at 4:09 p.m. indicated, Resident 73 had been fine since her roommate was no longer in the same room as her. Both Resident 73 and her family had voiced that they did not want Resident 53 to be roommates. An incident report was received on 1/23/23 from ED (Executive Director) at 12:51 p.m. The incident report indicated; the incident date was 11/1/22 at 11:30 a.m. The brief description of incident stated, 11/2/22 (sic, Resident 73's first name) stated to staff that (sic, Resident 53's first name) her roommate at the time pushed her into the hallway while she was seated in her wheelchair. Type of injury added was a small bruise noted on Resident 73's 4th finger of her right hand and was possibly pinched by the wheelchair moving forward. The follow up dated 11/9/22 indicated, Resident 53 and 73 will no longer be roommates. An interview with Resident 73 was conducted on 1/23/23 at 11:00 a.m. She indicated, Resident 53 had Alzheimer's and would get more confused during the night. She stated, when she and Resident 53 were roommates, Resident 53 would turn off the lights and yell at her to stop wasting electricity. She indicated the evenings were most unpleasant and that she had faced her double fists more times than I could count. She stated, since Resident 53 moved out of her room, she tries not to come in direct contact with her but, there have been a few times she wandered into her room in the middle of the night and was trying to get in bed with her new roommate. She indicated, the staff came in and had to redirect her out of the room. Resident 73 stated, I don't want her to terrify my roommate. Resident 73's annual MDS dated [DATE] indicated, she was cognitively intact. 2. An incident report dated 12/27/22 was received on 1/23/23 from ED (Executive Director) at 12:51 p.m. It indicated, on 12/27/22 Resident 14 stated, Resident 53 came into her room, so she grabbed her arm to redirect her when Resident 53 pushed back and caused Resident 14 to move backwards up against her door. No injury was noted. The immediate action taken was a pain and skin assessment was completed on Resident 14. Preventive measure stated, an investigation had been initiated into the interaction between Resident 14 and Resident 53 and a sign had been placed on Resident 53's door to identify it as hers. The follow up dated 1/3/23 indicated, Resident 14 wasn't showing any signs of distress from the incident and interviews conducted with staff didn't coincide with Resident 14's version of the incident. Resident 53 was unable to recall the incident and staff will continue to redirect Resident 53 as needed. A Social services note dated 12/27/2022 at 3:57 p.m. indicated, social services had spoken with Resident 14 that afternoon and asked her if she was still feeling unsafe. Resident 14 replied yes as long as she was still next door to her. Resident 14 stated, she was going to put her chair in front of door as long as Resident 53 was next door to her. A nursing note dated 12/27/2022 at 4:54 p.m. indicated, Resident 14's skin was assessed that morning and no bruising or skin issues were noted. Resident 14 had pointed to her right buttock/hip area and stated, right there, but I haven't bruised yet, but I will later. An interview with Resident 14 was conducted on 1/23/23 at 11:16 a.m. Resident 14 indicated, Resident 53 wanders at nighttime. On 12/26/22, Resident 53 had wandered into Resident 14's room so Resident 14 took Resident 53 by her arm and had guided her back out of her room. She stated, about an hour later, Resident 53 was back in her room near the doorway, so she approached her went to guide her out of her room when Resident 53 shoved me back and she had hit her hip on the walker which was behind her. Resident 14 stated, that area didn't have a bruise but I hurt for days. Resident 14 indicated, when referencing Resident 53 during the nighttime hours that she's like a crazy person at nighttime. She continued by stating, she was afraid of having her live next door to her. She admitted there were a few nights she had put her chair against the door because she was afraid of her. Resident 14's annual MDS dated [DATE] indicated, she was cognitively intact. The investigation file related to Resident 53 and 14's incident contained a handwritten sheet with the names of staff who worked the evening/night shift on 10/26/22 into 10/27/22. The handwritten note next to an agency CNA's name (certified nursing assistant 25) indicated, [sic, Resident 53's name] came in + [sic, and] started yelling @ [sic, at] her +[sic] felt fearful +[sic] was putting a chair to block her door .going into rooms, turning off lights, An interview with ED (Executive Director) was conducted on 1/23/23 at 12:11 p.m. ED indicated, he didn't believe the incident between Resident 53 and 73 was abuse related to Resident 53 pushing on resident 73's wheelchair and not her person. He further indicated, he did not report the incident between Resident 53 and 73 timely related to him being on vacation. An Abuse, Neglect, and Misappropriation Prohibition and Prevention Policy was received on 1/17/23 at 2:03 p.m. from ED. The policy indicated, Our abuse prevention/intervention program includes, but is not limited to, the following . j. Assessing, care planning, and monitoring of residents with needs and behaviors that may lead to conflict or neglect; k. Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans that can assist in resolving behavioral issues; . r. Reporting any allegation of abuse or neglect to the State licensing/certification agency .immediately with a brief description of the alleged occurrence. s. Thoroughly investigating each allegation regardless of source or credibility of information . Reporting to the Administrator .5 .Abuse is the 'willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .b. Verbal abuse is defined as any use of oral, written or gestured language . d. Physical abuse is defined as hitting, slapping, pinching, kicking .7. When an incident of resident abuse is suspected or determined, such incident must be reported to the Administrator, or designee, regardless of the time lapse since the incident occurred. 3.1-27(a)(1) 3.1-27(b)

Based on interview and record review, the facility failed to implement the facility's abuse policy and obtained criminal background checks prior to working in the facility for 2 of 10 staff members reviewed. (Certified Nurse Assistant trainee (CNAT) 4 and Dietary Aide (DA) 5) Findings include: 1. An employee records document indicated CNAT 4's start date in the facility was on 11/30/22. 2. An employee record indicated DA 5's start date in the facility was on 10/5/22. CNAT 4 and DA 5's personnel files were provided by Human Resources on 1/23/23 at 3:30 p.m. The files did not include criminal background checks that had been obtained for CNAT 4 nor DA 5 prior to working in the facility. CNAT 4 and DA 5's timecards that provided days worked in the facility were provided by Human Resources on 1/24/23 at 12:02 p.m. CNAT 4's time card indicated she had worked in the building on the following days: 11/30/22, 12/1/22, 12/2/22, 12/7/22, 12/8/22, 12/14/22, 12/15/22, 12/20/22, 12/21/22, 12/22/22, 12/25/22, 12/26/22, 12/27/22, 12/28/22, 12/29/22, 12/30/22, 1/2/23, 1/4/23, 1/5/23, 1/6/23, 1/7/23, 1/8/23, 1/9/23, 1/11/23, 1/12/23, 1/13/23, 1/16/23, 1/18/23, and 1/20/23. DA 5's timecard indicated DA 5 had worked in the facility on the following days: 10/5/22, 10/19/22, 10/20/22, 10/21/22, 10/25/22, 10/27/22, 10/28/22, 11/4/22, 11/5/22, 11/6/22, 11/10/22, 11/11/22, 11/17/22, 11/18/22, 11/19/22, 11/20/22, 11/24/22, 11/25/22, 12/1/22, 12/2/22, 12/03/22, 12/4/22, 12/8/22, 12/9/22, 12/15/22, 12/16/22, 12/17/22, 12/18/22, 12/22/22, 12/30/22, 12/31/22, 1/1/23, 1/5/23, 1/6/23, 1/12/23, 1/13/23, 1/14/23, 1/15/23, 1/19/23, and 1/20/23. An interview was conducted with Human Resources on 1/24/23 at 11:30 a.m. She indicated she was unable to provide background checks that had been obtained for CNAT 4 and DA 5 prior to working in the facility. The abuse policy was provided by the Executive Director on 1/17/23 at 2:03 p.m. It indicated .I. Background Screening Investigations. Our Community will not knowingly hire any individual who has a history of abusing other persons. The Community will conduct employment background screening checks, reference checks and criminal conviction investigation checks on individuals making application for employment with this facility. 1. The Human Resources Consultant, or other person designated by the administrator, will conduct employment background checks, reference checks and criminal conviction checks on persons making application for employment with this Community. Such screening will be initiated prior to employment or offer of employment. 2. When conducting background investigations, our facility may consult any or all of the following agencies: a. Local, state, and/or federal law enforcement agencies; b. Department of pubic safety; c. Banks or other financial institutions; d. Consumer reporting agencies; and e. Other agencies as may become necessary . 3.1-28(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely report a resident's alleged abuse for 1 of 2 incidents reviewed for abuse. (Residents 53 and 73) Findings include: The clinical record for Resident 53 was reviewed on 1/23/23 at 9:52 a.m. Resident 53's diagnoses included, but not limited to, cognitive social or emotional deficit following cerebral infarction (stroke), vascular dementia with behavioral disturbance, generalized anxiety disorder, and delusional disorder. Resident 53's quarterly MDS (minimum data set) dated 8/12/22 indicated, she had moderate cognitive impairment. Resident 53's quarterly MDS dated [DATE] indicated, she had no behaviors. An event note dated 10/29/22 indicated, Resident 53 had aggressively pushed her roommate, Resident 73, while in her wheelchair, out of their room and into the hallway, then shook her fist in Resident 73's face, and Resident 73 screamed. A nursing note dated 10/29/22 at 6:58 p.m. indicated, Resident 53 was moved to another room. A nursing note dated 10/31/2022 at 3:30 p.m. indicated, new orders were received to send Resident 53 to a psychiatric facility related to aggressive behaviors towards Resident 73. A nursing note dated 10/29/2022 at 4:36 p.m. and recorded as a Late Entry on 10/31/2022 at 3:41 p.m. indicated, Resident [sic, Resident 53] was physically aggressive towards roommate [sic, Resident 73] by pushing roommate out of room aggressively while roommate was in her wheelchair[sic] out into hallway then roommate screamed out and this resident shook her fist in roommates face.(sic) resident did not make contact with fist. Resident walked away from roommate . A nursing note from Resident 73's electronic health record (EHR) dated, 10/29/2022 at 4:49 p.m. indicated, QMA [sic, qualified medication assistant] reported to writer that resident stated her roommate pushed her out of her room by her w/c[sic, wheelchair]. Resident stated her finger did get pinched when her w/c[sic] moved. Head to toe shows only a small bruise on 4th finger of her right hand .Resident stated roommate threatens her to beat her up in the middle of the night. Resident stated once that she drew her fist at her and the nurse came in just in time to stop it. ED[sic, Executive Director] and DON[sic, Director of nursing] notified of incident . A Social services note from Resident 73's EHR dated 11/2/2022 at 4:09 p.m. indicated, Resident 73 had been fine since her roommate was no longer in the same room as her. Both Resident 73 and her family had voiced that they did not want Resident 53 to be roommates. An incident report was received on 1/23/23 from ED (Executive Director) at 12:51 p.m. The incident report indicated; the incident date was 11/1/22 at 11:30 a.m. The brief description of incident stated, 11/2/22 (sic, Resident 73's first name) stated to staff that (sic, Resident 53's first name) her roommate at the time pushed her into the hallway while she was seated in her wheelchair. Type of injury added was a small bruise noted on Resident 73's 4th finger of her right hand and was possibly pinched by the wheelchair moving forward. The follow up dated 11/9/22 indicated, Resident 53 and 73 will no longer be roommates. The incident occurred on 10/29/22 but the incident was not reported to the State until 11/1/22. An interview with Resident 73 was conducted on 1/23/23 at 11:00 a.m. She indicated, Resident 53 had Alzheimer's and would get more confused during the night. She stated, when she and Resident 53 were roommates, Resident 53 would turn off the lights and yell at her to stop wasting electricity. She indicated the evenings were most unpleasant and that she had faced her double fists more times than I could count. She stated, since Resident 53 moved out of her room, she tries not to come in direct contact with her but, there have been a few times she wandered into her room in the middle of the night and was trying to get in bed with her new roommate. She indicated, the staff came in and had to redirect her out of the room. Resident 73 stated, I don't want her to terrify my roommate. Resident 73's annual MDS dated [DATE] indicated, she was cognitively intact. An interview with ED (Executive Director) was conducted on 1/23/23 at 12:11 p.m. ED indicated, he didn't believe the incident between Resident 53 and 73 was abuse related to Resident 53 pushing on resident 73's wheelchair and not her person. He further indicated, he did not report the incident between Resident 53 and 73 timely because he was on vacation. An Abuse, Neglect, and Misappropriation Prohibition and Prevention Policy was received on 1/17/23 at 2:03 p.m. from ED. The policy indicated, Our abuse prevention/intervention program includes, but is not limited to, the following . j. Assessing, care planning, and monitoring of residents with needs and behaviors that may lead to conflict or neglect; k. Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans that can assist in resolving behavioral issues; . r. Reporting any allegation of abuse or neglect to the State licensing/certification agency .immediately with a brief description of the alleged occurrence. s. Thoroughly investigating each allegation regardless of source or credibility of information . Reporting to the Administrator .5 .Abuse is the 'willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .b. Verbal abuse is defined as any use of oral, written or gestured language . d. Physical abuse is defined as hitting, slapping, pinching, kicking .7. When an incident of resident abuse is suspected or determined, such incident must be reported to the Administrator, or designee, regardless of the time lapse since the incident occurred. 3.1-28(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly investigate two incidents of alleged abuse for 2 of 2 incidents reviewed for abuse. (Residents 53, 73 and 14) Findings include: The clinical record for Resident 53 was reviewed on 1/23/23 at 9:52 a.m. Resident 53's diagnoses included, but not limited to, cognitive social or emotional deficit following cerebral infarction (stroke), vascular dementia with behavioral disturbance, generalized anxiety disorder, and delusional disorder. Resident 53's quarterly MDS (minimum data set) dated 8/12/22 indicated, she had moderate cognitive impairment. Resident 53's quarterly MDS dated [DATE] indicated, she had no behaviors. 1. An event note dated 10/29/22 indicated, Resident 53 had aggressively pushed her roommate, Resident 73, while in her wheelchair, out of their room and into the hallway, then shook her fist in Resident 73's face, and Resident 73 screamed. A nursing note dated 10/29/22 at 6:58 p.m. indicated, Resident 53 was moved to another room. A nursing note dated 10/31/2022 at 3:30 p.m. indicated, new orders were received to send Resident 53 to a psychiatric facility related to aggressive behaviors towards Resident 73. A nursing note dated 10/29/2022 at 4:36 p.m. and recorded as a Late Entry on 10/31/2022 at 3:41 p.m. indicated, Resident [sic, Resident 53] was physically aggressive towards roommate [sic, Resident 73] by pushing roommate out of room aggressively while roommate was in her wheelchair[sic] out into hallway then roommate screamed out and this resident shook her fist in roommates face.(sic) resident did not make contact with fist. Resident walked away from roommate . A nursing note from Resident 73's electronic health record (EHR) dated, 10/29/2022 at 4:49 p.m. indicated, QMA [sic, qualified medication assistant] reported to writer that resident stated her roommate pushed her out of her room by her w/c[sic, wheelchair]. Resident stated her finger did get pinched when her w/c[sic] moved. Head to toe shows only a small bruise on 4th finger of her right hand .Resident stated roommate threatens her to beat her up in the middle of the night. Resident stated once that she drew her fist at her and the nurse came in just in time to stop it. ED[sic, Executive Director] and DON[sic, Director of nursing] notified of incident . A Social services note from Resident 73's EHR dated 11/2/2022 at 4:09 p.m. indicated, Resident 73 had been fine since her roommate was no longer in the same room as her. Both Resident 73 and her family had voiced that they did not want Resident 53 to be roommates. An incident report was received on 1/23/23 from ED (Executive Director) at 12:51 p.m. The incident report indicated; the incident date was 11/1/22 at 11:30 a.m. The brief description of incident stated, 11/2/22 (sic, Resident 73's first name) stated to staff that (sic, Resident 53's first name) her roommate at the time pushed her into the hallway while she was seated in her wheelchair. Type of injury added was a small bruise noted on Resident 73's 4th finger of her right hand and was possibly pinched by the wheelchair moving forward. The follow up dated 11/9/22 indicated, Resident 53 and 73 will no longer be roommates. An interview with Resident 73 was conducted on 1/23/23 at 11:00 a.m. She indicated, Resident 53 had Alzheimer's and would get more confused during the night. She stated, when she and Resident 53 were roommates, Resident 53 would turn off the lights and yell at her to stop wasting electricity. She indicated the evenings were most unpleasant and that she had faced her double fists more times than I could count. She stated, since Resident 53 moved out of her room, she tries not to come in direct contact with her but, there have been a few times she wandered into her room in the middle of the night and was trying to get in bed with her new roommate. She indicated, the staff came in and had to redirect her out of the room. Resident 73 stated, I don't want her to terrify my roommate. Resident 73's annual MDS dated [DATE] indicated, she was cognitively intact. The investigation file for the incident between Resident 53 and 73 was received on 1/23/23 at 3:04 p.m. The investigation file contained a copy of the incident report and an undated statement from ED (Executive Director). The ED's statement indicated, Staff called discussing incident with [sic, Resident 73's first name] and [sic, Resident 53's first name] . [sic, Resident 53] and [sic, Resident 73] are roommates, so I asked that [sic, Resident 53] be moved to another room. The investigation file did not contain: an interview with the person reporting the incident; any interviews of any witnesses or potential witnesses to the incident including staff, residents, and visitors; interviews with the residents involved; or interviews with staff (on all shifts) who have had contact with the resident before, during, and immediately after the period of the alleged incident. 2. An incident report dated 12/27/22 was received on 1/23/23 from ED at 12:51 p.m. It indicated, on 12/27/22 Resident 14 stated, Resident 53 came into her room, so she grabbed her arm to redirect her when Resident 53 pushed back and caused Resident 14 to move backwards up against her door. No injury was noted. The immediate action taken was a pain and skin assessment was completed on Resident 14. Preventive measure stated, an investigation had been initiated into the interaction between Resident 14 and Resident 53 and a sign had been placed on Resident 53's door to identify it as hers. The follow up dated 1/3/23 indicated, Resident 14 wasn't showing any signs of distress from the incident and interviews conducted with staff didn't coincide with Resident 14's version of the incident. Resident 53 was unable to recall the incident and staff will continue to redirect Resident 53 as needed. A Social services note dated 12/27/2022 at 3:57 p.m. indicated, social services had spoken with Resident 14 that afternoon and asked her if she was still feeling unsafe. Resident 14 replied yes as long as she was still next door to her. Resident 14 stated, she was going to put her chair in front of door as long as Resident 53 was next door to her. A nursing note dated 12/27/2022 at 4:54 p.m. indicated, Resident 14's skin was assessed that morning and no bruising or skin issues were noted. Resident 14 had pointed to her right buttock/hip area and stated, right there, but I haven't bruised yet, but I will later. An interview with Resident 14 was conducted on 1/23/23 at 11:16 a.m. Resident 14 indicated, Resident 53 wanders at nighttime. On 12/26/22, Resident 53 had wandered into Resident 14's room so Resident 14 took Resident 53 by her arm and had guided her back out of her room. She stated, about an hour later, Resident 53 was back in her room near the doorway, so she approached her went to guide her out of her room when Resident 53 shoved me back and she had hit her hip on the walker which was behind her. Resident 14 stated, that area didn't have a bruise but I hurt for days. Resident 14 indicated, when referencing Resident 534 during the nighttime hours that she's like a crazy person at nighttime. She continued by stating, she was afraid of having her live next door to her. She admitted there were a few nights she had put her chair against the door because she was afraid of her. Resident 14's annual MDS dated [DATE] indicated, she was cognitively intact. The investigation file related to Resident 53 and 14's incident contained a copy of the incident report and two handwritten sheets with the names of staff who worked the evening/night shift on 10/26/22 into 10/27/22. The hand written sheets with staff names and possible staff statements were not signed nor dated as to when they occurred of who conducted the interviews. The investigation file did not contain a written and signed statement from Resident 14 An Abuse, Neglect, and Misappropriation Prohibition and Prevention Policy was received on 1/17/23 at 2:03 p.m. from ED. The policy indicated, Our abuse prevention/intervention program includes, but is not limited to, the following . s. Thoroughly investigating each allegation regardless of source or credibility of information . Abuse Investigations 1. Should an incident or suspected incident of resident abuse, neglect .be reported, the Administrator .ensure the immediately protection and safety of the involved resident(s) and will appoint a member of management to investigate the alleged incident while retaining ultimate responsibility for ensuring a timely and thorough investigation . c. Interview the person(s) reporting the incident: d. Interview any witnesses or potential witnesses to the incident including staff, residents, and visitors; e. Interview the resident . g. Interview staff (on all shifts) who have had contact with the resident before, during, and immediately after the period of the alleged incident . 6. The following guidelines will be used when conducting interviews .c. The interview will be documented and, as appropriate, followed up with a written statement from the individual interviewed. 7. Witness reports will be reduced to writing. Witnesses will be required to sign and date such reports when possible. Reporting to the Administrator .5 .Abuse is the 'willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .b. Verbal abuse is defined as any use of oral, written or gestured language . d. Physical abuse is defined as hitting, slapping, pinching, kicking .7. When an incident of resident abuse is suspected or determined, such incident must be reported to the Administrator, or designee, regardless of the time lapse since the incident occurred. 3.1-28(d)

Based on interview and record review, the facility failed to perform a Significant Change of Status Minimum Data Set Assessment for a resident who experienced a fracture with a decline in ADL abilities for 1 of 1 resident reviewed for Minimum Data Set Accuracy (Resident 56) Findings include: The clinical record for Resident 56 was reviewed on 1/18/23 at 11:20 a.m. The Resident's diagnosis included, but were not limited to, diabetes. An Annual MDS (Minimum Data Set) Assessment, completed 9/1/22, indicated Resident 56 needed supervision with eating after staff set up, was able to walk in her room with limited assist of 1 staff person and was able to walk in the hallway with supervision of 1 staff member. A Quarterly MDS Assessment, completed 10/26/22, indicated Resident 56 needed extensive assist of 1 staff member with eating, and did not walk in her room or the corridor during the assessment period. During an interview on 1/20/23 at 10:44 a.m., the MDS Coordinator indicated that a Significant Change of Status MDS Assessment should have been completed instead of the 10/26/22 Quarterly MDS Assessment due to Resident 56 experiencing a fracture in October and having a decline in her ADL abilities. The facility used the RAI (Resident Assessment Instrument) manual as the policy for completing MDS Assessments. The Resident Assessment Instrument Version 1.16, last revised October 2018, read .A 'significant change' is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered 'self-limiting', 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan . 3.1-31(d)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a discharge summary recapitulation of the resident's stay and a final summary of the resident's condition was completed for a resident discharging to home for 1 of 2 residents reviewed for discharge. (Resident B) Findings include: The clinical record for Resident B was reviewed on 1/18/23 at 2:30 p.m. The diagnoses for the resident included, but were not limited to, Parkinson's Disease and dementia. The resident was admitted on [DATE] and discharged on 12/15/22. A nursing progress note dated 12/15/22 indicated Resident [B] discharging facility with wife to home at this time, transport provided by facility bus, all meds sent with resident and additional scripts sent to family's pharmacy of choice by NP [Nurse Practitioner] A discharge summary form for Resident B written by Unit Manager (UM) 2 dated 12/15/22 at 11:15 a.m., indicated Resident B was discharging from the facility to home with home health care. It did not include a clinical discharge narrative, special treatments and procedures or the condition of the resident at discharge. A discharge functional abilities assessment dated [DATE] indicated Resident B's function ability and self-care needed at the time of the discharge. The assessment did not include a recapitulation of the resident's stay nor a final summary of the resident's condition at that time of discharge. During a confidential interview on 1/18/23, She indicated Resident B was discharged from the facility on 12/15/22 to home on hospice care. She had observed that morning, Resident B was not feeling well and had a new red bump on his forehead. After leaving the facility, the resident arrived at the home incontinent with a new skin area to his bottom. An interview was conducted with Nurse Practitioner (NP) 6 on 1/20/23 at 11:14 a.m. She indicated on the morning of 12/15/22, Resident B was discharging to home. She was asked to assess Resident B by his representative due to the resident was running a fever, his CPAP had not been on during the night, and the resident had a small red bump on his forehead. It looked like a pimple. She had pushed on the skin, and it was blanchable. An interview was conducted with UM 2 on 1/20/23 at 2:48 p.m. She indicated Resident B had discharged on 12/15/22 at approximately 11:00 a.m., due to her nursing progress note time stamped at 11:15 a.m. She had documented the progress note shortly after the resident had left the building. The resident was not soiled prior to leaving the building. He did have one spot that was not blanchable on his bottom, and a little red bump on his forehead. She had assessed the little red bump on his forehead that morning, and the CPAP straps aligned placement to the little area on his forehead. She would not have noted the new skin area in the medical chart due to the resident was leaving shortly after. An interview was conducted with the Nurse Consultant (NC) on 1/20/23 at 10:15 a.m. She indicated she was unable to locate a discharge summary and a recap of Resident B's condition at that time of the discharge. A discharge planning policy was provided by the NC on 1/20/23 at 1:44 p.m. It indicated .I. When the community anticipates a resident's discharge to a private residence, another nursing care facility ., a discharge summary and a post discharge plan will be developed which will assist the resident to adjust to his or her living environment. II. The discharge summary will include a recapitulation of the resident's stay at this community and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's: A. Current diagnoses; B. Medical history (including any history of mental disorders and intellectual disabilities); C. Course of illness, treatment and/or therapy since entering the facility; D. Current laboratory, radiology, consultation, and diagnostic test results; E. Physical and mental functional status; F. Ability to perform activities of daily living .G. Sensory and physical impairments ., H. Nutritional status and requirements:, .I. Special treatments or procedures ., J. Mental and psychosocial status ., L. dental condition ., M. Activities potential ., N. Rehabilitation potential ., O. Cognitive status .,P. Medication therapy .XIII. A copy of the following will be provided to the resident and any receiving provider and a copy will be filed in the resident's medical records: A. An evaluation of the resident's discharge needs; B. The post-discharge plan; and C. The discharge summary . This Federal tag relates to Complaint IN00398672. 3.1-36(a)(1) 3.1-36(a)(2)

3. The clinical record for Resident 56 was reviewed on 1/20/23 at 11:57 a.m. Resident 56's diagnoses included, but not limited to, irritable bowel syndrome, congestive heart failure, weakness, and chronic obstructive pulmonary disease. A physician's order dated 8/11/22 indicated to give Resident 56 one 90 milligram capsule of IBgard (peppermint oil) orally three times a day before meals. Resident 56's October and December 2022 MARs (medication administration record) as well as January 2023 MAR were received on 1/24/23 at 9:27 a.m. from NC (nurse consultant). The October 2022 MAR indicated, on the following days and doses, the IBgard medication was unavailable: 10/1/22 - morning dose 10/2/22 - all three doses 10/3/22 - all three doses 10/4/22- all three doses 10/5/22 - all three doses 10/6/22 - all three doses 10/7/22 - dinner dose 10/8/22 - dinner dose 10/9/22 - all three doses 10/10/22 - morning dose 10/11/22 - all three doses 10/12/22- morning dose 10/13/22 - lunch and dinner doses 10/14/22 - morning and dinner doses 10/15/22- morning and dinner doses 10/16/22 - all three doses 10/17/22 - all three doses 10/18/22 - all three doses 10/19/22- all three doses 10/25/22 - lunch dose Resident 56's December 2022 MAR indicated on the following dates and doses the IBgard was unavailable: 12/1/22 - all three doses 12/2/22 - morning and lunch doses 12/17/22 - all three doses 12/18/22 - lunch and dinner doses 12/19 through 12/21/22 - all three doses 12/22/22 - lunch and dinner doses 12/23/22 - morning dose 12/24/22 - morning and dinner doses 12/25/22 - all three doses 12/26/22- all three doses 12/27/22 - morning dose 12/28/22- morning dose 12/29/22 - morning and lunch doses 12/30/22 - all three doses 12/31/22 - lunch and dinner doses Resident 56's January 2023 MAR indicated on the following dates and doses the IBgard was unavailable: 1/1/23 - all three doses 1/2/23 - morning dose 1/3/23 - all three doses 1/4/23 - lunch and dinner doses 1/5/23 - lunch and dinner doses 1/6/23 - morning and lunch doses 1/7/23 - lunch and dinner doses 1/8/23 - morning and lunch doses 1/9/23 and 1/10/23 - all three doses 1/14/23 - all three doses 1/18/23 - all three doses Resident 56's progress notes did not contain any notes regarding IBgard unavailability or communication with pharmacy regarding refills/re-orders. An interview with Pharmacy Technician (Pharm T 32) was conducted on 1/20/23 at 11:22 a.m. Pharm T 32 indicated, Resident 56's IBgard is not on a refill cycle and so it must be requested by nursing when the medication needs to be refilled. She indicated, the last time the IBgard was requested was on 11/30/22 and was filled on 12/1/22. She indicated, when requested and refilled, they send an 8-day supply of the IBgard. She also stated, when that medication was stocked there but, when requested it usually arrived the next day. Prior to the 11/30/22 request, the other more recent filled dates were 11/11/22 and 11/18/22. 3.1-37(a) 2. The clinical record for Resident 62 was reviewed on 1/19/23 at 11:30 a.m. The Resident's diagnosis included, but was not limited to, diabetes. A physician's order, dated 10/5/22, indicated to administer Novolog (type of insulin) Flexpen per sliding scale depending on blood glucose results. If blood sugar was 181 to 240 give 4 units of Novolog. On 1/19/23 at 11:30 a.m., LPN (Licensed Practical Nurse) 16 was observed administering insulin to Resident 62. LPN 16 indicated Resident 62's blood sugar had been 221. LPN 16 removed the Novolog insulin pen from the medication cart, took the cap off of the pen and attached the needle to the pen. LPN 16 then moved the dial on the insulin pen to 4 units. She did not prime the insulin pen prior to moving the dial to 4 units. She then performed hand hygiene and went to Resident 62's room. She donned a pair of disposable gloves and administered the 4 units of insulin to Resident 62. During an interview on 1/19/23 at 11:45 a.m., LPN 16 indicated that she did not normally prime the insulin pen prior to each dose. She only primed the pen when it was first opened. On 1/19/23 at 3:48 p.m., the Nurse Consultant provided the current Licensed Nurse Insulin Pen Skill Validation which read .12. Pulled off needle cap 16. Turn dose selector to 2 units 17. Held the needle pointing up .19. Keep needle pointing upwards, press push-button all the way in [dose selector returns to 0] drop of insulin should appear at the needle tip 20. Turned dose selector to number of units needed to inject, pointer should line up with the dose .22. Pressed the push button all the way in when injected . During an interview on 1/20/23 11:06 a.m., Registered Pharmacist 33 indicated that not priming the insulin pen would cause a small difference in the amount of insulin administered to the patient. Based on observation, interview, and record review, the facility failed to assist a resident with eating, as ordered; prime an insulin pen prior to administering an insulin dose; and administer medication as ordered for 1 of 6 residents reviewed for unnecessary medications, 1 of 1 resident randomly reviewed for injection administration, and 1 of 4 residents reviewed for ADLs (activities of daily living.) (Residents 56, 60, and 62) Findings include: 1. The clinical record for Resident 60 was reviewed on 1/17/23 at 3:21 p.m. His diagnoses included, but were not limited to, Parkinson's disease and dysphagia. The 6/27/22 ADL care plan, last revised 1/5/23, indicated he was unable to independently perform late loss ADLs related to his Parkinson's Disease and required assistance/encouragement for eating. Interventions were to monitor for any eating/swallowing/meal issues and provide assistance and encouragement as needed and report any issues. The 10/25/22 and 1/7/23 Quarterly MDS (Minimum Data Set) assessments indicated he required extensive assistance of one person for eating. The physician's orders read, Please feed resident Three Times A Day, for breakfast, lunch, and dinner, starting 7/26/22. There was an order to weigh the resident weekly, starting 6/24/22 and an order for speech therapy evaluation and treatment, starting 1/10/23. The 1/10/23 Speech Therapy Evaluation indicated his current level of function was that he required supervision at mealtime 91% to 100% of the time. He had no recent weight loss. His vision appeared within functional limits, but he was noted to close his eyes frequently, but responded to verbal cues to open them. He was right-handed; able to make needs known, confused, yet participative, cooperative, and easily distracted. He had reduced recognition of routine/tasks and required consistent instruction. He needed assistance feeding himself. The Clinical Bedside Assessment of Swallowing section of the evaluation indicated for thin liquids that Clinical s/s [signs/symptoms] dysphagia: full staff assist. Staff provided sips of liquids after 2-3 bites and verbally cued patient's attention to task for oral preparation. For Soft & Bite-Sized foods, Clinical s/s dysphagia: Full assist per staff. Patient requires cut solids with ground meat/moist to facilitate PO [by mouth] safety, bolus management. Staff provided setup and total assist with feeding, alternated solids/liquids, provided small bites and extra time. For Minced & Moist Foods, Staff to provide setup and verbal cues to alternate liquids/solids and to take small bites. For supervision, he required supervision/assistance at mealtime due to swallow safety 91% to 100% of the time. He had impaired cognitive skills for problem solving and demonstrated adequate cognitive skills to complete routine/simple living tasks only 0% to 25% of the time. The evaluation indicated a diagnosis of oropharyngeal phase dysphagia. An interview was conducted with CNA (Certified Nursing Assistant) 34 on 1/23/23 at 11:01 a.m. She indicated his ability to eat fluctuated. Sometimes he could do it on his own and sometimes he couldn't. Staff would sometimes provide him with weighted silverware during meals, and that helped him to eat on his own. She didn't think weighted silverware was part of his plan of care, staff just took it upon themselves to provide it. When he used regular silverware, he was more shaky She noticed him needing more assistance with eating in the last few months. He used to eat in the assisted dining room, but was currently eating in the main dining room, where the residents don't need as much assistance. She stated, He does need extra assistance sometimes, and I think he should be in assisted. We as CNAs pop in the main dining room, but we don't sit down and feed them. He'd only been in the main dining room for a week or two. An observation of Resident 60 was made on 1/23/23 at 12:23 p.m. during the lunch meal in the main dining room. He was sitting in his wheelchair at a table, directly across from another resident with his head down. A staff member placed his meal, regular silverware, and 2 drinks in front of him at 12:23 p.m., positioned him closer to the table, and left the table. His meal included ground ham, cheesy potatoes, a bowl of sauerkraut, a slice of red velvet cake, a piece of corn bread, a glass of soda, and a glass of water. By 12:29 p.m., he was not eating or drinking, nor had he attempted to eat or drink. The DM (Dietary Manager) came over to the table and verbally encouraged him to eat, but Resident 60 remained with his head down and did not attempt to eat. At 12:32 p.m., his tablemate continued eating her food, but Resident 60 remained still, with his head down, and was not attempting to eat. The DM came back to the table, then left and walked over to a sink in the dining room. At 12:36 p.m., Resident 60 remained at the table with his head down and had not attempted to eat. All of the food he was served remained untouched. At 12:37 p.m., the DM came back to the table, bent down beside him, left the table, and came back to the table. At 12:38 p.m., the DM asked Resident 60 if he was going to eat. Resident 60 then picked up his cup of soda and took a sip. The DM patted him on the back. Another staff member approached the table, picked up his fork and demonstrated picking up a bite of food. Resident 60 then picked up his spoon with his left hand, retrieved some potatoes, and placed them into his mouth. A staff member then placed a clothing protector on him at 12:42 p.m., as Resident 60 now had potatoes on his left thumb. At 12:43 p.m., Resident 60 put his spoon down on the table after having taken 3 bites of potatoes. A second observation of Resident 60 was made on 1/23/23 at 12:53 p.m. Resident 60 remained sitting at the table but was not eating. At 12:54 p.m., CNA 34 approached the table and encouraged him to open his eyes. CNA 34, while kneeling on the floor, retrieved a spoonful of potatoes and placed the spoon in his mouth. CNA 34 then fed him another bite and continued to encourage him to open his eyes. CNA 34 then suggested he try the cake, retrieved a bite of cake and fed him the bite while standing. CNA 34 then went to another table, got a chair and began feeding him at 12:56 p.m. At 12:58 p.m., CNA 34 continued to encourage him to eat, but was no longer feeding him. A third observation was made in the main dining room on 1/23/23 at 1:12 p.m. Resident 60 was no longer there. The majority of his food remained at his table place. The NC (Nurse Consultant) provided Resident 60's 1/23/23 lunch meal ticket. It indicated he ate 10% of his meal and 120 ml of fluid. An interview was conducted with the NC and DON (Director of Nursing) on 1/23/23 at 1:00 p.m. The DON indicated Resident 60 moved to the main dining room from the assisted dining room last week, per his daughter's request. His daughter thought he would eat better having interactions with other tablemates. His daughter was typically there with him and felt like he belonged in a higher functioning setting. The NC indicated staff was aware he may need more assistance, but to provide him one on one care during meals was not always possible. There were plenty of staff in the main dining room, but not enough to feed residents. An interview was conducted with NP (Nurse Practitioner) 6 on 1/23/23 at 2:43 p.m. She indicated she was tired of seeing him sitting in the dining room with his food sitting in front of him, so she wrote the order to feed him 3 times a day. Sometimes he did okay feeding himself, but she wanted him fed three times a day. She was unaware he was moved into the main dining room from the assisted dining room. He liked social interaction, so was not opposed to him being in the main dining room. Now that she knew he was moved, she could put him on weights 3 times weekly for 2 weeks and to report any loss. The facility should have informed her they switched dining rooms. If she had known, she would have informed nursing they needed to make sure he was eating. She stated, They should have let me know, so I could change the order for weights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure monitoring of urine outputs for a resident with a catheter for 1 of 1 resident reviewed for catheters. (Resident B) Findings include: The clinical record for Resident B was reviewed on 1/18/23 at 2:30 p.m. The diagnoses for the resident included, but were not limited to, Parkinson's Disease and dementia. The resident was admitted on [DATE] and discharged on 12/15/22. A urinary incontinence care plan for Resident B dated 12/5/22 indicated Resident has urinary incontinence and requires staff assist with toileting and toileting hygiene .Approach .Monitor I (intakes) and O (outputs) per facility protocol A I and O care plan for Resident B dated 12/1/22 indicated the staff was to accurately document intakes and outputs on the following shifts and times: day shift = 6:30 a.m. - 2:30 p.m., evening shift = 2:30 p.m. -10:30 p.m., night shift =10:30 p.m. - 6:30 a.m. A physician order dated 11/30/22 indicated Resident B was to have a 16 French catheter due to urinary retention. The vitals report for urine outputs for Resident B's catheter indicated the following days and shifts there were no urine output recorded on every shift: 12/1/22 8:25 a.m., - staff recorded large, 12/2/22 day and evening shift, 12/3/22 - day and evening shift, 12/4/22 - evening shift, 12/6/22 - day shift, 12/7/22 - evening shift, 12/9/22 - evening shift, and 12/14/22 - night shift An interview was conducted with Unit Manager 2 on 1/20/22 at 2:48 p.m. She indicated she thought the staff should at least record outputs twice a day. This Federal tag relates to Complaint IN00398672. 3.1-41(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure CPAP (a machine that assists with breathing utilizing air pressure) was placed on a resident as ordered for 1 of 1 resident's reviewed for respiratory care. (Resident B) Findings include: The clinical record for Resident B was reviewed on 1/18/23 at 2:30 p.m. The diagnoses for the resident included, but were not limited to, Parkinson's Disease and dementia. The resident was admitted on [DATE] and discharged on 12/15/22. A care plan for Resident B dated 12/5/22 indicated Resident has a diagnosis of sleep apnea and is at risk for respiratory difficulties or distress .Approach .Apply CPAP or Bipap (advice that assists with breathing utilizing air pressure) as ordered . A physician order for Resident B dated 11/30/22 indicated Home CPAP via home orders to be worn at HS (night) and for naps, staff to assist resident in applying face mask and turning machine on dx [diagnosis] obstructive sleep apnea discontinued on 12/6/22 A physician order for Resident B dated 12/6/22 indicated Staff was to apply CPAP machine on resident utilizing home settings and equipment. The settings were 15 cmh20 ramp 15 minutes (centimeters of water pressure and gradual increase measurement ). Start 9.0cm h20 with humidity room air. Discontinued after discharge 12/15/22. The November 2022 and December 2022 Medication and Treatment Records (MAR/TAR) for Resident B indicated the staff had documented CPAP placement until the order had discontinued on 12/6/22. Resident B's clinical record did not include documentation of the CPAP placement after 12/6/22. During a confidential interview on 1/18/23, She indicated staff was not ensuring Resident B wore the CPAP during sleeping hours. It was observed on 12/2/2, the resident's CPAP was not placed on the resident. On the morning of 12/15/22, Resident B was also observed not wearing the CPAP. It had been recorded; it had been off approximately since 2:00 a.m. An interview was conducted with Nurse Practitioner (NP) 6 on 1/20/23 at 11:14 a.m. She indicated on the morning of 12/15/22, she was asked to assess Resident B by his representative due to the resident was running a fever and his CPAP had not been on. He was in the process of discharging that morning. NP 6 had offered to do an x-ray, but the representative had declined. She just wanted to proceed with the discharge. An interview was conducted with the Nurse Consultant on 1/20/23 at 10:15 a.m. She indicated the 12/6/22 CPAP order was placed for Resident B, but in error it was not showing up on MAR/TAR. This Federal tag relates to Complaint IN00398672. 3.1-47(a)(6)

Based on interview and record review, the facility failed to assure a resident had adequate indication for use of an antibiotic and did not receive duplicate antibiotic therapy for 1 of 2 residents reviewed for urinary tract infections (Resident 77). Findings include: The clinical record for Resident 77 was reviewed on 1/17/23 at 2:30 p.m. The Resident's diagnosis included, but was not limited to, dementia and personal history of urinary tract infections. A physician's order, dated 6/2/22, indicated she was to receive nitrofurantoin macrocrystal (antibiotic) 50 md (milligram) daily for prophylactic due to diagnosis of personal history of urinary tract infection. This order was discontinued on 1/18/23. A care plan, dated 6/03/22, indicated Resident 77 had a history of urinary tract infections and was prescribed a prophylactic antibiotic. The goal was for her to be free from symptoms of UTI (urinary tract infections). The approaches, initiated 6/03/22, were to assist with incontinent care, to report continued or worsening symptoms of UTI, report adverse side effects of antibiotic, encourage fluids, and administer antibiotics as ordered. A Quarterly MDS (Minimum Data Set) Assessment, completed 10/26/22, indicated she had severely impaired cognition, needed extensive assistance of one staff member for toilet use, had not had a urinary tract infection in the last 30 days, and had received antibiotics for all 7 days of the assessment period. An Infection Control Event Report, dated 10/31/22, indicated Resident 77 had a possible UTI. The symptoms had started on 10/28/22. She had received Keflex (antibiotic) and Rocephin (Antibiotic). A culture had been performed. She had foul smelling urine, and the intervention was antibiotic treatment. A CBC (Complete Blood Count), completed 10/30/22, indicated she had elevated white blood cells of 14.2 with the normal reference range being 4.5-11.0. A urinalysis, completed 10/31/22, indicated that her urine was yellow and cloudy. it was negative for ketone, blood, protein, nitrite, and leukocytes. There were trace ketones, which was the only abnormal result. There was no culture and sensitivity complete to identify an organism or bacteria. A physician's order, dated 11/1/22, indicated she was to receive cephalexin (Keflex antibiotic) 500 mg twice daily for personal history of urinary tract infections. The November 2022 MAR (Medication Administration Record) indicated Resident 77 had received Cephalexin 500 mg on 11/2/22 in the morning and before bedtime, 11/3 in the morning and at bedtime, 11/4 in the morning, and 11/5 in the morning and at bedtime. The November 2022 MAR indicated she had received nitrofurantoin daily on 11/1/22 through 11/30/22, with the exception on 11/11, 11/13, 11/14, and 11/23/22. A Quarterly MDS Assessment, completed 11/8/22, indicated Resident 77 was severely cognitively impaired, had not had a urinary tract infection in the last 30 days, and had received an antibiotic for all 7 days of the assessment period. A physician's order, dated 1/14/23, indicated to obtain a urinalysis with culture and sensitivity. A physician's order, dated 1/14/23, indicated Resident 77 was to receive Bactrim DS (antibiotic) 800-160 mg, twice daily for five days for chronic kidney disease, with a discontinuation date of 1/16/23. A physician's order, dated 1/14/23, indicated Resident 77 was to receive ceftriaxone (antibiotic) 1 gram injection one time only on 1/14/22. A nursing progress note, dated 1/14/23 at 7:38 a.m., indicated Resident 77 had a urinalysis collected and sent to the lab. She had received the 1-time dose on ceftriaxone injection in the left buttock. A urine culture, dated 1/16/23, indicated Resident 77 had Escherichia Coli present in her urine that possessed ESBL (Extended Spectrum Beta-Lactamases), which could potentially become resistant to all beta-lactam drugs. The sensitivity indicated the organism was resistant to the following antibiotics: ampicillin, cefazolin, cefepime, ceftazidime, ceftriaxone, ciprofloxacin, levofloxacin, nitrofurantoin, and trimethoprim/ sulfamethoxazole. A physician's order, dated 1/16/23, indicated she was to receive ertapenem (antibiotic) 1 gram reconstituted with lidocaine (numbing medication) one time on 1/16/23. A physician's order, dated 1/17/23, indicated she was to receive ertapenem 1 gram, reconstituted with lidocaine, one time on 1/17/23. A physician's order, dated 1/18/23, indicated she was to receive ertapenem 1 gram, reconstituted with lidocaine, one time on 1/18/23. A physician's order, dated 1/17/23, indicated to institute contact isolation precautions related to her being positive for ESBL in her urine. A care plan, dated 1/17/23, indicated Resident 77 has ESBL. The goal was for her to be free of symptoms of UTI upon completion of antibiotics. On 1/17/23 at 2:00 p.m., Resident 17 was observed sitting in a chair in the common area. She was bent over with her head on the arm of the chair. A visitor was talking to her, and she did not respond. The visitor continued to talk with her and try to arise her. The visitor asked the staff to assist with waking her up. She did wake up and walk down the hall to visit. The January 2023 MAR indicated she had received nitrofurantoin 50 mg daily from 1/1/23 through 1/18/23 with the exception of 1/3/23 and 1/10/23, Bactrim (sulfamethoxazole/trimethoprim) 800/160 mg twice on 1/15/23 and once on 1/16/23, and ertapenem 1 gram on 1/16, 1/18, and 1/19/23. A nurse practitioner progress note, dated 1/18/23 at 4:49 p.m., indicated Resident 77 was seen for a follow up for UTI with ESBL and treatment with ertapenem 1 gram intramuscularly for 3 days. A new order was given to discontinue macrodantin (nitrofurantoin), as she has developed resistance to drug with ESBL E. Coli (Escherichia Coli). An Infection Event Progress Note, dated 1/19/23 at 2:40 p.m., indicated Resident 77 was very lethargic on that shift and unable to ambulate (walk). She had a poor appetite. An Infection Event Progress Note dated 1/19/23 at 6:32 p.m., indicated that NP (Nurse Practitioner) 9 had given an order to discontinue the ertapenem because Resident 77 had received all the doses required. A nurse practitioner progress note, dated 1/20/23 at 11:10 a.m., indicated Resident 77 was treated with ertapenem for 3 days only. She exhibited decreased function in dexterity after the third dose with neurological side effects of antibiotic. During an interview on 1/23/22 at 3:52 p.m., NP (Nurse Practitioner) 9 indicated she was unsure if she had been made aware of the negative urinalysis on 10/31/22. She had prescribed the Keflex due to leukocytosis (high white blood cells). It was not her normal pattern to prescribe Keflex for 5 days. Resident 77 had also received the nitrofurantoin. The nitrofurantoin had been prescribed as a prophylactic to head off infections due to her increased behaviors. She had discontinued it when she reviewed the culture which indicated Resident 77 had ESBL which was resistant to it. She was unsure if the prophylactic use had contributed to the development of the resistance. She had prescribed ertapenem to treat the ESBL E. Coli because it had the best sensitivity, but that the drug could be very neurotoxic (poisonous to the nervous system). Resident 77 had received 3 doses of it instead of 5 doses because her mental status had declined. The facility had discussed antibiotic stewardship with her and the Mc Geer's criteria. During an interview on 1/24/23 at 10:45 a.m., QMA (Qualified Medication Aide) 15 indicated that Resident 77 had been up for breakfast but kept falling asleep and had to be laid back down. She was unsure what was going on with Resident 77, but she had been declining. During an interview on 1/24/23 at 12:45 p.m., the IP (Infection Preventionist) indicated the Keflex Resident 77 had received in November had not met the Mc Greer's criteria for a urinary tract infection. She expected that antibiotic orders to the medication, dose, how many days it should be administered and the diagnosis. If culture and sensitivity was done, then the nurse practitioner would use that to prescribe the appropriate antibiotic. 3.1-48(a)(1) 3.1-48(a)(2) 3.1-48(a)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer a resident's antibiotic, as ordered, to 1 of 6 residents reviewed for unnecessary medications. (Resident L) Findings include: The clinical record for Resident L was reviewed on 1/19/23 at 10:56 a.m. His diagnoses included, but were not limited to, anxiety. He was admitted to the facility on [DATE] for aftercare following a joint replacement surgery revision. An interview was conducted with Resident L on 1/20/23 at 9:41 a.m. He indicated he did not receive his IV (intravenous) antibiotic as ordered for at least 3 days while at the facility. The 9/23/22 hospital discharge summary, signed 9/26/22 at 9:01 a.m., indicated he was admitted to the hospital on [DATE] with a diagnosis of infected right total hip arthroplasty. He underwent a resection hip arthroplasty with insertion of antibiotic-impregnated cement spacer. He was placed on IV antibiotics throughout the entire hospitalization. Infectious disease [ID] was consulted. The selection of the most appropriate antibiotic regimen was carried out by the Infectious Disease Service, as well as dosing, monitoring and safety of the antibiotics and PICC [peripherally inserted central catheter] line The patient was believed to be discharged to rehab [rehabilitation] after he was approved by [name of facility] in [name of a city.] Instead, the patient went home after discharge from the hospital, transported by his daughter Information regarding the care of the PICC line, antibiotic administration and appropriate follow up was provided by the infectious disease service Home Medications .vancomycin 1 GM [gram] = 10 mL [milliliters,] IVPB [intravenous piggyback,] Q12H [every 12 hours,] last dose 11/2/22 IV Antibiotics will continue to [sic] dosed, managed and monitored by the infectious disease department under the direction of [name of ID physician] for a total of 6 weeks postoperatively. The medication and dosing has been reviewed with the patient. FOLLOWUP: The patient will follow up for a two-week follow-up visit for wound inspection and general recovery. The facility's physician orders indicated to administer vancomycin intravenously twice a day upon rising and before bedtime, starting 9/25/22 through 10/19/22. The October, 2022 MAR (medication administration) indicated the vancomycin was not administered on the following dates and times due to the medication being unavailable: before bedtime on 10/5/22, at bedtime on 10/8/22, upon rising on 10/19/22, before bedtime on 10/10/22, and before bedtime on 10/12/22. The MAR indicated the vancomycin was not administered before bedtime on 10/11/22 due to IV completed. The 10/3/22 orthopedic note indicated, Good hygiene and timely IV antibiotics are pertinent to helping him clear his peri-prosthetic infection. An interview was conducted with the DON (Director of Nursing) on 1/19/23 at 3:20 p.m. She indicated she was unsure why the vancomycin was not administered as ordered. The 9/27/22 IV antibiotic care plan, discontinued on 11/3/22, indicated he required IV antibiotics related to infection and inflammatory reaction due to internal right hip prosthesis. An intervention was to administer the IV medication as ordered. The Licensed Nurse Medication Pass Clinical Skills Validation was provided by the NC (Nurse Consultant) on 1/23/23 at 9:57 a.m. Step 29 was to ensure medication was given within the 60 minutes before or after the time designated unless otherwise directed by the physician. This Federal Tag relates to Complaint IN00393035. 3.1-48(c)(2)

Based on observation, interview, and record review, the facility failed to assure the hub of an insulin pen was cleansed prior to attaching the needle, perform hand hygiene and don disposable gloves before touching medications for 2 residents randomly observed during medication administration (Resident 62 and 222). Findings include: 1. The clinical record for Resident 62 was reviewed on 1/19/23 at 11:30 a.m. The Resident's diagnosis included, but was not limited to, diabetes. On 1/19/23 at 11:30 a.m., LPN (Licensed Practical Nurse) 16 was observed administering insulin to Resident 62. LPN 16 removed the insulin pen from the medication cart, took the cap off of the pen and attached the needle to the pen. She did not cleanse the hub of the insulin pen with an alcohol swab prior to attaching the needle. She then performed hand hygiene and went to Resident 62's room. She donned a pair of disposable gloves and administered the insulin to Resident 62. During an interview on 1/19/23 at 11:45 a.m., LPN 16 indicated that she did not cleanse the hub of the insulin pen prior to attaching the needle. On 1/19/23 at 3:48 p.m., the Nurse Consultant provided the current Licensed Nurse Insulin Pen Skill Validation which read .12. Pulled off pen cap 13. Wiped rubber stopper with alcohol swab 14. Removed protective cover from disposable needle and screw on pen . 2. The clinical record for Resident 222 was reviewed on 1/20/23 at 9:11 a.m. The Resident's diagnosis included, but were not limited to, dysphagia (inability to swallow) and heart failure. On 1/20/23 at 9:11 a.m., LPN 1 was observed administering medications to Resident 222. LPN 1 went to a sink and performed hand hygiene, washing her hands with soap and water. When she finished washing her hands, she removed paper towel from the dispenser and turned off the water using the paper towel. She then used those paper towels to dry her hands and threw them away. LPN 1 then went to the medication cart and opened the cart with the keys from her pocket. She removed Resident 222's medications from the drawer. She opened the medications and put them into a plastic medications cup. While opening the medications packages, LPN 1 readjusted the surgical mask on her face several times and did not perform hand hygiene after touching her surgical mask. LPN 1 then indicated Resident 222 required her medication to be crushed. LPN 1 crushed the tablets and indicated she needed to open the capsules to place them in the applesauce. LPN 1 picked up a fish oil capsule, with her bare hands, no hand hygiene was performed, and attempted to use a lancet to puncture the capsule but was unable to squeeze the oil out of the capsule. LPN 1 indicated that normally she would use scissors to cut the capsule open in order to open the capsules. She withdrew pink handled scissors from the draw of the medication cart and wiped them with an alcohol swab. LPN 1 then wiped the scissors with a tissue from the tissue box on the medication cart to dry the alcohol off of the scissors. She took the fish oil capsule, in her bare hands without performing hand hygiene, and cut the end of the fish oil capsule. LPN 1 squeezed the capsule contents into the applesauce. LPN 1 then picked up the PreserVision Vitamin with her bare hand and cut it open, squeezing the contents into the apple sauce. LPN 1 then picked up the Florastor (supplement) and pulled the capsule open, using her bare hands, to empty the contents into the applesauce. LPN 1 then performed hand hygiene with alcohol get and stirred the applesauce containing the medications. LPN 1 administered the medications to Resident 22. On 1/20/23 at 3:14 p.m., the Nurse Consultant provided the current Handwashing/ Handrub Procedure which read .1. Turn on faucet .11. Rinse hands with water down from wrists to fingertips. 12. Dry thoroughly with single use towels. 13. Use towel to turn off faucet and discard towel . On 1/20/23 at 3:14 p.m., the Nurse Consultant provided the current Licensed Nurse Med Pass Clinical Skills Validation which read .6. Check medication administration record. 7. Gel hands 16. Tablets and capsules were handled so that fingers do not touch medication . This Federal Tag relates to Complaint IN00398672 3.1-18(b)(1) 3.1-18(l)

Based on interview and record review, the facility failed to implement an effective antibiotic stewardship program to include monitoring trends in antibiotic resistance and implementing a Quality Assurance and Performance Improvement program to address antibiotic usage for 1 of 2 residents reviewed for urinary tract infections and 1 of 5 residents reviewed for unnecessary medications (Resident 76 and 77). For more information about Resident 77 cross reference F 757. Findings include: 1. The clinical record for Resident 76 was reviewed on 1/17/23 at 3:00 p.m. The Resident's diagnoses included, but were not limited to, urinary tract infection and dementia. A Quarterly MDS (Minimum Data Set) Assessment, completed 10/25/22, indicated she had severely impaired cognition and required extensive assistance of 2 staff members for toileting. A physician's order, dated 11/10/22, indicated a urine culture was to be obtained for Resident 76. A urinalysis with a culture and sensitivity, dated 11/13/22, indicated Resident 76 had an organism identified as Escherichia Coli present in her urine that possessed ESBL (Extended Spectrum Beta-Lactamases), which could potentially become resistant to all beta-lactam drugs. The sensitivity indicated the organism was resistant to the following antibiotics: ampicillin, cefazolin, ceftazidime, ceftriaxone, ciprofloxacin, levofloxacin, and trimethoprim/ sulfamethoxazole. A physician's order, dated 11/14/22, indicated Resident 76 was to receive nitrofurantoin macrocrystal (antibiotic) 100 mg (milligrams) twice a day. The November 2022 Medication Administration Record indicated she had received nitrofurantoin 100 mg twice daily from 11/14/22 through 11/18/22. 2. The clinical record for Resident 77 was reviewed on 1/17/23 at 2:30 p.m. The Resident's diagnoses included, but was not limited to, dementia and personal history of urinary tract infections. A physician's order, dated 6/2/22, indicated she was to receive nitrofurantoin macrocrystal (antibiotic) 50 md (milligram) daily for prophylactic due to diagnosis of personal history of urinary tract infection. This order was discontinued on 1/18/23. An Infection Control Event Report, dated 10/31/22, indicated Resident 77 had a possible UTI. The symptoms had started on 10/28/22. She had received Keflex (antibiotic) and Rocephin (Antibiotic). A culture had been performed. She had foul smelling urine, and the intervention was antibiotic treatment. A CBC (Complete Blood Count), completed 10/30/22, indicated she had elevated white blood cells of 14.2 with the normal reference range being 4.5-11.0. A urinalysis, completed 10/31/22, indicated that her urine was yellow and cloudy. it was negative for ketone, blood, protein, nitrite, and leukocytes. There were trace ketones, which was the only abnormal result. There was no culture and sensitivity complete to identify an organism or bacteria. A physician's order, dated 11/1/22, indicated she was to receive cephalexin (Keflex antibiotic) 500 mg twice daily for personal history of urinary tract infections. The November 2022 MAR (Medication Administration Record) indicated Resident 77 had received Cephalexin 500 mg on 11/2 in the morning and before bedtime, 11/3 in the morning and at bedtime, 11/4 in the morning, and 11/5 in the morning and at bedtime. The November 2022 MAR indicated she had received nitrofurantoin daily on 11/1/22 through 11/30/22, with the exception on 11/11, 11/13, 11/14, and 11/23/22. A physician's order, dated 1/14/23, indicated to obtain a urinalysis with culture and sensitivity. A physician's order, dated 1/14/23, indicated Resident 77 was to receive Bactrim DS (antibiotic) 800-160 mg, twice daily for five days for chronic kidney disease, with a discontinuation date of 1/16/23. A physician's order, dated 1/14/23, indicated Resident 77 was to receive ceftriaxone (antibiotic) 1 gram injection one time only on 1/14/22. A nursing progress note, dated 1/14/23 at 7:38 a.m., indicated Resident 77 had a urinalysis collected and sent to the lab. She had received the 1-time dose on ceftriaxone injection in the left buttock. A urine culture, dated 1/16/23, indicated Resident 77 had Escherichia Coli present in her urine that possessed ESBL (Extended Spectrum Beta-Lactamases), which could potentially become resistant to all beta-lactam drugs. The sensitivity indicated the organism was resistant to the following antibiotics: ampicillin, cefazolin, cefepime, ceftazidime, ceftriaxone, ciprofloxacin, levofloxacin, nitrofurantoin, and trimethoprim/ sulfamethoxazole. A physician's order, dated 1/16/23, indicated she was to receive ertapenem (antibiotic) 1 gram reconstituted with lidocaine (numbing medication) one time on 1/16/23. A physician's order, dated 1/17/23, indicated she was to receive ertapenem 1 gram, reconstituted with lidocaine, one time on 1/17/23. A physician's order, dated 1/18/23, indicated she was to receive ertapenem 1 gram, reconstituted with lidocaine, one time on 1/18/23. The January 2023 MAR indicated she had received nitrofurantoin 50 mg daily from 1/1/23 through 1/18/23 with the exception of 1/3/23 and 1/10/23, Bactrim (sulfamethoxazole/trimethoprim) 800/160 mg twice on 1/15/23 and once on 1/16/23, and ertapenem 1 gram on 1/16, 1/18, and 1/19/23. A nurse practitioner progress note, dated 1/18/23 at 4:49 p.m., indicated Resident 77 was seen for a follow up for UTI with ESBL and treatment with ertapenem 1 gram intramuscularly for 3 days. A new order was given to discontinue macrodantin (nitrofurantoin), as she has developed resistance to drug with ESBL E. Coli (Escherichia Coli). During an interview on 1/23/23 at 3:52 p.m., NP (Nurse Practitioner) 9 indicated she was unsure if she had been made aware of Resident 77's negative urinalysis on 10/31/22. She had prescribed the Keflex due to leukocytosis (high white blood cells). It was not her normal pattern to prescribe Keflex for 5 days. Resident 77 had also received the nitrofurantoin. The nitrofurantoin had been prescribed as a prophylactic to head off infections due to her increased behaviors. She had discontinued it when she reviewed the culture which indicated Resident 77 had ESBL which was resistant to it. She was unsure if the prophylactic use had contributed to the development of the resistance. She had prescribed ertapenem to treat the ESBL E. Coli because it had the best sensitivity, but that the drug could be very neurotoxic (poisonous to the nervous system). Resident 77 had received 3 doses of it instead of 5 doses because her mental status had declined. The facility had discussed antibiotic stewardship with her and the Mc Geer's criteria On 1/24/23, the IP (Infection Preventionist) provided the October, November, and December 2022 Infection Control Data logs for the facility. She indicated that she did not specifically track ESBL infections on the infection control data logs. She monitored the Infection Events and the laboratory results to identify organisms that had caused infections. She did not receive reports from the pharmacy about antibiotic trends. She did not receive reports from the laboratory about infection trends in the facility. She discussed the facility antibiotic use monthly with the Director of Nursing Services, the Minimum Data Set Coordinator, and the Executive Director. The Medical Director, Pharmacist, and Nurse Practitioners did not normally attend the meeting where the antibiotic trends were discussed. The October 2022 Infection Control Data Log indicated there had been a total of 24 infection for the month. 7 of the infections did not meet the McGeer's criteria. There had been 12 urinary tract infections, which represented 50% of the facilities infections for the month of October. The November 2022 Infection Control Data Log indicated that there had been a total of 21 infections for the month. 6 of the infections did not meet the McGeer's criteria. There had been 11 urinary tract infections which represented 52% of the facilities infections for the month of November. The December 2022 Infection Control Data Log indicated that there had been a total of 32 infections for the month. 13 of the infections did not meet the McGeer's criteria. There had been 15 urinary tract infections, which represented 47% of the facilities infections for the month of November. During an interview on 1/24/23 at 11:07 a.m., the IP indicated she used the McGeer's criteria to determine if there was a true infection. She reviewed infections and made a progress note to if the infection met the criteria or not. The nurse practitioners came in while the residents were receiving antibiotics to evaluate them. She communicated to the nurse practitioners if the infections met the criteria for a true infection and if the resident was getting better or not. During an interview on 1/24/23 at 12:45 p.m., the Nurse Consultant and the Executive Director indicated that the Medical Director did not come to the QAPI (Quality Assurance and Performance Improvement) meetings and there was not an active action plan concerning urinary tract infections, antibiotic use, or antibiotic resistant bacteria. On 1/17/23 at 2:03 p.m., the Executive Director provided the Infection Prevention and Control Program Policy, dated 6/6/2019, which read .The elements of the infection prevention and control program consist of coordination and oversight, policies and procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety .C. The infection Prevention and Control Committee is responsible for reviewing and providing feedback on the overall program. 1. Surveillance data and reporting information is used to inform the committee of potential issues and trends. Some examples of committee reviews may include: a. Whether physician management of infections is optimal, b. Whether antibiotic use patterns need to be changed because of the development of resistant strains; c. Whether information about culture results or antibiotic resistance is transmitted accurately and in timely fashion, and d. Whether there is appropriate follow-up of acute infections. 2. The committee meets regularly, at least quarterly, and consists of team members from across disciplines, including the Medical Director Antibiotic Stewardship .A. Culture reports, sensitivity data, and antibiotic usage reviews are included in surveillance activities. B. Medical criteria and standardized definitions of infections are used to help recognize and manage infections. C. Antibiotic usage is evaluated, and practitioners are provided feedback on reviews . On 1/24/23 at 10:00 a.m., the IP provided the Infection Control Antibiotic Stewardship (page 38) policy which was undated, it read . Antibiotic Stewardship refers to a set of commitments and activities designed to 'optimize the treatment of infections while reducing the adverse events associated with antibiotic use.' . The IP [sic] and QA [sic] team is committed to provide our residents with safe and appropriate antibiotic usage in our communities. The QA [sic] committee will review the usage in the facility monthly and provide interventions to help reduce the usage of antibiotics in the facility .Quarterly, the prescribing physicians will receive a report of their ATB [sic] usage in the facility to better help with the proper prescribing of antibiotics .