Based on observation, interview, and record review, the facility failed to ensure a cognitively impaired resident was provided services to maintain a dignified existence related to available clothing for 1 of 3 residents reviewed for activities of daily living. (Resident 47) Finding includes: During an observation on 1/27/25 at 10:52 a.m., Resident 47 wore a gray long sleeve shirt and lounge pants as he walked out of his room. During an observation on 1/28/25 at 10:09 a.m., the resident wore gray long sleeve shirt and white/black plaid/checkered lounge pants, unchanged from the previous day, as he participated in an activity in the dining area. During an interview on 1/28/25 at 10:51 a.m., the resident tugged on his shirt and indicated that he did not have a change of clothing. The resident opened his drawer, which contained a blue polo Special Olympics shirt with his name on it. The resident opened his closet, which contained a tote with a button-up dress shirt. No other clothing items were observed in the resident's room. Resident 47's clinical record was reviewed on 1/28/25 at 3:03 p.m. Diagnoses included dementia, cerebral infarction, and mild intellectual disabilities. An annual Minimum Data Set (MDS) assessment, dated 12/4/24, indicated the resident had moderate cognitive impairment. The resident required partial assistance from staff for toileting, lower body dressing, and personal hygiene. The resident required supervision from staff for upper body dressing. The resident had frequent urinary and bowel incontinence. A current care plan, dated 11/29/24, indicated the resident required assistance and/or monitoring with morning care, evening care, and elimination. Interventions included, morning cares to include bathing and dressing (11/29/24), and evening cares to include bathing and dressing (11/29/24). A current care plan, dated 12/5/24, indicated the resident was unable to make daily decisions without cues and supervision. Interventions included, encourage resident to self-evaluate decisions made (12/5/24). A current care plan, dated 12/5/24, indicated the resident had absence of personal contact with sisters as they live out of town. Interventions included, Provide opportunity for resident to express feelings (12/5/24) A current care plan, dated 12/6/24, indicated the resident required assistance from staff with activities of daily living (ADL's) related to dementia and intellectual disability. Interventions included, provide assistance with dressing, grooming, and hygiene as needed (12/6/24). A Nurse's note, dated 11/27/24 at 3:40 p.m., indicated Resident 47 arrived at the facility from another nursing facility, and had brought belongings with him. The belongings were placed in his room. Review of Resident 47's inventory log, dated 12/6/24, indicated the following clothing items: 15 blouses/shirts, 1 pair of shorts, 1 slacks/trousers, 1 sweat/lounge top, 1 sweater/blazer, 2 undershirts, 1 pair of jeans, and a jean jacket. During an observation on 1/29/25 at 9:46 a.m., the resident wore a gray long sleeve shirt and white/black plaid/checkered lounge pants, unchanged from the previous observations, as he sat at a table in the dining area. During an interview on 1/29/25 at 3:47 p.m., CNA 4 indicated Resident 47 needed supervision to limited assistance from staff for activities of daily living. The resident was continent most of the time. He dressed himself and she believed that he had adequate clothing available. Staff was required to report to a nurse if a resident was without adequate clothing/personal items. During an interview on 1/29/25 at 3:47 p.m., CNA 5 indicated Resident 47 needed supervision to limited assistance from staff for activities of daily living. The resident was continent most of the time. He dressed himself and she believed that he had adequate clothing available. Staff was required to report to a nurse if a resident was without adequate clothing/personal items. During an observation on 1/30/25 at 9:46 a.m., the resident wore a gray long sleeve shirt and white/black plaid/checkered lounge pants, unchanged from the previous observations, as he participated in an activity in the dining area. During an interview on 1/30/25 at 11:31 a.m., CNA 6 indicated the resident lacked the ability to follow directions and often needed cued or a demonstration of the task to be completed. She gave the resident a shower on 1/27/25. The clothing that the resident had been wearing this week was obtained from the boutique due to the resident not having any clothing available at the time of his 1/27/25 shower. He lacked an adequate amount of clothing in his room and she had discussed this with another aide previously. He had plenty of clothing when he first arrived to the facility. His clothing had been missing prior to the resident's room change. She went to the boutique and to the lost and found in laundry when she needed clothing for the resident. She confirmed the closet was empty. A drawer had two rolled up items and one shoe. A second dresser drawer lacked any clothing. During an interview on 1/30/25 at 1:48 p.m., the SSD indicated the laundry staff labeled clothing when residents admitted to the facility. The standard policy was to send clothing items for labeling on the day of admission. She had a boutique in her office of donated clothing. Items selected from the boutique were required to go straight to laundry to be labeled with the resident's name. Three to five outfits could have been obtained at one time from the boutique. During an interview on 1/30/25 at 1:48 p.m., the Memory Care Support Specialist indicated that she was not aware of the resident's lack of clothing. Staff were required to inform her when residents lacked clothing. Multiple outfits should have been obtained from the boutique during the resident's clothing shortage. She did not think that the resident came with very much clothing when he admitted . She worked on the resident's unit Monday-Friday from 9 a.m.-5 p.m. She observed the resident in the same clothing the week of 1/27/25. She was aware the resident normally wore the same outfit for 2-3 days . During an interview on 1/31/25 at 1:25 p.m., Laundry Aide 11 indicated the resident received facility laundry services. A current facility policy, revised 4/18, titled Resident's Personal Laundry, provided by the SSD on 1/30/25 at 2:13 p.m., indicated the following: Policy .Staff will wash resident's personal laundry on a regular basis . Procedure .Once laundry is gathered . should be taken to the laundry room, sorted, washed, dried, folded or hung, and returned to the apartment timely . The clean, folded, or hung garments shall be returned along with the laundry container/bag to the resident's apartment. If assistance is required, staff shall assist with putting clothing in resident's closet and drawers 3.1-9(a) 3.1-9(b) 3.1-9(f)

Based on interview and record review, the facility failed to ensure nursing staff followed the five rights of medication administration (right resident, right medication, right dose, right time, and right route) to prevent a medication error for 1 of 5 residents reviewed for unnecessary medications. (Resident 8) Finding includes: Resident 8's clinical record was reviewed on 1/28/25 at 2:46 p.m. Diagnoses included peripheral vascular disease and a non-pressure chronic ulcer of an unspecified lower leg. A physician's order, dated 12/9/24, included hydrocodone-acetaminophen (narcotic pain reliever) 10-325 milligrams (mg) - give one tablet by mouth every six hours for pain. This medication was scheduled to be administered at the following times: 5:00 a.m., 11:00 a.m., 5:00 p.m., 11:00 p.m. The order was discontinued on 1/9/25. A current physician order, dated 1/9/25, included hydrocodone-acetaminophen 10-325 mg- give one tablet by mouth every four hours for pain. This medication was scheduled to be administered at the following times: 3:30 a.m., 7:30 a.m., 11;30 a.m., 3:30 p.m., 7:30 p.m., and 11:30 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 1/17/25, indicated the resident was cognitively intact. Opioids were received during the assessment period. A current care plan, dated 5/10/24, indicated the resident was at risk for pain related to peripheral vascular disease. Interventions included, administer medications as ordered. A Nurse's note, dated 1/11/25 at 5:18 a.m., indicated the resident received and additional dose of hydrocodone 10-325 mg in error. Vital signs were within normal limits. The resident was alert and oriented and monitored frequently. A Nurse's note, dated 1/11/25 at 5:46 p.m., indicated the provider ordered to observe the resident for 4 hours and to hold the next dose of hydrocodone. A Nurse's note, dated 1/11/25 at 2:03 p.m., indicated the resident was resting in his bed with even and non-labored respirations and no shortness of breath. The resident took medications per order. Review of the January 2025 MAR indicated Resident 8 received the scheduled dose of hydrocodone-acetaminophen on 1/11/25 at 3:30 a.m. The doses scheduled on 1/11/25 at 7:30 a.m., 11:30 a.m. and 3:30 p.m. were held. The dose scheduled on 1/11/25 at 7:30 p.m. was left blank. Review of the resident's narcotic count sheet indicated a dose of hydrocodone-acetaminophen 10-325 mg was administered in error on 1/11/25 at 5:00 a.m. by LPN 9. The previous dose scheduled on 1/11/25 at 3:30 a.m. was administered at 4:00 a.m. by LPN 9. During an interview on 1/31/25 at 9:20 a.m., the DON indicated LPN 9 had administered a dose of hydrocodone-acetaminophen 10-325 mg in error on 1/11/25. LPN 9 had administered the additional dose of medication based on her memory rather than looking at the new order prior to the medication administration. The previous order of the same medication had been due at 5:00 a.m., but the order had been changed and was not scheduled at that time. The physician and family were notified by LPN 9 of the medication error. Staff were not permitted to pass medications based on memory, nor without verification of the physician's order for the medication. During an interview on 1/31/25 at 9:45 a.m., the DON indicated LPN 9 administered the additional dose of medication on 1/11/25 at 5:00 a.m. If the nursing staff charted by exception, they would not have charted anything in the clinical record unless abnormalities were found, when a resident received a medication in error. During an interview on 1/31/25 at 10:10 a.m., LPN 9 indicated she had administered an additional dose of the resident's hydrocodone-acetaminophen 10-325 mg in error on 1/11/25 by accident. She automatically got out the dose that had previously been ordered to administer at 5:00 a.m. (no longer ordered at that time) and administered it to the resident. The Medication Administration Record (MAR) had not triggered her to administer the dose at 5:00 a.m., as the next dose was not due until 7:30 a.m. She was in a hurry because she had assisted another staff member on another unit with medication administration and had her own medication cart as well. She felt she had adequate time to complete her tasks, but she rushed and it was her fault. The facility required staff to check the five rights prior to administration of medications. She had notified the provider and the on-call nurse manager, assessed the resident, and obtained vitals. The provider gave her orders to monitor the resident for sedation for four hours, and to hold the next dose of hydrocodone-acetaminophen 10-325 mg scheduled for 1/11/25 at 7:30 a.m. The on-call nurse instructed her to continue the resident's assessments. This occurred at the end of her shift and she had reported the medication error all of the above mentioned orders to RN 10 during morning report, at the end of her shift around 6:00 a.m. on 1/11/25. During an interview on 1/31/25 at 10:28 a.m., the DON indicated additional doses were held because the order to hold the hydrocodone-acetaminophen for the next dose had been entered and timed to hold until 11:00 p.m. During an interview on 1/31/25 at 11:03 a.m., RN 10 indicated she provided care for the resident on 1/11/25 after he had the medication error on the previous shift. LPN 9 had given her report at the shift change and made her aware of the resident's medication error and the need for continued observation for sedation. She was uncertain of the specific length of time the resident needed observed on her shift. LPN 9 had explained the hydrocodone was on hold and the orders had been placed in the computer. She was unaware the medication was ordered to be held only for the next dose. She was unaware of any other reason the resident's hydrocodone-acetaminophen 10-325 mg was held for additional doses. A current facility policy, revised 11/2018, titled Medication Errors, provided by the Corporate Nurse Consultant on 1/31/25 at 12:26 p.m., indicated the following: POLICY . It is the policy of this provider to ensure resident residing in the facility are free from medication errors 3.1-14(i)

Based on observation, record review, and interview, the facility failed to post the daily facility census number and actual hours worked of licensed and unlicensed nursing staff directly responsible for resident care per shift daily. Finding includes: During an observation and record review, on 1/28/25 at 11:43 a.m., the Nursing Staffing Data was posted from 1/28/25- 2/3/25 on the wall outside the Business Office and indicated the following: On 1/28/25, the total number of licensed and unlicensed staff were 2 Registered Nurses (RN), 2 Licensed Practical Nurses (LPN), 2 Qualified Medication Aides (QMA) and 15 Certified Nursing Assistants (CNA). The form lacked a shift to shift breakdown. The form lacked a census number. On 1/29/25, the total number of licensed and unlicensed staff were 2 RNs, 2 LPNs, 2 QMAs and 15 CNAs. The form lacked a shift to shift breakdown. On 1/30/25, the total number of licensed and unlicensed staff were 2 RNs, 1 LPN, 3 QMAs and 15 CNAs. The form lacked a shift to shift breakdown. On 1/31/25, the total number of licensed and unlicensed staff were 1 RN, 4 LPNs, 1 QMA and 15 CNAs. The form lacked a shift to shift breakdown. During an interview, at the time of the observation, the Administrator indicated he completed staffing weekly, as it was easier to keep track of that way. The previous 4 weeks remained in the plastic holder behind the current posting. During an observation and record review, on 1/31/25 at 11:00 a.m., of the Nursing Staffing Data, the census number column remained blank for 1/29/25, 1/30/25, and 1/31/25. During an interview, on 1/31/25 at 11:25 a.m., the Administrator indicated the Director of Nursing filled out the direct care staffing numbers on the Nursing Staffing Data form. He indicated he did not see a shift to shift breakdown on the form. During an interview, on 1/31/25 at 11:30 a.m., the DON indicated she filled out the forms with the nursing staffing information for a 24-hour time frame and not shift to shift. She indicated some of the previous dates were missing a census number. A facility policy, last revised 7/23, titled, Posted Nurse Staffing Data and Retention Requirements, provided by the Administrator on 1/31/25 at 12:35 p.m., indicated the following: .The facility must post the following information at the beginning of each shift .c. Resident census. d. The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered nurses, licensed practical nurses, certified nursing aides .

Based on observation and interview, the facility failed to ensure food was prepared and served under safe and sanitary conditions for 1 of 3 units observed during dining (Cottage Unit). This had the potential to affect 21 of 21 residents who were served meals on the Cottage Unit. Findings include: During a Cottage Unit dining observation on 1/27/25 from 11:43 a.m. through 12:03 p.m. the following was observed: CNA 13 handled Resident 45's sloppy joe sandwich with her bare hands while she assisted the resident with his meal in the dining room. CNA 13 handled Resident 46's breaded tenderloin sandwich with her bare hands while she set up the residents food for the resident to eat in the dining room. CNA 13 grasped three of Resident 45's cups from the top, touching the rim of each cup, at the dining room table. During an interview on 1/30/25 at 12:08 p.m., the Memory Care Support Specialist indicated that the residents' cups should have been handled at the bottom of the cup. It was not proper technique to touch the rim of the cup. The proper procedure to assist a resident with a sandwich depended on a resident's abilities. Staff should have assisted residents' with their condiments and then placed the top bun on the sandwich using a fork or spoon. Staff should have never used their hands. During an interview on 1/30/25 at 12:10 p.m., CNA 6 indicated cups were required to be handled from the bottom, avoiding the rim. After she applied condiments, she flipped the top bun onto the sandwich. She held up her hands and demonstrated she used her hands to place the top bun on the sandwich. During an interview on 1/30/25 at 12:26 p.m., CNA 13 indicated that cups should not have been touched by staff around the rims. The top bun of a sandwich should have been placed using silverware or gloves. She had touched the above mentioned sandwiches and cups because it was a habit. Perhaps she was rushed and just forgot to do the proper technique. A current facility policy, dated 1/24, titled Hand Hygiene in the Dining Room, provided by the MDS Coordinator on 1/30/25 at 2:22 p.m., indicated the following: Do Not Touch Food With Your Hands (Gloved or Ungloved) . Always use utensils when touching food . Avoid Touching Food Contact Surfaces of Dishware . (cup rims, surfaces of silverware ) 3.1-21(i)(3)

Based on record review and interview, the facility failed to protect a resident's dignity and failed to assist him with ADL care, leaving him in a soiled bathroom for another staff member to assist following an incontinence episode for 1 of 2 residents reviewed for quality of care. (Resident C) Using the reasonable person concept, it would be likely that a dependent, vulnerable person unable to care for themselves could experience recurrent fear or anxiety when the facility staff failed to assist them during a vulnerable episode of incontinence where he was found to be unsupervised, and covered in feces, seated on a bathroom floor with staff closing the door. Findings include: A complaint filed with the Indiana Department of Health indicated Resident C had been in a bathroom, alone, with his door shut and was unable to open doors due to his diagnoses. Resident C's clinical record was reviewed on 10/9/24 at 11:15 a.m. Diagnoses included dementia, depression, psychotic disorder with delusions, anxiety disorder, dystonia, and history of alcohol abuse. A quarterly Minimum Data Set (MDS) assessment, dated 11/19/24, indicated the resident had severe cognitive impairment, required substantial/maximal assistance with eating and was dependent on staff for toileting, oral hygiene, bathing, dressing, mobility, and transfers. The resident was able to ambulate with supervision and touching assistance. A current care plan, dated 9/11/23, indicated Resident C required assistance with toileting due to incontinence of bowel and bladder, impaired mobility, and potential to play in his own feces at times. Interventions included, (10/8/24) resident's legal representative wished for his dignity to be maintained as much as possible during times of incontinence and to allow privacy by guiding him to his room as he allows. During an observation on 12/9/24 at 11:45 a.m., Resident C was seated at a table in the dining area being assisted by a staff member to eat lunch. He was bent forward in his seat with his face positioned down. A document provided by the Administrator, dated 11/22/24 and titled, [Resident C] Investigation summary, indicated the following: A surveillance system was reviewed and CNA 8 was observed on the memory care unit to take CNA 2 home due to sickness. CNA 8 and CNA 2 talked for a few seconds, then CNA 8 began to walk down the hallway looking into resident rooms. When she got to Resident C's room, she entered for approximately one minute then reappeared. She then entered another resident room where CNA 4 was providing care to a resident. Then CNA 8 and CNA 2 left the facility. CNA 4 was observed approximately three minutes later exiting the room she had been providing care and entering Resident C's room. After just a few seconds, CNA 4 was observed in the hallway using her cell phone. CNA 5 was observed entering the unit and going into Resident C's room. The two CNAs were seen escorting Resident C down the hallway to the shower room. CNA 4 reported to the Administrator she had found Resident C in the bathroom, soiled with feces on his feet, pants, shirt, and beard. A conclusion statement indicated [Resident C] was found in his toilet area by CNA 8. She closed the door to the toilet to provide dignity. [Resident C] was not in any distress from being in his toilet area alone as none of the 3 CNAs reported that he was displaying any distress and the internal surveillance showed [Resident C] calmly walking with staff to the shower. [Resident C] was cared for within a reasonable period of time, approximately 6-7 minutes. However, CNA 8 should have stayed with the resident until the staff responsible for his care could arrive. The summary lacked specific time stamps from the surveillance video. During a telephone interview on 12/9/24 at 6:22 p.m., CNA 8 indicated she knew she should have changed Resident C before she left the facility. She didn't know why she had not cleaned him up. He was seated on the floor of his bathroom, with his pants down. There was feces on his back, his front, his socks. It was all over him. The CNA indicated there was feces on the walls and floor of the bathroom. She had reported his condition to CNA 4, who was working on that unit, and then she left the facility for her break and to take CNA 2 home. During an interview on 12/9/24 at 2:14 p.m., CNA 4 indicated Resident C was part of her assignment. CNA 4 was providing care to another resident in a room across the hallway from Resident C. CNA 2 was providing care to the resident's roommate and had finished and left the room. CNA 2 and CNA 8 returned to the room she was working in and reported Resident C was covered in feces. CNA 8 indicated she had shut him in the bathroom. When she completed caring for the resident, which she thought was around three minutes, she went across the hall to Resident C's room. The bathroom door was closed and when she opened it, she observed Resident C seated on the floor with feces in his hair, face, entire clothing, and socks. The walls, sink, and floor were also smeared with feces. When Resident C saw her, he began to curse at her. She indicated to Resident C she was going to get help and would return. She indicated she left the bathroom door open about 12 inches or so. She left the room and informed CNA 5 that she needed his assistance with Resident C as soon as possible. She indicated CNA 5 was assisting other residents to smoke, and arrived on the memory care unit about 6-7 minutes after she had spoken with him. CNA 5 was able to get Resident C to the shower room. CNA 4 indicated she remained in the room to clean up the bathroom. She was surprised that CNA 2 and CNA 8 would leave Resident C in that condition and had shut the door to the bathroom leaving him alone. She called the administrator as soon as she could to report the incident, as she felt it was possible abuse leaving him like that and leaving the facility. During an interview on 12/9/24 at 1:58 p.m., CNA 5 indicated he was outside with other residents during smoke time. CNA 4 had indicated Resident C needed assistance and was covered in feces. Resident C could become aggressive and it was usually a two staff job to care for him. CNA 5 indicated it was about 5-7 minutes before he completed the smoke time supervision. When he arrived in Resident C's room, the bathroom door was closed. The resident was seated on the floor of the bathroom. Resident C was more agitated that his usual when getting him to the shower, but calmed when he felt the water. During an interview on 12/9/24 at 12:34 p.m., the Administrator indicated the reason CNA 8 had shut the door to the bathroom was so he would not come out into the hallway. If the resident had wanted to come out, the Administrator felt the resident would have done so because he could open and close doors. He may not do this on command, but he had seen him open doors before. During an interview on 12/10/24 at 10:16 a.m., the Administrator indicated CNA 2 was scheduled on the memory care unit on 11/21/24 from 2:00 p.m. to 10:00 p.m. and became ill. CNA 8 was preparing to go on break and was going to take her home. It was like anyone else at the end of their shift, they reported off to the staff before leaving the facility. It was not CNA 8's end of shift, but she was not assigned to that unit to begin with and her immediate assignment was to take CNA 2 home. A current facility position description, revised 10/2014, titled, Certified Nursing Assistant Position Description, provided by the DON on 12/9/24 at 1:40 p.m., indicated the following: .Essential Position Functions .Provides delivery of care in a compassionate, quality manner with kindness, respect and dignity A current facility policy, revised June 2023, titled, Abuse Prohibition, Reporting, and Investigation, provided by the Administrator on 12/10/24 at 10:16 a.m., included the following: Policy: .American Senior Communities has established policies and procedures which will provide personnel with the knowledge and training to further ensure each resident is treated with individual respect and dignity Neglect Failing to provide personal hygiene resulting in embarrassment, depression, poor self-esteem . This Federal tag relates to complaint IN00447929. 3.1-28(c)

Based on interview and record review, the facility failed to report an allegation of abuse to the Indiana Department of Health for 1 of 2 residents reviewed for quality of care. (Resident C) Finding includes: During an interview on 12/9/24 at 2:14 p.m., CNA 4 indicated she called the Administrator on 11/21/24 following an incident with Resident C, who was part of her assignment. She was providing care to another resident in a room across the hallway from Resident C. CNA 2 was providing care to the resident's roommate and had finished and left the room. CNA 2 and CNA 8 returned to the room she was working in and reported Resident C was covered in feces. CNA 8 indicated she had shut him in the bathroom. When CNA 4 completed caring for the resident, which she thought was around three minutes' time, she went across the hall to Resident C's room. The bathroom door was closed and when she opened it, she observed Resident C seated on the floor with feces in his hair, face, entire clothing, and socks. The walls, sink, and floor were also smeared with feces. When Resident C saw her, he began to curse at her. She was surprised that CNA 2 and CNA 8 would leave Resident C in that condition and had shut the door to the bathroom leaving him alone. She called the administrator as soon as she could to report the incident, as she felt it was possible abuse leaving him like that and leaving the facility. During an interview on 12/9/24 at 12:34 a.m., the Administrator indicated they had looked into the incident regarding Resident C. The corporate nurse consultant had also looked at the incident and they felt it was not abuse or neglect. The Administrator had reviewed the surveillance video from that evening. During an interview on 12/10/24 at 10:16 a.m., the Administrator indicated CNA 4 had called him the evening of 11/21/24 and reported the situation with Resident C and the two CNAs who had left the facility. He asked CNA 4 if the two other CNAs had informed her they were leaving the facility, and she replied yes. He indicated he told her that this was not abuse, but poor care on their part. He indicated to CNA 4 he would take care of it in the morning. The facility did not report the alleged abuse to the Indiana Department of Health. A current facility policy, revised June 2023, titled, Abuse Prohibition, Reporting, and Investigation, provided by the Administrator on 12/10/24 at 10:16 a.m., indicated the following: .Reporting/Response: .The Executive Director will follow the reporting guidance delineated through the Indiana State Department of Health, Division of Long-Term Care Incident Reporting Policy Review of the Indiana Department of Health policy titled Long Term Care Abuse and Incident Reporting Policy, effective date 12/8/23 through 12/8/24, and retrieved from https://www.in.gov/health/ltc/files/LTC-Abuse-Reporting.pdf, indicated the following: .B. Types of Incidents Reportable Under Federal and State Rules .3. Deprivation of goods and services by staff: The deprivation of goods and services by staff is a form of abuse in which residents are deprived by staff of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. In these cases, staff has the knowledge and ability to provide care and services, but choose not to do it, or acknowledge the request for assistance from a resident(s), which result in care deficits to a resident(s) .11. Neglect: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress Cross reference F550. This Federal tag relates to complaint IN00447929. 3.1-28(c)

Based on interview and record review, the facility failed to conduct a complete and thorough investigation of alleged neglect for 1 of 2 residents reviewed for quality of care. (Resident C) Findings include: A document provided by the Administrator, dated 11/22/24, titled, [Resident C] Investigation summary, indicated the following: A surveillance system was reviewed and CNA 8 was observed on the memory care unit to take CNA 2 home due to sickness. CNA 8 and CNA 2 talked for a few seconds, then CNA 8 began to walk down the hallway looking into resident rooms. When she got to Resident C's room, she entered for approximately one minute then reappeared. She then entered another resident room where CNA 4 was providing care to a resident. Then CNA 8 and CNA 2 left the facility. CNA 4 was observed approximately three minutes later exiting the room she had been providing care and entering Resident C's room. After just a few seconds, CNA 4 can be observed in the hallway and used her cell phone. CNA 5 was observed entering the unit and going into Resident C's room. The two CNA's were seen escorting Resident C down the hallway to the shower room. CNA 4 reported to the Administrator she had found Resident C in the bathroom, soiled with feces on his feet, pants, shirt, and beard. A conclusion statement indicated the following: [Resident C] was found in his toilet area by CNA 8. She closed the door to the toilet to provide dignity. [Resident C] was not in any distress from being in his toilet area alone as none of the 3 CNAs reported that he was displaying any distress and the internal surveillance showed [Resident C] calmly walking with staff to the shower. [Resident C] was cared for within a reasonable period of time, approximately 6-7 minutes. However, CNA 8 should have stayed with the resident until the staff responsible for his care could arrive. The summary lacked specific time stamps from the surveillance video. During an interview on 12/9/24 at 2:14 p.m., CNA 4 indicated she called the Administrator on 11/21/24 following an incident with Resident C, who was part of her assignment. She was providing care to another resident in a room across the hallway from Resident C. CNA 2 was providing care to the resident's roommate and had finished and left the room. CNA 2 and CNA 8 returned to the room she was working in and reported Resident C was covered in feces. CNA 8 indicated she had shut him in the bathroom. When CNA 4 completed caring for the resident, which she thought was around three minutes' time, she went across the hall to Resident C's room. The bathroom door was closed and when she opened it, she observed Resident C seated on the floor with feces in his hair, face, entire clothing, and socks. The walls, sink, and floor were also smeared with feces. When Resident C saw her, he began to curse at her. She was surprised that CNA 2 and CNA 8 would leave Resident C in that condition and had shut the door to the bathroom leaving him alone. She called the administrator as soon as she could to report the incident, as she felt it was possible abuse leaving him like that and leaving the facility. During a telephone interview on 12/9/24 at 6:22 p.m., CNA 8 indicated she knew she should have changed (cleaned) Resident C before she left the facility. She didn't know why she had not cleaned him up. He was seated on the floor of his bathroom, with his pants down. There was feces on his back, his front, his socks. It was all over him. She indicated there was feces on the walls and floor of the bathroom. She had reported his condition to the CNA 4, who was working on that unit, and then she left the facility for her break and to take CNA 2 home. During an interview on 12/9/24 at 12:34 a.m., the Administrator indicated they had looked into the incident regarding Resident C. The corporate nurse consultant had also looked at the incident and they felt it was not abuse or neglect. The Administrator had reviewed the surveillance video from that evening. The surveillance video was no longer available and had been overwritten. During an interview on 12/10/24 at 10:16 a.m., the Administrator indicated CNA 4 had called him the evening of 11/21/24 and reported the situation with Resident C and the two CNAs who had left the facility. He asked CNA 4 if the two CNAs had informed her they were leaving the facility, and she replied yes. He indicated he told her that this was not abuse, but poor care on their part. He indicated to CNA 4 he would take care of it in the morning. He indicated no employee statements or investigation documentation were available. He believed he may have put them in the shredder box because the incident was not considered abuse or neglect. The facility had not reported the alleged abuse to the Indiana Department of Health. A current facility policy, revised June 2023, titled, Abuse Prohibition, Reporting, and Investigation, provided by the Administrator on 12/10/24 at 10:16 a.m., included the following: .Reporting/Response: .The Executive Director will follow the reporting guidance delineated through the Indiana State Department of Health, Division of Long-Term Care Incident Reporting Policy Review of the Indiana Department of Health policy titled Long Term Care Abuse and Incident Reporting Policy, effective date 12/8/23 through 12/8/24, and retrieved from https://www.in.gov/health/ltc/files/LTC-Abuse-Reporting.pdf, indicated the following: .B. Types of Incidents Reportable Under Federal and State Rules .3. Deprivation of goods and services by staff: The deprivation of goods and services by staff is a form of abuse in which residents are deprived by staff of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. In these cases, staff has the knowledge and ability to provide care and services, but choose not to do it, or acknowledge the request for assistance from a resident(s), which result in care deficits to a resident(s) .11. Neglect: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress Cross reference F550 and F609. This Federal tag relates to complaint IN00447929. 3.1-28(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure narcotic medication administration was documented according to policy for 3 of 3 residents (Resident A, E, and F), and that controlled substance reconciliation was complete and accurate according to facility policy for 3 of 3 medication carts, to assure medications were not diverted by a staff member. Findings include: Review of a Facility Reported Incident dated 9/26/24 at 1:20 p.m., indicated Resident A had reported she had not received her scheduled pain medication on 9/25/24 from the night nurse. Following an investigation, LPN 3 was suspended until the investigation could be completed. a. The clinical record review for Resident A was completed on 10/22/24 at 10:38 a.m. Diagnoses included schizoaffective disorder/depressive type, anxiety disorder, and chronic pain syndrome. She admitted to the facility on [DATE]. A physician's order, dated 9/13/24, indicated to give morphine (pain medication) extended release 15 mg (milligram) every eight hours for pain. The order was discontinued on 9/18/24. A current physician's order, dated 9/18/24, indicated to give morphine extended release 30 mg, every eight hours for pain. A review of the documentation of narcotic administration indicated the following: On 9/13/24 at 5:00 a.m., an EDK (emergency drug kit) Narcotic form was completed for Morphine 15 mg extended release. A note on the form indicated the pharmacy had authorized one tablet to be removed. The form indicated two tablets were removed. The form was signed by LPN 3. On 9/15/24 at 5:00 a.m., an entry on the narcotic medication count sheet for Resident A had an entry signed by LPN 3 that was marked out with a line through it, and the word dropped indicated next to her signature indicating descruction of the dropped medication. The entry lacked any other staff initials, signature, or indication of disposal. An entry below indicated another dose was removed on 9/15/24 at 6:00 am. On 9/24/24 at 5:00 a.m., entry on the narcotic medication count sheet for Resident A had an entry signed by LPN 3 that was marked out with a line. The record lacked an explanation or staff co-signature/initials. An entry below indicated another pill was removed by LPN 3 and was dated and timed 9/24/24 at 5:00 a.m. b. The clinical record review for Resident E was completed on 10/22/24 at 9:20 a.m. Diagnoses included colon cancer, malnutrition, and colostomy. The resident was admitted on [DATE] and was discharged to another facility on 10/7/24. A physician's order, dated 6/18/24, indicated to provide hydrocodone-acetaminophen (narcotic pain medication) 5-325 mg, every four hours as needed for moderate to severe pain. The order was discontinued on 7/25/24. A physician order, dated 7/25/24 indicated to provide hydrocodone-acetaminophen 10-325 mg, every four hours as needed for pain. The order was discontinued on 9/23/24. A physician's order, dated 9/23/24, indicated to provide hydrocodone-acteaminophen 5-325 mg, every four hours as needed for pain. The order was discontinued on 10/7/24. On 7/19/24 at 9:00 p.m., an entry on the narcotic medication count sheet for Resident E had an entry signed by LPN 3 that was marked out with a line. The record lacked an explanation of reason for duplicate pills being obtained or staff co-signature/initials. An entry below indicated another pill was removed by LPN 3 and was dated on 7/19/24 at 9:00 p.m. On 7/28/24 at 3:30 a.m., an entry on the narcotic medication count sheet for Resident E had an entry signed by LPN 3 that was marked out with a line. The record lacked an explanation of reason for duplicate pills being obtained or staff co-signature/initials. An entry below indicated another pill was removed by LPN 3 and was dated on 7/18/24 at 3:30 a.m. On 8/24/24 at 2:30 a.m., an entry on the narcotic medication count sheet for Resident E had an entry signed by LPN 3 that was marked out with a line. The record lacked an explanation of reason for duplicate pills being obtained or staff co-signature/initials. An entry below indicated another pill was removed by LPN 3 and was dated on 8/24/24 at 2:40 a.m. c. The clinical record review for Resident F was completed on 10/22/24 at 10:05 a.m. Diagnoses included chronic kidney disease III, diabetes mellitus type II, acute respiratory failure, and depression. The resident was admitted on [DATE]. A physician order, dated 5/24/24, indicated to provide oxycodone (pain medication) 5 mg, every four hours as needed. The order was discontinued on 7/11/24. A physician's order, dated 7/11/24, indicated to provide hydrocodone-acetaminophen 5-325 mg, every six hours as needed. On 7/19/24 at 7:00 p.m., an entry on the narcotic medication count sheet for Resident F had an entry signed by LPN 3 that was marked out with a line. The record lacked an explanation of reason for duplicate pills being obtained or staff co-signature/initials. An entry below indicated another pill was removed by LPN 3 and was dated on 7/19/24 at 7:00 p.m. On 8/24/24 at 4:30 a.m., an entry on the narcotic medication count sheet for Resident F had an entry signed by LPN 3 that was marked out with a line through it, and the word dropped indicated next to her signature. The record lacked a staff co-signature/initials indicating descruction of the dropped medication. An entry below indicated another pill was removed by LPN 3 and was dated on 8/24/24 at 4:30 a.m. On 9/7/24 at 3:30 a.m., an entry on the narcotic medication count sheet for Resident F had an entry signed by LPN 3 that was marked out with a line. The record lacked an explanation of reason for duplicate pills being obtained or staff co-signature/initials. An entry below indicated another pill was removed by LPN 3 and was dated on 9/7/24 at 3:30 a.m. 2. Review of the medication cart narcotic Shift Change Verification of Controlled Substances sheet, included the following: a. The [NAME] 100 hall, [NAME] 200 hall, and Memory Care unit medication carts for August 2024 lacked documentation for item count which includes number of cards, bottles, or boxes containing narcotic medications. The record lacked any additions or removals of narcotic medications. b. The [NAME] 100 hall, [NAME] 200 hall, and Memory Care unit medication carts for September 2024 lacked documentation through night shift on 9/27/24 for item count which includes number of cards, bottles, or boxes containing narcotic medications. The record lacked any additions or removals of narcotic medications through this time. During an interview on 10/22/24 at 11:38 a.m., the DON indicated the staff should have reported any incomplete or incorrect documentation entered by LPN 3 when performed the shift to shift narcotic counts. She indicated the staff were not completing the narcotic count shift to shift record appropriately and thoroughly. She has performed staff education upon completing the investigation of possible diversion of narcotic medications. She had been unable to determine an accurate count of the potential diverted narcotic medications due to poor shift to shift documentation. A current facility policy, dated 11/2015, titled, Controlled Substances, provided by the Administrator on 10/21/24 at 2:44 p.m., included: Policy The staff at the Community must also maintain strict records of the controlled substances stored in the Community as well as the dose given to the resident. It is essential to make certain the resident requiring the controlled substance receives it as ordered by the physician .Procedure .5.all unused medication will be destroyed with two licensed nurses and document on the medication destruction logs. A current facility policy, dated 2/1/2018, titled, Inventory of Controlled Substances, provided by the DON on 10/22/24 at 9:10 a.m., included: Policy: It is the policy of [provider name] to ensure that the incoming and outgoing nurses count all controlled substances at the change of each shift and document on the Shift Change Verification of Controlled Substances form. Procedure: .The on-coming and off-going nurse will also count the narcotic cards, boxes, and bottles to ensure accurate reconciliation. The off-going nurse will document an explanation on the Shift Change Verification of Controlled Substance form if there are any discrepancies or changes with the card, box, or bottle counts. If there are unexpected changes in the shift verification of controlled substances the Director of Nursing Services will be notified immediately. This Federal deficiency is related to Complaint IN00444118. 3.1- 25(b)(3)

Based on observation, interview, and record review, the facility failed to implement care plan approaches to prevent falls for 1 of 3 residents reviewed for accident prevention. (Resident 51) Findings include: Resident 51's clinical record was reviewed on 1/4/24 at 10:52 a.m. Current diagnoses included, dementia, difficulty walking, weakness, and low back pain. The resident had a history of falls, fall events, and injuries of unknown origins as follows: 7/7/23-The resident had a fall in the shower room. 7/31/23- The resident stumble with his walker entering his room and landed on his knees. 8/13/23-The resident was found on the floor by his bed. 10/7/23- The resident had an unwitnessed fall. 11/27/23- The resident had fall in the hallway which resulted in a skin tear. 12/4/23-The resident had an unwitnessed accident which resulted in a laceration on his forehead and abrasion on his nose. A 12/5/23, 7:48 p.m. IDT (Inter Disciplinary Team) progress note indicated the most likely cause for the injury was an unwitnessed fall. The resident had a current care plan problem/need regarding the risk for falls and related injury, initiated 9/16/22. Approaches to this problem included brightly colored signage on walker to encourage use (11/27/23) and non-skid strips on floor next to bed (10/9/23). A 12/5/23, quarterly, Minimum Data Set (MDS) assessment indicated the resident was cognitively impaired, was rarely or never understood by others, used a walker for mobility, and rejected care 1 to 3 days of the assessment period. During the survey period from 1/4/24 at 11:01 a.m. until 1/8/24 at 10:01 a.m., floor strips were not present on the floor by the resident's bed. There was no visible signs of adhesive residue on the floor where strips had been removed. During an observation on 1/4/24 at 11:16 a.m., the resident was in the dining room with his walker near his dining seat. There was no bright signage on the walker. During an observation on 1/5/24 at 11:44 a.m., the resident was in the dining room with his walker near his dining seat. There was no bright signage on the walker. During an observation and interview on 1/8/23 at 10:01 a.m., RN 5 indicated there were no non-skid strips by Resident 51's bed. The resident was resting in the bed at the time. RN 5 looked at the resident's walker and indicated there was no bright signage or any signage posted. She did not remember the last time she had seen either item in place. During an interview on 1/8/24 at 10:07 a.m., the Dementia Unit Manager indicated she did not know why Resident 51 did not have non-skid strips on his floor nor signage on his walker. The CNA assignment sheet specifically identified needed tools and devices. If a staff member noticed these items were missing, they should notify the charge nurse or unit manager to correct the problem. Review of the CNA assignment sheet provided by the Dementia Unit Manager on 1/8/24 at 10:10 a.m. indicated Resident 51 should have brightly colored signage on walker to encourage use and non-skid strips next to bed. During an interview on 1/8/24 at 10:33 a.m., the DON indicated she did not know why the bright signage or non-skid strips were not in place. She reviewed the resident's record and the resident's bed placement was changed on 12/4/23 as an intervention. Perhaps the placement of the non-skip strips in the new location was accidentally overlooked. A current, 8/2022, policy titled, Fall Management Policy, provided by the DON on 1/8/24 at 10:40 a.m., indicated the following: .Facilities must implement comprehensive, resident-centered fall prevention plans for each resident at risk for falls or with a history of falls 3.1-35(b)(1)

Based on observation, interview, and record review, the facility failed to ensure oxygen therapy was administered according to physician order for 1 of 1 resident reviewed for oxygen therapy. (Resident 22) Finding includes: During an observation on 1/3/23 at 3:26 p.m., Resident 22 was in bed in her room. Her oxygen was on via nasal cannula and set at 4 liters per minute. The oxygen concentrator was to the left of the resident's bed. During an interview at the time of observation, the resident indicated she had trouble with staff putting her oxygen on in the mornings because they failed to adjust the oxygen setting once they removed the Trilogy (non-invasive mechanical ventilator) mask. She was unable to ambulate, and the oxygen concentrator was not within reach. She relied on staff to manage her respiratory equipment. During an observation on 1/4/23 at 8:09 a.m., the resident was in bed with her oxygen on via nasal cannula at 4 liters per minute. The resident indicated staff had just removed her Trilogy mask and put the nasal cannula on her. Resident 22's clinical record was reviewed on 1/4/24 at 11:35 a.m. Diagnoses included chronic obstructive pulmonary disease (COPD), shortness of breath, multiple sclerosis, and generalized muscle weakness. An order, dated 1/26/22, indicated Trilogy on at bedtime and off upon waking with oxygen at 4 liters per minute. An order, dated 11/22/22, indicated oxygen at 3 liters per minute was to be worn daily via nasal cannula. An annual Minimum Data Set assessment, dated 11/9/23, indicated the resident was cognitively intact. She was dependent for toileting, personal hygiene, and lower body dressing. The resident was dependent on staff to roll left and right and to move from sitting to lying. Chair transfers, toilet transfers, and sit to stand transfers were not attempted due to the resident's medical condition. Special treatments included oxygen therapy and a non-invasive mechanical ventilator. A care plan, revised 12/27/23, indicated the resident was at risk for impaired gas exchange related to COPD with shortness of breath. Interventions included administer oxygen as ordered (11/16/21), and Trilogy machine for sleep apnea (3/1/23). A Nurse's Note, dated 10/10/23, indicated the resident's oxygen was on at 4 liters per minute via nasal cannula. During an observation on 1/5/24 at 9:18 a.m., the resident was in bed with oxygen on at 4 liters per minute via nasal cannula. The resident indicated staff had removed her Trilogy mask for her that morning and placed the nasal cannula on her. During an interview at the time of observation on 1/5/24 at 2:54 p.m., LPN 2 indicated the resident's oxygen via nasal cannula was on 4 liters per minute. The oxygen should have been set at 3 liters per minute according to the physician order. During an interview on 1/5/24 at 3:05 p.m., the DON indicated oxygen therapy should have been administered according to the physician orders. A current, undated, facility document, titled Oxygen Concentrator, provided by the DON on 1/5/24 at 4:13 p.m., indicated the following: .Purpose .To provide Oxygen for therapeutic use by utilizing a concentrator that converts ambient air to a higher concentration level of oxygen . Procedure 1) Verify and understand the physician's order. 2) Know the flow rate and duration of use . 9) Adjust the flow meter control knob to the flow setting prescribed by the physician. The graduated line of the meter should be aligned with the center of the floating ball 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to utilize infection prevention and control strategies regarding storage and maintenance of respiratory equipment for 1 of 7 residents reviewed for infection control. (Resident 22) Finding includes: During an observation on 1/3/23 at 3:26 p.m., Resident 22 was in bed in her room. Her oxygen was on via nasal cannula. The nasal cannula oxygen tubing was dated 12/24/23. The Trilogy (non-invasive mechanical ventilator) mask was not in use and was directly against the Trilogy machine on the right side of the bed. During an interview at the time of observation, the resident indicated she was unable to ambulate and both the oxygen concentrator and the Trilogy machine were not within reach. She relied on staff to manage her respiratory equipment. The resident had never seen staff use a barrier or bag for the Trilogy mask when they removed it from her face. During an observation on 1/4/23 at 8:09 a.m., the resident was in bed with her oxygen on via nasal cannula. The oxygen tubing date remained unchanged from the previous day. The Trilogy mask rested directly against the Trilogy machine on the side of the mask that fits against the residents face when worn. The resident indicated staff had just removed her Trilogy mask and placed it on the Trilogy machine in the corner . Resident 22's clinical record was reviewed on 1/4/24 at 11:35 a.m. Diagnoses included chronic obstructive pulmonary disease (COPD), shortness of breath, multiple sclerosis, and generalized muscle weakness. An order, dated 1/26/22, indicated Trilogy on at bedtime and off upon waking with oxygen at 4 liters per minute. An order, dated 11/22/22, indicated oxygen at 3 liters per minute worn daily via nasal cannula. An order, dated 12/17/21, indicated oxygen tubing and humidity were to be changed once a day on Sundays. An annual Minimum Data Set assessment, dated 11/9/23, indicated the resident was cognitively intact. She was dependent for toileting, personal hygiene, and lower body dressing. Special treatments included oxygen therapy and a non-invasive mechanical ventilator. A current care plan, revised 12/27/23, indicated the resident was at risk for impaired gas exchange related to COPD with shortness of breath. Interventions included administer oxygen as ordered (11/16/21) and Trilogy machine for sleep apnea (3/1/23). During an observation on 1/5/24 at 9:18 a.m., the resident was in bed with oxygen on at 4 liters per minute via nasal cannula. The nasal cannula oxygen tubing remained dated 12/24/23. The Trilogy mask was not in use and rested directly against the contaminated surface of the Trilogy Machine on the side that rests against the face when worn. A barrier was not in use, and it was not in reach of the resident. The resident indicated staff had removed her mask for her that morning and placed it on the Trilogy machine in the corner. During an interview at the time of observation on 1/5/24 at 2:54 p.m., LPN 2 indicated the resident's nasal cannula oxygen tubing was dated 12/24/23. Oxygen tubing should have been changed according to the order, every Sunday. The resident's Trilogy mask was placed directly on top of the Trilogy machine and should have been stored in a bag when it was not in use. During an interview on 1/5/24 at 3:05 p.m., the DON indicated oxygen tubing should have been changed every Sunday according to the physician orders. Trilogy masks and Continuous Positive Airway Pressure (CPAP) masks should have been stored in a bag when they were not in use. Improper storage and maintenance of respiratory equipment were potential risks for infection. During an interview on 1/5/24 at 4:14 p.m., the DON indicated the facility policy lacked information on how the respiratory equipment should be stored. A current facility policy, dated 3/2022, titled Infection Prevention and Control Program Policy, provided by the facility following entrance conference on 1/2/24 at 1:50 p.m., indicated the following: .POLICY: The facility shall establish and maintain infection prevention and control program [IPCP] designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections . GOALS: The goals of the infection prevention and control program are to: 1. Decrease the risk of infection to residents through investigation and surveillance . 5. Maintain compliance with state and federal regulations related to infection prevention and control 3.1-18(a)

Based on observation, interview and record review, the facility failed to allow residents food choices and preferences for 4 of 6 residents reviewed. (Resident 29, Resident 42, Resident 47 and Resident 215) Findings include: 1. During an interview on 10/28/22 at 1:46 p.m., Resident 29 indicated he had not received a menu of what the facility planned to serve for any meals. The staff had not asked him to select his meals nor given him any choices regarding breakfast, lunch or supper each day. He preferred to stay in his room in the morning. He received a food tray at each meal, but the items he received on his meal trays each day were not chosen by him. Resident 29's clinical record was reviewed on 10/31/22 at 3:33 p.m. Diagnoses included chronic pain, chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic neuropathy, other recurrent depressive disorders, lack of coordination, and bilateral primary osteoarthritis of knee. A current dietary order indicated a regular diet with the following special instructions: may have ground meats at the resident's request. A 7/22/22, Quarterly Minimum Data Set (MDS) assessment indicated the resident's cognitive status was moderately impaired. He required limited assistance of 1 staff member for bed mobility, transfers and toileting. The resident required extensive assistance of 1 staff member for dressing. A wheelchair was utilized for mobility. He lacked any exhibited rejection of care behaviors. A current care plan for cognitive loss, indicated the resident exhibited cognitive impairment. Interventions included, give resident choices throughout the day regarding decisions and provide the resident with prompts and cues as needed. During an interview at the time of observation on 11/1/22 at 12:37 p.m., the resident sat in his wheelchair in his room. His lunch tray was in front of him on his over-the-bed table. His lunch tray lacked any method for the resident to make a meal selection. He indicated staff members had not asked him what he wanted to eat for his meals the next day. During an interview at the time of observation on 11/2/22 at 10:39 a.m., the resident sat in his wheelchair in his room and watched television. He indicated staff members had not given him any choices for his meals for the next day. Every meal each day was a surprise, sometimes for the better and sometimes for the worse. Review of the Activities Attendance Record for the resident, provided by the Activity Director on 11/2/22 at 11:29 a.m., indicated the resident had not attended the Coffee and Meal Plans Activity any times from 10-1-22 to 10-31-22. 2. During an observation at the time of interview on 10/28/22 at 11:10 a.m., Resident 42 was in her bed with the television on. She indicated she fractured her back 3 years ago so she required a significant amount of assistance to get out of bed. She preferred to remain in bed rather than to bother the staff members. Though she was on hospice, she still wanted to have some choices when it came to meals. She was not made aware what the facility planned to serve each day. A menu was not provided. She indicated a meal tray was delivered each meal but she just got whatever they brought her. If she sent the tray away they sent the facility chosen alternative. She never had any options to select for each meal. Resident 42's clinical record was reviewed on 10/31/22 at 3:56 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, recurrent major depressive disorder, rheumatoid arthritis, general anxiety and wedge compression fracture of first lumbar vertebra. A current dietary order for a regular diet was in place. An 8/26/22, Quarterly MDS assessment indicated the resident's cognitive status was intact. She required extensive assistance of 2 staff members to total dependence for bed mobility, transfers, dressing and toileting. She lacked any exhibited rejection of care behaviors. A current care plan for death with dignity and physical comfort indicated the resident's advanced directive wishes were honored. Interventions included to involve the resident in care and decision making to the maximum potential and provide food and fluids for comfort or based on resident preferences. A current care plan for depression indicated the resident had a diagnosis of major depressive disorder. Interventions included, but were not limited to, emphasize and promote independence and feelings of control/choice. During an interview on 11/1/22 at 11:30 a.m., the resident indicated she preferred meals in her room. She had not been to the dining room. Staff had not asked her to make any choices for her meals so she was unaware what they planned to bring her. She had asked for a menu but it was not provided. During an interview at the time of observation on 11/1/22 at 12:31 p.m., her lunch tray was on her over-the-bed table at bedside. The tray lacked any method for menu selections. She indicated she was unaware why staff members were unable to find a menu for the week to ensure she was informed of the meals in advance. No one had offered her meal choices for the next day. During an interview on 11/2/22 at 10:45 a.m., the resident indicated activities staff members still had not offered her any menu choices for the next day. Review of the Activities Attendance Record for the resident, provided by the Activity Director on 11/2/22 at 11:29 a.m., indicated the resident had not attended any Coffee and Meal Plans Activities for the month of October. 3. During an observation at the time of interview on 10/28/22 at 1:14 p.m., Resident 47 was in her bed, wore pajamas and had the television on. She indicated the residents were only permitted to choose their meals for the next day if they went to the dining room for coffee. Since she did not feel well and wanted to stay in bed in her pajamas, she did not have the opportunity to make meal selections for the next day. Resident 47's clinical record was reviewed on 10/31/22 at 1:11 p.m. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and other intervertebral disc degeneration, lumbar region. A current dietary order for a regular diet was in place. An Annual MDS assessment, dated 9/16/22, indicated the resident's cognitive status was intact. She required extensive assistance of 2 staff members for bed mobility, transfers, and toileting. A wheelchair was required for mobility. She lacked any exhibited rejection of care behaviors. A current care plan for activities indicated the resident enjoyed independent activity persuits such as word searches, puzzles and other reading materials. A long term goal indicated the resident would participate in independent activities to their level of satisfaction. Interventions included, but were not limited to, offer items for room. During an interview at the time of observation on 11/1/22 at 11:05 a.m., the resident was in her pajamas in bed and watched television. She indicated she had not been to the dining room. Staff had not offered her menu selections for the next day. During an interview at the time of observation on 11/2/22 at 12:53 p.m., the resident indicated she had not gone to the dining room to make menu selections. Staff had not offered her menu selections for the next day. She would like to have made her own choices for each meal especially when she did not feel well. She preferred to have chosen all of her meals each day, but the facility had not offered her any menu options when she had not gone to the dining room. Since she had a stroke, she required assistance to get up and preferred to stay in bed. Review of the Activities Attendance Record for the resident, provided by the Activity Director on 11/2/22 at 11:29 a.m., indicated they resident had not attended the Coffee and Meal Plans Activity from 10/1/22 to 10/31/22. 4. During an interview at the time of observation on 10/28/22 at 2:03 p.m., Resident 215 indicated the doctor wanted her up in the wheelchair only once per day to avoid additional risks of a compromised external fixation device on her right lower leg. She was in her bed with her right leg elevated and the external fixation device in place. A mechanical lift was used to get her in the wheelchair. As a result, she chose to get up during the time she went to smoke. She ate in her room. No one offered her the opportunity to select any meals. A meal was just sent to the resident's room. She was not provided a menu. If she did not want the meal they sent to her room, then they brought a peanut butter and jelly sandwich to replace it but she was not offered any options. She made the dietary department aware not to send tomatoes on her tray, but they still sent tomatoes. Resident 215's clinical record was reviewed on 10/31/22 at 3:20 p.m. Diagnoses included, but were not limited to, nondisplaced bimalleolar fracture of right lower leg, subsequent encounter for open fracture, anxiety disorder, other specified depressive episodes, nicotine dependence and other chronic pain. A current care plan for activities indicated the resident enjoyed activities such as word searches, bingo and being outside. A long term goal indicated the resident would participate in independent activities to their level of satisfaction. Interventions included provide independent supplies for room as needed when scheduled programming does not meet the resident's preferences or interests. A Nurse's note, dated 10/29/22 at 1:49 p.m. indicated the resident was alert and oriented to person, place and time. During an observation at 11/1/22 at 12:08 p.m., Certified Nurse's Aide (CNA) 11 delivered a lunch tray to the resident. The meal ticket was observed with no tomatoes listed at the bottom. Tomatoes were sent on her meal tray. During an observation on 11/1/22 at 12:11 p.m., an unidentified staff member came to the resident's room and informed her the dietary department was notified again of her preference for no tomatoes. Review of the Activities Attendance Record for the resident, provided by the Activity Director on 11/2/22 at 11:29 a.m., indicated they resident had not attended the Coffee and Meal Plans Activity any since she admitted during the month of October. During an interview on 11/1/22 at 4:23 p.m., CNA 8 indicated she was unaware how the dietary department received the residents meal choices. Meal choices were not obtained during second shift. During an interview on 11/1/22 at 4:26 p.m., CNA 9 indicated she was unaware know how meal choices were offered and sent to the dietary department. During an interview on 11/1/22 at 4:33 p.m. Registered Nurse (RN) 6 indicated the activities department collected meal choices in the dining room on a tablet. She was not certain when the meal choices were obtained. During an interview on 11/1/22 at 4:40 p.m., the Activity Director indicated the residents who came to the dining room during coffee time, before 11:45 a.m., have their meal choices entered for the next day by an activity staff member. The residents who had the physical ability to go to the Coffee and Chat in the dining room, but chose not to attend, received a system generated standard meal ticket rather than resident chosen meals. Next, an activity staff member offered meal choices to the 3 residents in the facility who were not able to attend the Coffee and Chat in the dining room. Resident 42 was listed as a resident unable to attend the Coffee and Chat. Residents 29, 47 and 215 were not listed as unable to attend. Residents who attended Coffee and Chat in the dining room were offered the opportunity to choose their drinks, made choices between the main meal and expanded alternates and condiment selections. When a resident, who did not attend Coffee and Chat to select their meals, refused the standard meal, the facility chosen alternate meal was provided. They were not given different expanded options for an alternate. He indicated they previously provided weekly paper menus to the residents but they have not done that for quite some time. The electronic menu selection only provided the day by day menu options. During an interview at the time of observation on 11/2/22 at 9:38 a.m., Coffee and Chat was underway in the dining room with 7 residents in attendance. Activity Assistant 7 obtained meal choices for breakfast, lunch and dinner from the residents for the next day. Choices included the drinks, main coarse or expanded alternates and the way they wanted their eggs cooked for breakfast. Residents 29, 42, 47 and 215 were not in attendance. Meal choices were not offered at a later time to the resident's who did not attend Coffee and Chat. Instead, they received the standard meal. During an interview on 11/2/22 at 9:59 a.m., the Dietary Manager indicated the meal tickets were printed from Meal Tracker the evening they were collected by the activity staff member. Every resident had a meal ticket printed even if they did not choose the meals. The alternate meal was Chef's Choice, if the standard meal was refused, because they lacked adequate time to make individualized requests at the last minute. If they attended in the dining room and chose an alternate, the residents had more alternate options. Food allergies and preferences should not have been sent to the residents on their meal tray. Food preferences were collected within 72 hours of the resident's admission. The printed meal tickets did not differentiate if they were system generated due to non-selection or manually generated due to the residents' choices. A request was made for copies of meal tickets from 10/24/22 to 11/2/22. She indicated she did not have a way to print previous meal tickets because they are wiped clean on a daily basis. Further documentation of meal tickets was not provided prior to the survey exit on 11/2/22 at 4:07 p.m. During an interview on 11/2/22 at 11:51 a.m., the Administrator indicated the residents had the right to choose if they wanted to participate in an activity. He indicated the resident who were able to make their meal choices in the dining room, but did not attend during that time, received a system selected standard meal ticket. Residents did not have menus. During an interview on 11/2/22 at 12:10 p.m., the Director of Nursing (DON) indicated the residents who did not come out of their room would not have had access to the menu to see what was served. During an interview on 11/2/22 at 12:12 p.m., the Assistant Director of Nursing (ADON) indicated the residents had to take responsibility and attend in the dining room to make their own meal choices if they were able. It would have been burdensome on staff to go to the residents' rooms when the residents chose not to attend in the dining room to make their meal selections. This change was made to encourage residents to participate more. A current document, titled RESIDENT RIGHTS, provided by the Administrator on 10/27/22 at 3:00 p.m., indicated the following: The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident Exercise of Rights .The resident has the right to exercise his or her rights as a citizen or resident of the United States, and to be free from interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights Self-Determination .A resident has the right to: Choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care Make choices about aspects of his or her life in the facility that are significant such as schedules, including but not limited to sleeping, waking, eating, and bathing 3.1-3(u)(1)