Every finding on record at Byron Health Center

Based on observation, interview and record review, the facility failed to ensure proper labeling, storage, and sanitation were maintained in the kitchen. 103 of 103 residents who resided in the facility and received food from the kitchen.Findings include:During an initial observation of the kitchen on 3/25/2026 at 9:12 AM, the following items in the walk-in freezer were observed to be open to air, undated and did not contain an expiration date: one bag of frozen chips and one box of cinnamon rolls.In the refrigerator, a container of beef base was observed to be open, without a lid and did not contain an open date or expiration date.In dry storage, the following items were observed to be open, undated and did not contain an expiration date: elbow macaroni removed from its original packaging and placed in a plastic container, two bags of bread with approximately 10 slices each, one bag with 11 hamburger buns, two bags with one submarine bun each and one bag of whole wheat bread with three slices.On the countertop in the kitchen, the following items were observed to be open, tied in a knot and did not contain an open or expiration date: two bags of bread with six slices each, one bag of bread with 11 slices and one bag of bread with 20 slices.In the reach-in freezer, a box of frozen hamburgers was observed to be open to air and did not contain an open or expiration date.On the spice rack, a container of dill weed seasoning was observed to be open and did not contain a lid.On the back cabinets, Raisin Bran and Trix cereal were observed to be removed from their original packaging and placed in separate plastic containers that did not contain an open date.During an interview, on 3/25/2026 at 9:20 AM, the Dietary Manager (DM) indicated the facility labeled and dated all items when opened. The DM indicated the facility followed expiration dates if items remained in their original packaging. The DM confirmed the items identified did not contain an expiration date or open date. The DM further indicated all food should have been closed when stored and should not have been left open to air.A current facility policy, Food Receiving and Storage Policy, dated 12/2008, provided by the DM on 3/26/2026 at 11:19 AM, indicated Dry food that are stored in bins will be removed from original packaging, labeled, and dated. All foods stored in the refrigerator or freezer will be covered, labeled, and date.2. During an observation of the kitchen, on 3/25/2026 at 9:12 AM, a set of keys was observed sitting on the steam table serving area. The handwashing sink was observed to contain brown chunks and white debris. The grill was observed to have black buildup between the grill grates and black char buildup underneath the grill grates. The grill foil was observed to have a large accumulation of black buildup.A review of the weekly cleaning list provided by the Executive Director on 3/26/2026 indicated the grill foil, grill grates and shelving were cleaned by the AM [NAME] on Monday, 3/23/2026. The cleaning list indicated the grill and stovetop were cleaned by the PM [NAME] on Tuesday, 3/24/2026.During an interview, on 3/25/2026 at 9:25 AM, the DM indicated the black buildup was from cooking breakfast. The DM indicated staff may have had food on their hands when using the handwashing sink. The DM also indicated the keys should not have been left on the kitchen serving area.A current facility policy, Cleaning and Sanitizing of Kitchen Equipment, dated 4/26/2025, provided by the DM on 3/26/2026 at 11:19 AM, indicated all food service equipment and food-contact surfaces shall be cleaned and sanitized between tasks and at a frequency that prevents contamination.410 Indiana Administrative Code (IAC) 16.2-3.1-21(i)(2) and (3)

Based on observation, record review, and interview the facility failed to have effective implementation of interventions to maintain kitchen sanitation for 103 of 103 residents residing in the facility ate food prepared in the kitchen.Findings include: A review of survey results, dated 5/19/25, indicated the facility was cited for F812. The citation included maintaining sanitation, open food items, labeling of food, and food open being dated.During an observation, on 03/25/2026 at 9:12 AM, in the kitchen there was a bag of frozen chips and cinnamon rolls in freezer open to air no open dates. Beef base without an open date, elbow macaroni in clear bin without a date, white bread, whole wheat bread, hamburger buns, and sub buns without dates. Dill weed seasoning without a lid, open to air. These were similar issues compared to the recertification survey dated 5/19/25 with F812 being cited 2 years in a row. In an interview, on 3/31/26 at 9:59am, the Executive Director (ED) indicated herself and the Assistant Executive Director did various observations of the kitchens and kitchenettes of the neighborhoods. The ED did not have any documentation of the observations. The ED indicated the committee had been working on food temperatures, labeling, dating, and cleanliness since last April. The facility had some change over in the dietary aids and felt this corrected the problem until annual survey results. No policy was given at time of exit.

Based on observation, interview, and record review, the facility failed to ensure cervical collars were provided and maintained for 2 of 2 residents reviewed (Resident 2, and Resident 20). Findings include:1) In an observation, on 03/25/2026 at 10:04 AM, Resident 2 was observed lying in bed with no cervical collar in place around her neck. In an observation, on 03/27/2026 at 10:43 AM, Resident 2 was observed lying in bed with no cervical collar in place around her neck. In an observation, on 3/30/2026 at 11:15 AM, a soft cervical collar was observed on the bedside stand next to Resident 2's bed. Resident 2's record was reviewed on 03/25/2026 12:27 PM. Diagnoses included cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. A current significant change Minimum Data Set (MDS) assessment, dated 1/21/2026, indicated Resident 2 had a Basic Interview for Mental Status (BIMS) score of 9 (moderate cognitive impairment). A review of physician orders, dated 12/11/2025, indicated Resident 2 should wear a cervical collar while in bed and for all meals for contracture of the neck management. Nurse Practitioner's (NP) Progress notes, dated 12/12/2025 at 7:45 AM, indicated Occupational Therapy had suggested use of a soft cervical collar to maintain neck alignment when eating meals. The NP indicated Resident 2 liked wearing the collar and wanted to wear it more frequently than current order parameters. No additional progress notes pertaining to use or refusal of Resident 2's cervical collar were available for review. Resident 2's current care plan, dated 1/26/2026, did not address use or refusal of a soft cervical collar. A current CNA Kardex, provided by the Administrator on 3/30/2026 at 1:26 PM, did not include instructions for the use of a soft cervical collar for Resident 2. In an interview, on 03/30/2026 12:56 PM, Certified Nurse Aide (CNA) 11 indicated Resident 2 trialed a cervical collar for meals only a few weeks ago but was unsuccessful. CNA 11 indicated she understood the collar was discontinued due to non-use. In an interview, on 03/30/2026 1:08 PM, the Director of Nursing (DON) indicated the facility had been discussing with the family Resident 2's decline in eating. The DON indicated a soft collar was used when Resident 2 was eating meals consistently. The DON indicated Resident 2 was being offered food for pleasure only and would be receiving a feeding tube soon, so the soft cervical collar was not being used. In an interview, on 03/30/2026 at 2:10 PM, the DON indicated Resident 2's cervical collar was currently in the laundry because it was dirty. The DON indicated any refusal should have been documented, and frequent refusals should have been cause for re-evaluation of the appropriateness of the device. The DON indicated the cervical collar was normally used for eating, but Resident 2 preferred to wear the device more often. She indicated the terms of the order were a compromise to accommodate Resident 2's preferences. The DON indicated the order should have been entered into the computer requiring a sign-off of acceptance or refusals each shift to track usage. In an interview, on 03/31/2026 at 8:42 AM, The Director of Therapy (DOT) indicated Resident 2 had a soft cervical collar implemented for a right-sided contracture of the neck. The DOT indicated Resident 2 had initially refused to take the cervical collar off, wishing to wear the collar while up in her chair and during meals. The DOT indicated she heard about Resident 2 refusing the collar about a month ago. The DOT indicated documentation of Resident 2 refusing the collar was the responsibility of the nursing department. A current policy, titled Braces and Assistive Devices- Assessment and Management, dated 10/23/2025, provided by the Administrator on 3/30/2026 at 12:47 PM, indicated refusals and follow up actions pertaining to an assistive device use should be documented and the care plan should be updated. The policy indicated the care plan should address the type of device, application instructions, monitoring guidelines, and any specific risks. 2. During an observation, on 3/25/2026 at 1:39 PM, Resident 20 was observed with her head leaning to the left side. Resident 20 was observed not to have her mechanical back splint in place. A food tray was in front of the resident, the plate was full and the chocolate milk was untouched. Resident 20 was not eating. During an observation, on 3/26/2026 at 1:34 PM, Resident 20 was observed with her head leaning to the left side and was not wearing her mechanical back splint. A food tray was in front of the resident with a food cover over the plate. During an observation, on 3/27/2026 at 12:37 PM, Resident 20 was observed with her head leaning to the left side and was not wearing her mechanical back splint. A full food tray was in front of the resident and she was not eating. Resident 20's record was reviewed on 3/25/2026. Diagnoses included unspecified intracranial injury with loss of consciousness of unspecified duration, hemiplegia affecting the left non-dominant side and traumatic subarachnoid hemorrhage without loss of consciousness. A review of the current care plan indicated Resident 20 had a problem of activities of daily living (ADL) self-performance deficit, with a goal to continue to feed herself meals with supervision through the next review. Interventions included application of a cervical/back splint during meals and removal after meals. A review of physician orders, dated 2/17/2025 at 5:30 PM, indicated the resident was to wear a cervical brace during all meals, angled approximately 30 degrees in extension, with a towel under the brace to reduce pressure. A review of the record indicated the last Minimum Data Set (MDS) assessment was completed on 1/6/2026. The MDS did not indicate Resident 20 utilized splints or braces. On 3/30/2026 at 10:19 AM, Resident Engagement (RE) provided a delivery receipt, dated 3/8/2026, for a back splint strap cover for Resident 20. During an interview, on 3/27/2026 at 12:39 PM, Certified Nursing Assistant (CNA) 9 indicated Resident 20 should have had the brace on; however, she may have removed it. CNA 9 asked the resident if she wanted the brace applied and the resident indicated she did. CNA 9 assisted with applying the brace however, Resident 20's head slipped out. CNA 9 repositioned the resident and attempted to reapply the brace again, but the resident's head slipped out again. CNA 9 indicated Resident 20's head continued to fall out of the brace and stated she was unsure if anyone had notified the Nurse Practitioner or Therapy regarding the issue. CNA 9 indicated she would obtain additional staff assistance. During an interview, on 3/27/2026 at 12:47 PM, CNA 10 attempted to position Resident 20's head in the brace however, the Velcro released and the resident's head fell forward. CNA 10 indicated the facility had recently repaired the Velcro on the brace. CNA 10 indicated Resident 20 was sliding further into her seat and the Velcro was unable to support her head. CNA 10 indicated she had not been instructed to implement any alternative interventions if the brace was ineffective and was unaware if the Nurse Practitioner or therapy had been notified. CNA 10 attempted to reposition the resident again however, the resident's head continued to fall out of the brace. CNA 10 asked Resident 20 if she wanted her to assist her with eating, Resident 20 indicated she did. During an interview, on 3/30/2026 at 9:56 AM, the Director of Therapy (DOT) indicated therapy was initially responsible for the brace however, after discharge from therapy services, any issues were managed by restorative nursing. The DOT indicated therapy completed screenings every three months to ensure the assistive device remained appropriate. The DOT indicated she was aware that the Velcro had continued to come undone. The DOT did not indicate any other actions had been taken to ensure Resident 20's brace was safe and fit properly. During an interview, on 3/30/2026 at 10:10 AM, the DOT indicated the last assessment was completed on 10/26/2025 and indicated therapy completed quarterly screenings to ensure appropriateness of assistive devices. The DOT did not indicate any additional actions were taken when staff informed them a brace or splint was not fitting properly. During an interview, on 3/30/2026 at 10:10 AM, the RE indicated the Velcro for Resident 20's brace was replaced on 3/8/2026. RE indicated staff had not reported any ongoing issues and indicated she was not made aware of concerns with the brace prior to last week. During an interview, on 3/30/2026 at 1:48 PM, Qualified Medication Aide (QMA) 15 indicated nursing staff should notify restorative nursing through the facilities internal communication systems to report issues with assistive devices. QMA 15 indicated restorative nursing would notify therapy if needed. QMA 15 further indicated that a resident's head slipping out of an assistive device was a condition that should have been reported. During an interview, on 3/31/2026 at 8:41 AM, the DOT indicated therapy initially recommended the assistive device due to positioning concerns identified by social services and occupational therapy completed the assessment and trial. The DOT stated Resident 20 was missed for her scheduled reassessment, which should have occurred approximately three months after the last assessment. The DOT indicated the resident was on the list for reevaluation as therapy was waiting for an order. A current facility policy, dated 7/31/2024, provided by the Executive Director, indicated the facility will assess all residents for the need and proper use of braces and assistive devices upon admission, with changes in condition and periodically as part of the comprehensive care plan process. nursing staff would report changes in mobility or tolerance. and reassess quarterly with MDS review. 410 IAC (Indiana Administrative Code) 16.2-3.1-42(2)

Based on record review and interview the facility failed to ensure neurological assessments were completed after falls for 3 of 8 residents reviewed. (Resident 6, Resident 13, and Resident 29)Findings include: Resident 6's record review began on 3/25/26 at 1:36pm. Diagnosis included epilepsy, dementia, and diabetes. In an interview, on 03/26/2026 at 1:46 PM, Licensed Practical Nurse 8 (LPN), explained the procedure for unwitnessed fall follow through. LPN 8 explained staff assess the resident for any injuries, attempt to figure out the cause of the fall, start neurological assessments, then did neuros every 15mins afterward x4, then neurological assessment (neuros) every hour x4, and then neuros every shift x 72 hours. The nurse would contact the provider and family. The nurse was to do a skin assessment, post fall assessment, dehydration assessment, and document findings in a progress note. In an interview, on 03/27/2026 at 11:12 AM, DIrector of Nursing (DON) indicated neuros were to be done after an unwitnessed fall every 15 minutes for the first hour, then hourly x4, and then every shift x3 days. Medical provider and family were to be notified. After each fall an intervention should be put into the care plan. A morse fall scale assessment should be done. On 3/30/26 at 10:15am, a review of Resident 6's neurological assessments indicated the following assessments were not completed for an unwitnessed fall:11/29/25 23:00 and 23:5811/30/25 1:03am and 2:00am 12/1/25 2nd shft12/2/25 3rd shift 2. Resident 13's record review began on 3/25/26 at 11:42am diagnosis included epilepsy, dementia, and diabetes.Resident 13's current care plan, dated 2/3/25, indicated he was at risk of falling. With a goal for fall to be minimized using care plan interventions to prevent injury through next review period. One intervention was to follow facility fall protocol. A review of neuro assessments indicated 9/16/25, 9/17/25 and 9/18/25 were missing 2nd shift neurological assessments.A review of neuro assessments, dated 12/20/25, was missing assessments at the following times; 10:20am, 10:35am, 10:50am, 11:05am, 12:05pm, 1:05pm, 2:05pm, and 3:05pm.A review of 12/21/25 neuro assessments indicated there were missing assessments for 1st and 2nd shift. A review of neuro assessments, dated 3/17/25, indicated no neuro assessment, were documented for the following times 4:15am, 4:30am, 5:30am. There were no neurological assessments every shift x72 hours for the dates of 3/18/25, 3/19/25, and 3/20/25.3. Resident 29's record review began on 3/25/26 at 12:41pm. Diagnosis included dementia, abnormal posture, and diabetes.In an interview, on 03/27/2026 at 2:04 PM, the DON indicated she was unable to locate neuros for the following falls: 4 on 11/10/25, 1 on 11/11/25, 1 on 11/12/25 and two on 11/13/25. The DON indicated the nurses began the 10/24/25 fall neurological assessments. She was unsure what happened the next three days. She was unable to find neuro assessments dated 10/25 through 27/2025 for Resident 29. A current policy, titled Falls Clinical Protocol, dated 11/16/17 was provided by the Executive Director on 3/26/26 at 11:29am indicated the following: In addition, the nurse shall assess and document/report the following:.Vital signsRecent injury, especially fracture or head injuryMusculoskeletal function, observing for change in normal range of motion, weight bearing, etc.Change in cognition or level of consciousnessNeurological statusPainFrequency and number of falls Precipitating factors, details on how fall occurredAll current medications, especially those associated with dizziness or lethargyAll active diagnosis. There were no specific directions of how often neurological assessments were to be done in the policy. 410 IAC (Indiana Administrative Code) 3.1-45(a)

Based on interview and record review, the facility failed to ensure a verbalization of suicidal ideation was investigated for 1 of 1 resident reviewed (Resident 77).Findings include:Resident 77's record was reviewed on 03/25/2026 at 11:25 AM. Diagnoses included Alzheimer's disease, anxiety, and depression.A current admission Minimum Data Set (MDS) assessment, dated 1/27/2026, indicated Resident 77 had a Basic Interview for Mental Status (BIMS) score of 4 (cognitively impaired).Resident 77's current care plan, dated 4/26/26, titled depression with history of suicidal ideation, indicated Resident 77 had a problem of depression. Interventions included redirecting Resident 77 when making comments related to suicidal ideation and notifying a supervisor immediately when suicidal comments were made.A progress note, dated 3/9/2026, at 4:24 PM, indicated Resident 77 told Volunteer 4 she had nothing to live for and wanted to kill herself. No additional progress notes regarding suicidal ideation were available for review. In an interview, on 03/27/2026 at 11:07 AM, the Director of Nursing (DON) indicated any resident verbalizing suicidal ideation should be asked if they had a plan to harm themselves. The DON indicated the resident's care plan for those types of issues should be reviewed and followed. The DON indicated a resident voicing suicidal ideation may be sent out for inpatient psychiatric care by the nurse practitioner if deemed appropriate. In an interview, on 03/27/2026 at 11:38 AM, Qualified Medicine Aide (QMA) 3 indicated upon a verbalization of suicidal ideation, staff should contact a supervisor and remain with the resident ensuring safety until given further instructions. QMA 3 indicated she was not aware of any recent statements by any residents. QMA 3 indicated she regularly worked on the unit Resident 77 resided on. QMA 3 indicated upon admission several months ago, Resident 77 was confused, and made suicidal remarks. QMA 3 indicated she was not aware of Resident 77's suicidal verbalization on the 9th of this month. In an interview, on 03/27/2026 at 11:45 AM, Life Enrichment Specialist (LCS) 2 indicated volunteers filled out a visit log describing 1 to 1 visits conducted with residents. LCS 2 indicated she collected 1 to 1 visit logs and entered visit notes into the computer on a weekly basis, LCS 2 indicated she read the statement of suicidal ideation on 3/18/2026 when she entered the log into the computer. LCS 2 indicated she should have reported the statement of suicidal ideation to the Resident Engagement Specialist as soon as she was aware. A document titled 1:1 log, provided by the Administrator on 03/27/2026 12:40 PM, indicated during a 3-minute visit with Volunteer 4 on 3/9/2026, Resident 77 indicated she had nothing to live for and wanted to kill herself . In an interview, on 03/27/2026 11:57 AM, Volunteer 4 indicated Resident 77 told him she had nothing to live for and wanted to kill herself on 3/9/2026. Volunteer 4 indicated he said kind words to Resident 77 and offered support. Volunteer 4 indicated he was unable to immediately find the unit nurse, so he went to the adjacent unit and reported the verbalization to the staff on that unit. In an interview, on 03/27/2026 1:13 PM, the Administrator indicated upon a report of suicidal verbalizations, staff should notify the nursing supervisor, initiate policy interventions such as performing a [NAME] suicide risk assessment and ensuring resident safety. The Administrator indicated results of the assessment should be reported to the provider and staff should follow any ensuing orders The Administrator indicated she had just become aware of the verbalization and was investigating where the communication lapse had occurred.A current policy, titled Suicide Threats, dated 2/28/2018, provided by the Administrator on 3/27/2026 at 12:51 PM, indicated staff should report any threats of suicide immediately to the Nurse Supervisor while maintaining supervision of the resident. The Nurse Supervisor or Resident Engagement Specialist should complete a Columbia Suicide Severity Rating Scale for the resident and report findings to the provider. Any applicable provider orders should be followed, and the details of the situation should be documented.410 IAC (Indiana Administrative Code) 16.2-3.1

Based on observation, interview and record review, the facility failed to ensure appropriate infection control practices related to the storage of resident care equipment for 1 of 2 residents reviewed (Resident 79).Findings include:During an observation on 3/25/2026 at 10:11 AM, the following was observed: Resident 79 was sitting in a recliner in his room and had a portable urinal bottle with yellow liquid inside hanging by the handle on the trash bin, dated 3/19/2026.During an observation on 3/26/2026 at 1:27 PM, the following was observed: Resident 79 was sitting in a recliner in his room and had a portable urinal bottle with yellow liquid inside hanging by the handle on the trash bin.During an observation on 3/27/2026 at 12:47 PM, the following was observed: Resident 79 was sitting in a recliner in his room and had a portable urinal bottle with yellow liquid inside hanging by the handle on the trash bin. A glove, plastic drinking cup, piece of folded paper and three paper towels were observed in the trash can.During an observation on 3/27/2026 at 1:15 PM, the following was observed: Resident 79 had a portable urinal sitting on top of his table. Also on the table were three remote controls and a piece of folded paper.Resident 79's record was reviewed on 3/25/2026. Diagnoses included altered mental status and diabetes mellitus.A review of Resident 79's current care plan did not indicate the resident required a urinal to be kept at the bedside or within immediate reach while seated in a recliner.In an interview on 3/27/2026 at 12:47 PM, Certified Nursing Assistant (CNA) 9 indicated the portable urinal hanging on the trash can was an infection control concern. CNA 9 indicated she was unsure where to place the urinal, as the resident's table had items on it. CNA 9 indicated Resident 79 went to the bathroom often and liked to have the urinal close by. Certified Nursing Assistant (CNA) 9 indicated she would dump the urinal and provide a fresh urinal.In an interview on 3/27/2026 at 12:47 PM, the Director of Nursing (DON) indicated that after a resident used a portable urinal, staff were expected to clean it and place it on the back of the toilet. The DON indicated clean portable urinals should be stored on the back of the toilet when not in use. The DON indicated this was the first time she had been made aware of Resident 79 storing the urinal on the trash can. The DON indicated the care plan should reflect if a resident preferred to have the urinal stored close by. The DON indicated Resident 79's care plan did not indicate such a preference.A current policy dated 10/2010, provided by the Executive Director, indicated: If the resident keeps his urinal at his bedside, check it frequently. Empty and clean it as necessary. Note on the resident's care plan his request to keep the urinal at his bedside. Remove urinal. Place it on a paper towel on the bedside stand. Cover the urinal immediately with a urinal cover or paper towel. Clean wash basin and return to designated storage area.410 IAC (Indiana Administrative Code) 16.2-3.1-18(a)

Based on interview and record review the facility failed to ensure adequate supervision was in place to prevent residents from leaving the facility unsupervised for 1 of 3 residents reviewed (Resident B). Resident B was unsupervised, walked approximately 3 miles across heavily traveled streets. Resident B's unsupervised wandering could result in death. The Immediate Jeopardy began on 6/15/25 when the facility failed to prevent Resident B from leaving the facility unsupervised. The Executive Director (ED) and Assistant Administrator were notified of the Immediate Jeopardy on June 17, 2025, at 12:34 PM. The Immediate Jeopardy was removed on June 18, 2025, but noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: An investigation file was provided by the ED on 6/17/25 at 9:15 AM. The file included an incident report, dated 6/15/25 at 12:56 PM, indicating Resident B was brought back to the facility by the local police department. The police indicated Resident B was found at an apartment complex on [NAME] Street (approx. 3 miles from the facility and having to cross heavy traffic). The report indicated Resident B indicated she went to her old apartment complex to check on the repairs needed. The file included statements of the following: The Chief Financial Officer (CFO)'s statement indicated she was working in the lobby on 6/15/25 and interacted with Resident B multiple times. The CFO indicated she observed Resident B exit the front door at 9:40 AM, returned at 9:45 AM, exited again at 9:55 AM, and returned at 9:55 AM. CFO indicated she observed Resident B exit again at 10:03 AM with no return after camera footage review. CFO indicated at 12:49 PM she received a call from Resident B's friend, who indicated Resident B was at her former apartment on [NAME] Street and the police told her friend they were going to bring the resident back to the facility. CFO indicated she notified Nursing Supervisor 4 who indicated Resident B had returned to the facility with the police. According to Google earth, Resident B would have crossed 2 main highly traveled streets from the facility to reach her prior residence at an apartment complex. Resident B's record was reviewed on 6/17/25 at 9:54 AM. Diagnosis included: unspecified mental disorder due to known physiological condition and chronic obstructive pulmonary disease. Resident B resided on the unsecured [NAME] neighborhood (facility unit) Resident B's care plan, dated 5-16-25, did not include the resident's ability to exit the facility alone or interventions for wandering. The care plan did not indicate how often the resident's whereabouts should be checked. Resident B's physician's orders, dated 5/16/25, indicated Resident B could go out on leave of absence (LOA) with family/friends. Resident B's Brief Interview for Mental Status (BIMS), dated 5/22/25, indicated Resident B had a BIMS score of 3/15 -severely impaired cognition. The resident was independently mobile, her mood scores did not indicate sadness or was seeking to go home. There were no exit seeking behaviors indicated on the MDS. She did have pacing behaviors indicated. Resident B's admission assessment, dated 5/16/25, indicated Resident B's reason for admission was due to memory issues. Resident B's wandering assessments, dated 5/16/25, 5/19/25 and 6/3/25, indicated Resident B was at high risk for wandering. The assessments did not address the risk for elopement. No elopement risk assessments were completed. A nursing note, dated 6/11/25, indicated Resident B was wandering around another neighborhood (unit within the facility) and reported she was lost. Staff directed the resident back to her room. A nursing note, dated 6/12/25, indicated Resident B was wandering and pacing around other neighborhoods (units throughout the facility). The note indicated Resident B told staff she was moving out of the facility and did not need to be at the facility. A nursing note, dated 6/15/25 at 1:45 PM, indicated Resident B was brought back to the facility by the local police department. The police officer indicated Resident B was at her old apartment approximately 3 miles away from the facility. The note indicated Resident B left without signing out, having a friend or family accompanying her, or alerting staff. Resident B told staff she left the facility a couple days ago, returned today but was unsure who brought her back. Resident B indicated she went to her old apartment to check on the work that was completed. There were no other notes to indicate Resident B wandered or felt lost between 6/12/15 and 6/15/25. An LOA form was provided by the ED on 6/17/25 at 1 PM. The LOA form indicated Resident B signed out with family/friends on 5/26/25 and 5/31/25. The LOA form did not include a signature for an outing on 6/15/25 related to Resident B's absence. During an interview, on 6/17/25 at 9:07 AM, Licensed Practical Nurse (LPN) 6 indicated Resident B resided on the [NAME] Neighborhood, an unsecured unit within the facility. The resident left the faciity on 6/15/25 without notifying staff or signing out of the LOA book. LPN 6 indicated Resident B was brought back to the facility by the local police department around 12:40 PM. LPN 6 indicated prior to Resident B exiting the facility, she had last seen her around 9 AM and was at her baseline. LPN 6 indicated she did not know Resident B had left the facility. During an interview, on 6/17/25 at 9:15 AM, Certified Nurse Aide (CNA) 7 indicated she last saw Resident B on 6/15/25 around 9 AM. CNA 7 indicated Resident B was in the main lobby area. Resident B usually ambulated independently and wandered the facility but never exited the facility without family/friends. The resident was fairly alert and cared mostly for herself. She indicated the resident usually ate lunch in the main dining room rather than on the neighborhood (facility unit), so she did not miss the resident at lunchtime. CNA 7 indicated she did not know Resident B had exited the facility. During an interview, on 6/17/25 at 9:25 AM, Nursing Supervisor 4 indicated she was notified Resident B was dropped off by the local police department on 6/15/26 at 12:46 PM. Nursing Supervisor 4 indicated she completed an assessment and talked to Resident B upon return. Nursing Supervisor 4 indicated Resident B was confused compared to baseline. Nursing Supervisor 4 indicated Resident B indicated she had walked to her old apartment to check in on the landlord repairs. Nursing Supervisor 4 indicated Resident B thought she had been away from the facility for the past 3 days and returned on 6/15/25 but was unsure who brought her back to the facility. During an interview, on 6/17/25 at 9:34 AM, the CFO indicated she was working in the lobby on 6/15/25. She indicated she had witnessed Resident D exit the building unsupervised prior to 6/15/25, but the resident always returned in a few minutes independently. The CFO indicated she had received a call from Resident B's friend, who indicated Resident B was picked up by the police at her old apartment and the police were headed back to the facility. The CFO took no action on 6/15/25 between 10:03 AM and 12:49 PM to ensure Resident B's safety. During an interview, on 6/17/25 at 12:47 PM, Resident B's son indicated he was not in the area on 6/15/25. He indicated Resident B had moved to the facility due to memory issues. She was unable to recall short-term memory items i.e. repetitive notes regarding the same issue, dates and times. He indicated prior to moving to the facility, Resident B lived in an apartment alone about 3 miles away from the facility. Resident B's son indicated on 6/15/25 the facility notified him Resident B had walked to her old apartment. He indicated the facility staff indicated the local police department brought Resident B back to the facility. During an interview, on 6/17/25 at 1:09 PM, Registered Nurse (RN) 5 indicated Resident B often wandered throughout the other neighborhoods (facility unit). RN 5 indicated Resident B was not safe to leave the facility alone due to her confusion. RN 5 indicated on 6/12/25 Resident B reported she was leaving the facility but was redirected. RN 5 indicated she did not know Resident B had exited the facility on 6/15/25. During an interview, on 6/18/25 at 10 AM, Resident's B former neighbor indicated the resident walked from the facility to the her prior residence at an apartment complex on 6/15/25. She indicated the resident had indicated she was coming home. Resident B's former neighbor indicated the resident had dementia. Resident B's former neighbor indicated a police officer had asked her if she knew the resident. She indicated the resident had told the police it took her 3 days to walk to her apartment complex. The neighbor indicated she called the facility and asked if the resident was missing. Staff indicated the resident was not missing and staff had seen resident recently. During an interview, on 6/18/25 at 9:50 AM, the ED indicated Resident B went to the her prior residence at an apartment complex on 6/15/25 either by walking or bus. The ED indicated the police were working outside the apartment complex and the resident went up to the police officer with a map to her apartment. The ED indicated Resident B asked the police officer for assistance to her apartment and the police officer called the landlady. The landlady indicated Resident B no longer lived at the apartment complex, she had moved to the facility. The police brought the resident back to the facility. During an interview, on 6/18/25 at 10:05 AM, the Social Services Director (SSD) indicated Resident B had a BIMS score of 3/15 (severely impaired) and was at high risk of wandering. SSD indicated during the admission assessment, Resident B refused to answer multiple questions which resulted in a BIMS of 3. SSD indicated the admission, 72 hour and 1 month wandering assessment included Resident B's dementia diagnosis, independent ambulation without a device, frequently walked around the facility and low BIMS score. This indicated resident was at risk for unsafe wandering. The SSD indicated interventions in place included to engage in activities. The SSD indicated Resident B did not exhibit exit seeking behaviors, was alert to place and person with mixed clarity and became confused at times. The SSD indicated residents who are at risk for wandering are not monitored at specific timeframes but are encouraged to participate in activities for connection. During an interview on 6/18/25 at 11:04 AM, LPN 8 indicated she assisted Resident B on 6/11/25. LPN 8 indicated Resident B indicated her son had stolen her apartment and then indicated her apartment was getting repaired. Resident B also indicated she would be back to her house in a couple days. LPN 8 indicated Resident B was easily redirected. A policy, dated 7/20, titled Missing Resident/Elopement, was provided by the ED on 6/17/25 at 1 PM. The policy indicated staff should attempt to prevent residents from elopement through assessment and interventions. The policy indicated an elopement risk assessment should be completed upon return to the facility. A policy, last revised 5/13/25, titled Care Plan - Comprehensive, was provided by the ED on 6/17/25 at 1 PM. The policy indicated resident's comprehensive care plans are designed to reflect the resident's current standards of practice for problem areas and conditions. The Immediate Jeopardy that began on 6/15/25 was removed and the deficient practice corrected on 6/18/25 when the facility re-educated all staff on facility policies for unsafe wandering and elopement, assessments and appropriate interventions but will remain at the lower scope and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. This citation relates to Complaint IN00461523. 3.1-45(a)

Based on observation, interview and record review the facility failed to ensure kitchen sanitation was maintained, opened food items were labeled and dated, and baking trays were thoroughly air dried. 95 of 96 residents residing in the building were served food prepared in the kitchen. Findings include: During an observation on [DATE] at 9:07 AM, A container of ice cream was observed in the walk-in freezer. The dietary manager (DM) opened the container and dip marks where ice cream had been removed were observed. No open date was observed on the container. A large, covered cart was observed in the back of the walk-in cooler with a discard date of [DATE]. The DM lifted the cart cover revealing individual pieces of cake on plates and bowls of fruit. The fruit and cake were not individually covered and appeared dry. A large bin labeled flour was observed with a scoop lying in the flour supply. A large bin labeled sugar was observed with a scoop lying in the sugar supply. Four chef salads were observed on plates covered with plastic wrap inside the reach-in cooler. No date was observed on any of the salads. An open box of popsicles was observed in the reach in freezer with an expiration date of [DATE]. A box was observed inside a reach in freezer containing frozen hamburger patties inside a plastic bag. The plastic bag was open leaving the meat open to air. A plastic bag containing breaded chicken strips was observed on a shelf in the freezer. The plastic bag was open with the meat open to air. A plastic bag containing French fries was open with the French fries open to air. No open dates were observed on the hamburger patties, chicken strips or French fries. A shelf next to the fryer was observed with a large amount of yellow oily liquid and brown specks of debris. The reach in freezer across from the fryer had multicolored streaks and splatters on the front of the doors. 3 of 4 baking pans had clear liquid dripping from them when separated in the ready to use baking pan storage stack. In an interview on [DATE] at 9:08 AM, the Dietary Manager (DM) indicated the container of ice cream should have been dated when opened. The DM indicated the cart containing the expired fruit and cake should have been disposed of on [DATE]. The DM indicated scoops for flour and sugar should be stored outside the supply. The DM indicated salads in the reach-in cooler should have been dated. The DM indicated the expired box of popsicles should have been discarded upon expiration. The DM indicated packages frozen hamburgers, chicken strips and French Fries should be closed after use to prevent air exposure and dated when opened. The DM indicated the fryer area, including the freezer doors, should have been cleaned after its last use, the previous evening. The DM indicated all baking pans should be air dried on a drying rack and stacked only after they were completely dry. A current policy titled Food Receiving and Storage dated ,d+[DATE] provided by the Administrator on [DATE] at 1:23 PM indicated Food Services or other staff should always maintain clean food storage areas. The policy indicated all food stored in the refrigerator or freezer should be covered, labeled and dated with a use by date. A current policy titled Preventing Foodborne Illness- Food Handling, dated ,d+[DATE] provided by the Administrator on [DATE] at 1:23 PM indicated all food service equipment should be sanitized according to current guidelines. A current policy titled Dishwashing Machine Use, dated ,d+[DATE] indicated after running items through the dishwasher, the items should be allowed to air dry. 3XXX,d+[DATE](i)(2) 3XXX,d+[DATE](i)(3)

Based on observation, record review, and interview the facility failed to ensure dignity was maintained for 1 of 1 resident reviewed. (Resident 10) Findings include: During an observation, on 5/15/25 at 7:26AM, Licensed Practical Nurse (LPN) 6 administered medications to Resident 10. The medications were administered in a common area while Resident 10 was sitting eating breakfast at dining table. The medications administered included Trulicity, a subcutaneous injection of a hypoglycemic agent. The Trulicity injection was administered in Resident 10's right upper quadrant of his abdomen after Resident 10 pulled up his shirt revealing his abdomen. In an interview, on 5/15/25 at 9:56AM, LPN 6 indicated she normally would stop giving medications and assist in serving breakfast rather than administering medications during breakfast. In an interview, on 5/15/25 at 10:10AM, Registered Nurse (RN) 5 indicated nurses were not permitted to give medications in the common area during breakfast due to dignity issues as well as residents were to enjoy their meal without interruptions. Resident 10's record review began on 5/15/25 at 2:06PM. The record indicated diagnoses included type 2 diabetes, chronic gingivitis, and unspecified dementia. Resident 10's care plan did not specify a preference to take medications in the common areas. A current policy, titled Quality of Life-Dignity undated, was provided by the administrator on 5/15/25 at 10:23AM. The policy indicated, 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .9.Staff shall maintain an environment in which confidential clinical information was protected, for example: b. signs indicating the resident's clinical status or care needs shall not be openly posted in the resident's room unless specifically requested by the resident or the resident's family member. Discreet posting of important of information 10. Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures . A current policy, titled Administered Oral Medications undated , was provided by the Administrator on 5/15/25 at 10:23AM. The policy indicated, 26. If the resident desires, return the door and curtains to the open position . 3.1-3(a)

Based on observation, interview and record review the facility failed to ensure privacy of electronic and paper medical information for 1 of 20 residents reviewed. (Resident 80) Findings include: During an observation, on 5/14/25 at 10:30 AM, a computer screen on top of a medicine cart was open with Resident 80's name, picture, medication list and other personal health information visible on the screen. A paper worksheet was lying on top of the medicine cart displaying vital signs and other health information for residents on the unit. The medicine cart was observed in a hallway leading to the common areas of the unit where staff and residents were observed passing by. During an observation, on 5/14/25 at 12:31 PM, Registered Nurse (RN) 5 was observed seated next to Resident 80 in the dining room assisting her with lunch. RN 5 rose from her chair, walked to the medicine cart, activated the lock and returned to her seat. The computer on top of the medicine cart was open to Resident 80's medication list and picture. A worksheet with visible vital signs and other resident information was observed sitting on top of the cart. Residents and staff were walking around the area preparing for the lunch meal and were in close enough proximity to view the computer screen and paper. Resident 80's record was reviewed on 5/14/25 at 1:14 PM. Diagnoses included cerebral palsy, abnormal weight loss, dysphagia, and altered mental status. A review of Resident 80's current significant change Minimum Data Set Assessment (MDS) dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was 3 (cognitively impaired). During an interview, on 5/14/25 at 12:40 PM, RN 5 indicated she had prepared and administered Resident 80's medications, but had forgotten to lock the screen when she stepped away from the cart. She indicated the computer screen should have been locked and the worksheet should have been turned over to keep resident information private. During an interview, on 5/16/25 at 12:26 PM, the Director of Nursing (DON) indicated computer screens should be locked when staff were not present and attending to them. The DON indicated any paper records should not have visible resident information in unsecured areas, such as on top of medication carts. A current policy titled Protected Health Information, Management and Protection of, dated 4/07 provided by the Administrator on 5/16/25 at 1:12 PM indicated all personnel with access to resident information should ensure the information is managed and protected to prevent unauthorized disclosure. A current policy titled Confidentiality of Information, dated 7/10/19, indicated all resident records should be safeguarded to protect the confidentiality of the information. The policy indicated access to medical records should be limited to staff and consultants providing care to the resident. 3-1(p)(5)

Based on record review and interview the facility failed to ensure a bed hold policy was given prior to discharge to 2 of 3 residents reviewed. (Resident 35 and Resident 47) Findings include: 1) Resident 35's record review began on 5/13/25 at 10:33AM. Resident 35's diagnoses included kidney failure, respiratory failure, and pneumonitis due to inhalation of food and vomit. On 10/8/24 Resident 35 was sent to the hospital. There was no documentation to indicate a bed hold had been explained to her or the family in the medical record. The facility was unable to show proof a bed hold was given prior to discharge. 2) Resident 47's record review began on 05/14/25 at 1:34 PM. Resident 47's diagnoses included respiratory failure, dysphagia, and altered mental status. Resident 47 was sent to the hospital on 3/8/25 there was no documentation to indicate a bed hold had been explained to him or his family in the medical record. The facility was unable to provide proof a bed hold was given prior to discharge. In an interview, on 05/16/25 at 12:27 PM, the Director of Nursing (DON) indicated a bed hold policy should have been documented in the progress notes. The DON indicated the resident, a family member, or power of attorney should always be informed of a bed hold policy at discharge prior to leaving the building. A current policy titled, Holding Bed Space was provided by the Administrator on 5/16/25 at 1:12PM. The policy indicated, Our facility shall inform residents upon admission and prior to transfer for hospitalization s or therapeutic leave of our bed-hold policy . No state rule applies.

Based on observation, interview and record review the facility failed to ensure assessments were accurately recorded for 2 of 2 residents reviewed. (Resident 1, Resident 35) Findings include: During an observation on 05/16/2025 at 1:38 PM the following was observed: the Director of Nursing approached Resident 1 to check pupils. Upon shining a flashlight in the left eye, the pupil appeared dilated, round and nonreactive to light; the right pupil appeared round, non-dilated, and reacted to light. Resident 1's record was reviewed on 05/14/2025 at 12:53 PM. Diagnoses included 6th abducent nerve palsy (affects the ability to turn the eye outward), 3rd oculomotor nerve palsy (affects the ability for eye to look straight ahead, also effects the pupils ability to constrict to light leaving the pupil dilated), and blepharoconjunctivitis (inflammation of the eyelid and conjunctiva (mucus membrane of eye)). A review of Resident 1's current quarterly MDS indicated their BIMS (Basic Interview for Mental Status) score was 5 (severe cognitive impairment). A review of Resident 1's current care plan titled Impaired Vision related to dry eye syndrome, blepharitis (inflamed, itchy eyelids), and ptosis (eyelids droop over eye) indicated the resident had a problem with inflamed, droopy eyelids, with a goal date of 07/23/2025. Interventions included washing eye lids with baby shampoo as ordered, referring to optometry as ordered, and head CT scan as ordered. There was no care plan for unequally sized pupils. A review of progress notes dated 04/30/2025 at 11:43 AM indicated when Resident 1 was seen by the eye doctor, they recommended for her to be sent to the ER for ptosis. The eye doctor believed it could be life threatening. Resident 1 refused to have an MRI performed, but agreed to a CT of the head. Resident 1 had known irregular pupils, had no mental status changes, no headache, no recent head trauma, and no complaints of eye pain. Skilled charting dated 2024 indicated Resident 1's pupils were equal, round, and reactive to light on 07/08, 07/16, 07/22, 07/29, 08/06, 08/12, 08/19, 08/27, 09/02, 09/09, 09/17, 09/30, 10/05, 10/14, 10/21, 10/29, 11/04, 11/05, 11/19, 11/25, 12/02, 12/19, and 12/25. Skilled charting dated 2025 indicated Resident 1's pupils were equal, round, and reactive to light on 01/01, 01/09, 01/22, 02/05, 02/12, 02/20, 03/13, 04/02, 04/03, and 04/24. A review of Resident 1's CT of the Head without contrast, dated 05/08/2025, indicated no acute findings. In an interview, on 05/14/25 at 10:34 AM, the Administrator indicated Resident 1's pupils had been unequal in size since 2022. In an interview, on 05/14/25 at 12:53 PM, the DON indicated the PERRLA (Pupils Equal, Round, and Reactive to Light and Accommodation) documentation needed to be better, and staff would be educated on performing neurological assessments and documentation. In an interview, on 05/16/25 at 09:40 AM, LPN 7 indicated pupils are to be checked when a fall happens and with mental status changes. Resident 1 had not had any mental status changes recently and the nurse was not aware of the resident having unequal pupils. In an interview, on 05/16/25 at 10:00 AM, RN 5 indicated skilled assessments are typically done weekly. If an assessment was missed, then she would make sure to get that done and charted. Resident 35's record was reviewed on 05/13/25 at 10:33 AM. Diagnoses included acute respiratory failure with hypoxia, pneumonitis (swelling and irritation of lungs) due to inhalation of food and vomit, and dysphagia (difficulty eating). A review of Resident 35's current quarterly MDS indicated their BIMS (Basic Interview for Mental Status) score was 3 (severe cognitive impairment). A review of physician's orders, dated 11/13/24, indicated to focus documentation for breath sounds, fever, oxygen saturation below 92% on room air, and increased respiratory rate greater than 24 breaths per minute every shift for 7 days. A review of physician's orders, dated 11/13/24, 11/25/24, and 12/20/24, indicated Resident 35 received chest X-rays for pneumonia and pleural effusion (fluid accumulation between lungs and chest wall). A physician's order, dated 12/11/24, indicated to completeanother follow up chest X-ray for pneumonia with effusion drainage related to recent chest tube removal. Change in condition supportive documentation, dated 11/15/24, indicated no breath sounds were assessed on second shift. On 11/16/24 no breath sounds were assessed for first or second shift. On 11/17/24 no breath sounds were assessed for third shift. In an interview, dated 05/14/25 at 10:53 AM, the DON indicated Resident 35 should have been assessed every shift as ordered. A current policy, dated 02/2014, provided by the DON indicated neurological assessments should include drooping eyelids, facial paralysis, asymmetry, and pupil size. A current policy dated 02/2014 provided by the DON indicated lung sounds, respirations, cough, consistency and color of sputum, oxygen use and oxygen saturations, and shortness of breath should be assessed during comprehensive assessments. 3.1-37 46818

Based on observation, interview and record review, the facility failed to ensure oxygen tubing was appropriately applied and stored when not in use for 1 of 2 residents reviewed. (Resident 28) Findings include: During an observation on 5/13/25 at 12:04 PM oxygen tubing was lying across Resident 28's bed unbagged. The bedside oxygen concentrator was turned on, releasing oxygen while Resident 28 was in the dining room. During an interview on 5/13/25 at 12:05 PM, Licensed Practical Nurse (LPN) 2 indicated bedside oxygen should be turned off when not in use and oxygen tubing should be bagged when not in use. LPN 2 indicated she was unable to find a bag in Resident 28's room to place her oxygen tubing in. During an observation on 05/15/25 10:19 AM, Resident 28 was observed lying on her right side in bed with her chin tucked to her chest, breathing in a labored manner. She was not wearing the oxygen. Resident 28's oxygen tubing was about 2.5 feet away from the resident lying neatly coiled, unbagged on a bedside table. The tubing was attached to an oxygen concentrator that was turned on and releasing oxygen. Resident 28's wheelchair was about 8 feet away from her bed. Resident 28's record was reviewed on 5/15/25 at 10:28 AM. Diagnoses included chronic respiratory failure with hypoxia, hypoxemia, shortness of breath, and need for assistance with personal care. A review of Resident 28's current quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated their Basic Interview for Mental Status (BIMS) score was 3 (cognitively impaired). The MDS indicated the resident utilized oxygen therapy. A review of Resident 28's current care plan regarding Impaired gas exchange indicated the resident had a problem of shortness of breath, with a goal date of 7/5/25. Interventions included monitoring for signs and symptoms of acute respiratory insufficiency including labored breathing and administering oxygen as directed. A review of physician orders dated 2/17/25 at 4:00 PM indicated oxygen should be administered up to 5 liters per minute for hypoxia or shortness of breath. A review of progress notes did not indicate any refusal of care or oxygen dated 5/15/25. During an interview on 5/15/25 at 10:23 AM, LPN 3 indicated Resident 28 was poorly positioned due to the head of the bed being raised and the resident sliding down causing her chin to tuck toward her chest resulting in labored breathing. She indicated Resident 28 would not have been able to place her oxygen tubing on the table as it was out of her reach and physical ability. She indicated Resident 28 was not able to self-transfer or walk from where her wheelchair was positioned across the room. She indicated Resident 28 should have been positioned better and should have had her nasal cannula placed in her nostrils. A current policy dated 10/2010, provided by the Administrator on 5/15/25 at 11:35 AM indicated staff should turn on the oxygen at the time of application and place the oxygen device on the resident. A current policy titled Oxygen Storage, dated 8/22/14 did not address storage of oxygen supplies when not in use. 3.1-47(a)(6)

Based on interview and record review the facility failed to ensure fall prevention interventions were followed for 1 of 4 resident reviewed (Resident B). Findings include: A facility reported incident file was provided by the Executive Director on 2/21/25 at 10:15 AM. The file included the following: The file, dated 2/4/25, indicated around 6:40 PM, Certified Nurse Aide (CNA) 5 assisted Resident B in the shower. Resident B was in the shower chair, started to foam at the mouth and turned blue. CNA 5 ran out of the room, left the resident alone in the shower chair, and got help. Upon return, CNA 5 and Qualified Medication Aide (QMA) 4 found Resident B on the floor of the shower. CNA 5's statement, undated, indicated while she assisted Resident B with a shower, Resident B foamed at the mouth. CNA 5 indicated she ran to get the nurse and upon return found Resident B on the floor of the shower. CNA 5's statement also indicated she did not witness the fall as she had ran to get the nurse and then came back. CNA 5 indicated she had left Resident B alone in the shower chair. QMA 4's statement, undated, indicated she was alerted by CNA 5, Resident B had turned blue and foamed at the mouth. QMA 4 indicated when she entered the room, Resident B was observed on the floor of the shower. In at interview, on 2/21/25 at 11:35 AM, the Director of Nursing (DON), indicated CNA 5 assisted Resident B with a shower in the shower chair. The DON indicated Resident B started to foam at the mouth and turned blue. The DON indicated CNA 5 left Resident B alone in the shower chair and ran to get assistance. The DON indicated when CNA 5 and QMA 4 returned to the room, Resident B was on the floor. The DON indicated Resident B had an unwitnessed fall while CNA 5 was out of the room. In an interview, on 2/21/25 at 11:25 AM, QMA 7 indicated when a resident was in the shower chair, the resident should never be left alone. QMA 7 indicated when additional assistance was needed, the call light should be pulled or staff yell out for help. QMA 7 indicated she would never leave the resident alone. In an interview, on 2/21/25 at 11:08 AM, CNA 6, indicated a resident was never left in the shower chair alone. CNA 6 indicated when a resident became unresponsive or had a change in condition while in the shower, she pulled the call light or yelled for help. Resident B's record was reviewed on 2/21/25 at 10:54 AM. Diagnosis included: history of a traumatic brain injury, muscle weakness, and quadriplegia. A quarterly fall assessment, dated 11/20/24, indicated Resident B was at high risk for falls. A current care plan indicated Resident B had a history falls due to a traumatic brain injury. The care plan indicated Resident B needed assistance with transfers and showers. A policy, dated 10/2005, titled Falls - Clinical Protocol, was provided by the DON on 2/21/25 at 11:45 AM. The policy did not indicate fall prevention interventions for high fall risk residents. This citation relates to Complaint IN00452850. 3.1-45(a)

Based on observation, interview and record review, the facility failed to ensure residents were free from mental and physical abuse by staff for 1 of 3 resident's reviewed (Resident D). The deficient practice was corrected on 2/1/24 prior to the start of the survey and was therefore past non-compliance. Findings include: A Indiana IDOH (Indiana Department of Health) incident report, dated 1/30/24 at 7:00 p.m., indicated the Administrator had viewed the facility camera, located on the male secured unit, for investigation of a staff members reported injury. The camera footage indicated at 5:04 a.m., QMA 2 walked into the nurse office followed by Resident D in his wheelchair. The resident was next seen on the floor outside the nurse office followed by his wheelchair coming out after him. He got back into his wheelchair and left the area. QMA 2 was observed to follow Resident D and removed the backpack off the back of his chair. A struggle between the 2 ensued and QMA 2 swung the backpack at the resident. QMA 4 came into view and ran towards the area where QMA 2 and the Resident were struggling over the backpack. QMA 2 took the backpack and threw it over into the kitchenette. Around 5:10 a.m., LPN 5 (Licensed Practical Nurse) entered the video pushing a cart carrying blue pharmacy bins. She was observed to be pointing at the resident, and pushed the cart towards him. LPN 5 then went behind and moved the residents wheelchair towards the exit door to the courtyard where she tipped him forward towards the door. QMA 4, QMA 6, and LPN 5 were seen with the resident at the door while QMA 2 walked around holding her right wrist. The resident was observed to go behind the nurse station to get his backpack, then went out to his wheelchair. At 5:15 a.m., Resident D was observed back in his wheelchair, seated outside the nurse office where QMA 2, QMA 4, and QMA 6 appeared to be speaking to the resident. LPN 5 was observed drawing up medication into a syringe. At 5:20 a.m., QMA 4 moved behind the resident while QMA 2 and QMA 6 held the residents hands down on the arms of his wheelchair. LPN 5 administered the injection. After the medication was administered, Resident D was observed propelling himself down the hallway following the 4 staff members. On 2/16/24 at 10:55 A.M., Resident D's record was reviewed. Diagnoses included Schizoaffective disorder, medication induced Parkinsonism, psychotic disorder with delusions, restlessness and agitation, anxiety disorder, and insomnia. An admission MDS (Minimum Data Set) assessment, dated 1/31/24, was completed following an extended stay at an inpatient psychiatric hospital. The resident had no cognitive impairment and was responsible for himself. The assessment indicated he had hallucinations and delusions. He had physical behaviors 1-3 days, verbal behaviors 4-6 days, behaviors not directed towards others 4-6 days, and wandering 1-3 days. His behaviors had worsened since his last assessment and hospitalization . The resident was prescribed multiple psychotropic medications to control his behaviors, hallucinations, and delusions. A behavior management plan of care, updated 2/13/24, indicated Resident D was physically and verbally aggressive towards staff and peers. He would grab at staff, block staff in areas, throw items, had intrusive behaviors such as interrupting conversations or talking over others, shadowing/following staff and peers, inappropriate usage of the phone (calling 911 to report delusional thoughts), name calling, yelling, screaming, and made excessive religious comments. At times he would refuse care and medications. The resident had visual and auditory hallucinations, would talk and respond to internal and unseen stimuli, talking in different voices. The behavior management plan of care had numerous interventions in place to keep the resident and his peers safe. On 2/19/24 at 10:00 A.M., Resident D was observed off the secured unit, sitting in his wheelchair next to the receptionist desk where a staff member sat, providing 1:1 supervision. He was playing a religious program on his MP3 player, had an open bible sitting next to him on the counter, and was speaking profanities to himself. On 2/19/24 at 10:45 A.M., the Administrator was interviewed. She indicated she interviewed Resident D on 1/30/24 at 3:00 p.m. He denied issues with staff and made comments about hitting women regardless of their color. When asked, he indicated he felt safe at the facility but had spent enough time here and it was time to move on. After viewing the video, the Administrator made several attempts to contact the 4 staff members involved in the incident to obtain statements. She was able to speak with 2 of the 4 employees including QMA 2 who alleged the resident had injured her wrist. The Administrator indicated all 4 employees were terminated on 1/30/24 before 5:30 p.m., their access to the facility and facility used media were terminated. There had been no reported concerns from residents, staff, or visitors regarding care provided by the 4 ex-employees prior to the incident on 1/30/24. The Administrator indicated the police were notified, she had spoken with IDOH CNA investigators and was fully cooperating with their investigation. Resident D was being monitored for psychosocial distress but hadn't had any change in behaviors or moods. A current facility policy, provided by the Administrator on 2/16/24 at 10:30 A.M. and titled Abuse Prevention Program, stated Our residents have the right to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment and involuntary seclusion The past non-compliance deficiency began on 1/30/24 and deficient practice corrected on 2/1/24 after the facility terminated the 4 employees involved in the incident, reported the incident to local law authorities and IDOH as required. Resident D was immediately monitored and continued to be monitored for psychosocial distress related to the incident. The facility completed education with all staff on the abuse prevention program, compassion fatigue, and de-escalation techniques and handling of agitated residents. On 1/31/24 and 2/1/24, all staff were re-educated on the facility's abuse policy/procedure, de-escalation techniques, and educated on compassion fatigue. The facility monitored and will continue to monitor staff interaction with residents each shift x 4 weeks, then will continue to monitor daily until 100% compliance is reached. The results will be monitored through the facility QAPI plan. This tag relates to Complaint IN00427412. 3.1-27(a)(b)

Based on observation, interview, and record review the facility failed to ensure comprehensive assessments were performed related to skin conditions for 1 of 3 residents reviewed. (Resident 65). Findings include: During an observation on 6/12/23 at 12:14 PM the following was observed: Resident 65 had a dime-sized dry, scabbed area on the right palm-side of the wrist. The resident indicated he wore a wrist brace frequently. Resident 65's record was reviewed on 6/12/23 at 2:15 PM. Diagnoses include scoliosis (curvature of the spine), contracture of muscle (stiffening of muscles due to lack of use), and muscle weakness. Resident 65's current quarterly MDS indicated their BIMS (Basic Interview for Mental Status) score was 13 (cognitively intact). There was no current care plan to address Resident 65's abrasion to the right wrist. Current physician orders indicated there were no orders to assess the skin under the splint for Resident 65's contracture of their right hand. Progress notes dated 6/12/2023 at 5:53 PM indicated Resident 65's right hand was clean, dry, and intact. There were no progress notes to indicate the scabbed area on Resident 65's wrist right wrist had been assessed, when the area had been discovered, the characteristics of the area, if physician and family notification had been completed. In an interview on 6/13/23 at 2:02 PM, Employee 5 indicated the right wrist had a scabbed area with pink surrounding tissue. A current policy dated 6/16/23 provided by the Administrator titled Skin Tears - Abrasion and Minor Breaks, indicated to record the following in the residents' medical record: 1. The site and description of the abrasion or wound. 2. The date and time the abrasion was discovered. 3. The date and time the injury occurred, if known. 4. The date and time the wound care was given. 3.1-37

Based on observation, interview, and record review the facility failed to ensure range of motion exercises and therapy devices were completed as ordered for 1 of 2 residents reviewed. (Resident 65) Findings include: In an observation of Resident 65 on 6/12/23 at 10:15 he did not have splint in his right hand. Resident 65's right hand was contracted. Resident 65's left and right foot had foot drop. During an interview with Resident 65 on 6/12/23 at 12:15 he indicated the staff do not always do his exercises, nor do they use his splint consistently. Resident 65 was alert and oriented x3 throughout the interview. Resident 65's record was reviewed on 6/13/23 at 3:37PM. His current quarterly MDS (MDS) Minimal Data Set assessment dated [DATE] indicated the following: Section C- Cognitive Patterns indicated Resident 65 BIMS score (Brief Interview of Mental Status) was 13. The score of 13 indicated minimal cognitive decline. Section E-Behavior indicated Resident 65 did not refuse care. Section G-Functional Status-indicated Resident 65 required extensive assist with many areas of daily living. Functional limitation in range of motion indicated there were no limitations in upper or lower extremities. Mobility devices indicated no assistive devices. The functional rehabilitation potential was not completed. Section I-Active Diagnosis- indicated Resident 65 had contracture of muscles at multiple sites. Resident 65's medication administration record and treatment administration record dated June 1st through June 13th, 2023, indicated the following: The order: Splint: apply splint/brace for 6 hours; staff to wash, rinse, dry, and apply lotion before splint application, scheduled for 6am. There was no documentation of completion on 6/1, 6/3, 6/4, 6/5, 6/6, 6/7, 6/9, and 6/10. The order: Active range of motion to left upper extremity to be completed every shift. There was no documentation of completion of range of motion exercises Between June 1, and June 10 , 2023. The order: Active range of motion to right upper extremity to be completed every shift was documented as completed once on 6/3 and once on 6/5. There was no other documentation of completion of exercises. Resident 65's record did not have documentation of any refusals of care. Resident 65's current care plan had the focus of at risk for reduced joint mobility dated 9/29/22 with last revision to goal on 5/17/23. A goal was to have no contractures to left upper extremity and right shoulder and elbow. An intervention was to perform range of motion exercises as prescribed. A policy titled; Range of Motion Exercises dated October of 2010 was provided by the Administrator on 6/16/23 at 9:42AM. The policy indicated Documentation the following information should be recorded in the resident's medical record: 1. The date exercises were performed. 2. The name and title of the individual who performed the exercises. 3. The type of range of motion exercises completed. 4. Whether the exercise was active or passive. 5. The initials of the person who performed exercises. 6. How long the exercises were conducted. 7. Any problems or complaints made by the resident related to exercises. 8. If the resident refused the treatment, the reason why and the intervention taken. 9. The signature and title of the person recording the data. 3.1-42(a)(2)

Based on observation, interview, and record review the facility failed to ensure oxygen tubing was properly stored and labeled when not in use for 1 of 5 residents reviewed. (Resident 44) Findings include: During an observation on 6/12/23 at 9:56 AM oxygen tubing and a humidifier bottle about 1/3 full of water was observed attached to the oxygen concentrator in Resident 44's room next to her bed. No dates were observed on the bottle or tubing. The tubing was coiled on top of the oxygen concentrator with the last 6 inches of the tubing, including the nasal cannula, hanging over the front portion of the concentrator. The tubing was not in a labeled bag. In an interview on 6/12/23 at 9:56 AM, Licensed Practical Nurse (LPN) 2 indicated oxygen tubing and humidifier bottles should be changed weekly and dated when changed. She also indicated tubing not in use should be placed in a dated bag. She picked up an unlabeled plastic bag from Resident 44's bedside table across the room and placed the tubing in the bag. In an interview on 6/14/23 at 10:21 AM, the Administrator indicated oxygen tubing should be labeled, dated, and changed weekly. She also indicated the tubing should be stored in a labeled and dated plastic bag when not in use. Resident 44's record was reviewed on 6/14/23 at 8:58 AM. Diagnoses included chronic obstructive pulmonary disease, anoxic brain damage, not elsewhere classified, pneumonia, organism unspecified, and heart failure, unspecified. Resident 44's current quarterly MDS dated [DATE] indicated her BIMS (Basic Interview for Mental Status) score was unable to be obtained because Resident 44 was unable to complete the interview. The MDS indicated Resident 44 required total assistance of one to two staff to perform activities of daily living. Resident 44's current care plan titled I am at risk for shortness of breath indicated Resident 44 had a problem of shortness of breath, with a goal date of 7/19/23. Interventions included use of oxygen. Physician orders dated 5/2/23 indicated oxygen was ordered to be administered as needed at 2 liters per minute for aspiration pneumonia. Progress notes indicated oxygen was administered on 6/4/23, 6/5/23, 6/7/23, 6/8/23, and 6/10/23. Medication administration records dated 6/23 and treatment administration records dated 6/23 did not indicate tubing changes had been performed. A current policy titled Oxygen Administration dated October 2010 provided by the Administrator on 6/13/23 at 1:32 PM did not address tubing changes or storage of tubing while not in use. The Administrator indicated the facility did not have a policy pertaining to tubing changes and storage. 3.1-47 (a)(4)(5)(6)

Based on interview and record review, the facility failed to ensure a resident was free from misappropriation of property for 1 of 1 residents reviewed (Resident D). Findings include: An Indiana report form, submitted by the facility, on 11/16/22 at 3:40 p.m., indicated potential misappropriation of resident property had occurred. The facility investigated the allegation and terminated the involved employee after determining the allegation was substantiated. On 12/12/22 at 11:51 A.M., Resident D's record was reviewed. Diagnoses included Alzheimer's disease and general anxiety disorder. He resided on the secured male memory care unit. The resident was able to ambulate by himself and wandered daily throughout the unit. An Investigation Summary Report, provided by the Administrator during an interview on 12/12/22 at 11:30 a.m., indicated Resident D had a Roku remote that had been reported missing on 11/11/22. A statement by LPN 5 (Licensed Practical Nurse) on 11/15/22, indicated she had reviewed the security camera footage at the nurses station where Resident D resided. She saw that CNA 7 (Certified Nurse Assistant) had clocked out at the end of her shift on 11/10/22 at 10:15 p.m. and then walked over to the nurses station counter where the Roku remote sat, grabbed it and put it into her pocket. The Administrator indicated an immediate investigation was started and CNA 7 was terminated on 11/16/22 for taking a resident's personal property. She indicated there were no other reports of missing items on the unit and the facility replaced the stolen Roku remote. On 12/12/22 at 12:43 P.M., LPN 5 was interviewed. She indicated, on 11/11/22 around 11:30 a.m., Resident D's spouse was visiting and reported to her the Roku remote could not be found. The resident had a Roku television in his room where staff would play movies, TV, or music for him at night when he had anxious behaviors. Resident D's spouse had requested the remote be kept at the nurse's station so he wouldn't misplace it and staff had access to it. The Roku remote was kept behind the nurses station/counter in a drawer. She indicated staff were alerted and looked for the remote over the weekend and the following Monday. On Tuesday, 11/15/22, LPN 5 reviewed the security camera footage to see if another resident had picked up the remote because it still hadn't been found. Upon review, she saw CNA 7 had taken the remote, following her shift on 11/10/22. LPN 5 reported the information to her supervisor. A current policy, titled Abuse Prevention Program and provided by the Administrator on 12/12/22 at 11:30 a.m., stated the following: Our residents have the right to be free from abuse, neglect, exploitation, misappropriation of resident property This Federal tag relates to Complaint IN00394955. 3.1-28(a)

Based on observation, interview, and record review, the facility failed to ensure recipes were followed when preparing pureed foods for 17 of 17 residents reviewed. (Resident 77, Resident 75, Resident 28, Resident 33, Resident 35, Resident 70, Resident 20, Resident 2, Resident 55, Resident 62, Resident 56, Resident 74, Resident 65, Resident 38, Resident 44, Resident 57, and Resident 1). In an interview on 8/30/22 3:22 PM, the administrator and dietary manager indicated 17 residents received pureed diets from the facility kitchen. Resident 77's record was reviewed on 9/1/22 1:40PM. Diagnoses included type 2 diabetes mellitus without complications, vitamin D deficiency, unspecified, dysphagia, oropharyngeal phase, nutritional [CONDITION(S)], unspecified, gastro-[CONDITION(S)] reflux disease without esophagitis. Dietary orders included regular diet, pureed texture, honey consistency, individual bowls, nosey cups maroon spoon for diet. Resident 75's record was reviewed on 9/1/22 1:45PM. Diagnoses included dysphagia, oropharyngeal phase, type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene. Dietary orders included regular diet, pureed texture, nectar consistency, may use nosey cup, adaptive equipment: maroon spoon with every meal. Resident 28's record was reviewed on 9/1/22 1:56PM. Diagnoses included type 2 diabetes mellitus without complications, feeding difficulties, unspecified, dysphagia, oropharyngeal phase, gastritis, unspecified, with bleeding, gastrointestinal hemorrhage, unspecified, [CONDITION(S)]. Dietary orders included regular diet, pureed texture, nectar consistency, double portion at breakfast for diet order. Resident 33's record was reviewed on 9/1/22 2:04PM. Diagnoses included type 2 diabetes mellitus without complications, dysphagia, oropharyngeal phase, gastro-[CONDITION(S)] reflux disease without esophagitis. Dietary orders included regular diet, pureed texture, nectar consistency, may have regular chocolate milk, maroon spoon/small spoon. Resident 35's record was reviewed on 9/1/22 2:14PM. Diagnoses included dysphagia, oropharyngeal phase, post gastric surgery syndromes, [CONDITION(S)], unspecified, spastic [CONDITION(S)] [CONDITION(S)]. Dietary orders included regular diet, pureed texture, regular/thin consistency, double entree/protein at meals, deep dish, spouted cup with straw see restorative program, prefers to use long handled teaspoon related to [CONDITION(S)] infantile [CONDITION(S)]. Resident 70's record was reviewed on 9/1/22 2:23PM. Diagnoses included personal history of [CONDITION(S)], vitamin D deficiency, unspecified, dysphagia, oropharyngeal phase, [CONDITION(S)], gastro-[CONDITION(S)] reflux disease without esophagitis. Dietary orders included regular diet, pureed texture, nectar thick consistency, maroon spoon, divided plate. Resident 20's record was reviewed on 9/1/22 2:29PM. Diagnoses included [CONDITION(S)], unspecified, dysphagia, oropharyngeal phase. Dietary orders included regular diet, pureed texture, nectar consistency, may have regular consistency carbonated drinks, to be upright for meals and 20 minutes following all intakes, maroon spoon for diet. Resident 2's record was reviewed on 9/1/22 2:40PM. Diagnoses included type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene, hypermagnesemia, dysphagia, oropharyngeal phase, [CONDITION(S)], personal history of other malignant neoplasm of large intestine, acquired absence of other specified parts of digestive tract. Dietary orders included regular diet, pureed texture, regular/thin consistency, may have mechanical soft snacks with distant supervision, maroon spoon, divided dish. Resident 55's record was reviewed on 9/1/22 4:14PM. Diagnoses included type 2 diabetes mellitus without complications, vitamin D deficiency, unspecified, dysphagia, oral phase. Dietary orders included regular diet, pureed texture, regular/thin consistency, individual bowls, double portions, may have mechanical soft snacks with supervision for diet order. Resident 62's record was reviewed on 9/1/22 4:18PM. Diagnoses included personal history of [CONDITION(S)], traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, subsequent encounter, other symptoms and signs involving the musculoskeletal system, other symptoms and signs involving the nervous system, vitamin D deficiency, unspecified. Dietary orders included regular diet, pureed texture, regular/thin consistency, double portions of entree/protein at meals for weight loss and varied intakes. Resident 56's record was reviewed on 9/1/22 4:27PM. Diagnoses included, dysphagia, oropharyngeal phase. Dietary orders included regular diet, pureed texture, nectar consistency. Resident 74's record was reviewed on 9/1/22 4:33PM. Diagnoses included nutritional [CONDITION(S)], unspecified, dysphagia, oral phase, personal history of [CONDITION(S)] disease, vitamin D deficiency. Dietary orders included regular diet, pureed texture, regular/thin consistency. Resident 65's record was reviewed on 9/1/22 4:36PM. Diagnoses included dysphagia, oral phase. Dietary orders included regular diet, pureed texture, regular/thin consistency. Resident 38's record was reviewed on 9/1/22 4:38PM. Diagnoses included type 2 diabetes mellitus without complications, gastrointestinal hemorrhage, unspecified, vitamin D deficiency, unspecified, dysphagia, oral phase, disorders of magnesium metabolism, unspecified, hypo-osmolarity and [CONDITION(S)], [CONDITION(S)], gastro-[CONDITION(S)] reflux disease without esophagitis. Dietary orders included regular diet, pureed texture, regular/thin consistency. Resident 44's record was reviewed on 9/1/22 4:44PM. Diagnoses included, dysphagia, oropharyngeal phase, [CONDITION(S)]. Dietary orders included regular diet, pureed texture, pudding consistency. Resident 57's record was reviewed on 9/1/22 4:47PM. Diagnoses included, dysphagia, oropharyngeal phase, hypo-osmolarity and [CONDITION(S)], [CONDITION(S)]. Dietary orders included regular diet, pureed texture, nectar consistency, sit upright during oral intake, remain upright for 30 minutes following oral intake, spouted cup, position upright in wheelchair, bed, no straws, staff to assist with eating. Resident 1's record was reviewed on 9/1/22 4:53PM. Diagnoses included [CONDITION(S)] disease, [CONDITION(S)], vitamin D deficiency, unspecified, gastro-[CONDITION(S)] reflux disease without esophagitis, dysphagia, oropharyngeal phase. Dietary orders included regular diet, pureed texture, nectar consistency, may have regular consistency for chocolate milk. During an interview on 8/29/22 at 11:36AM, Cook 3 indicated she was preparing pureed beef and noodles for 23 residents, 23-25 servings. Cook 3 indicated she had a guide to tell her the number of residents on each hall that received pureed food. She would measure, using the # (number) 6 scoop, the number of servings needed to serve the residents on a hall and place it in a metal pan, cover the pan and place in the warmer for delivery to the hall. Cook 3 indicated she had already prepared some beef and noodles. Cook 3 indicated she had prepared mashed potatoes, and she followed the instructions on the box. During an observation on 8/29/22 at 11:43PM, Cook 3 used a plastic pitcher like scoop, placed 3 scoops of previously prepared beef and noodles into a robot coupe (device that chops and blends food). She added brown colored liquid from a large glass measuring cup to the beef and noodles in the robot coupe. Cook 3 indicated that she estimated she had added about 1/2 cup of broth. She turned on the robot coupe to blend the food, added additional broth which she estimated was about 1/8 cup and turned on the robot coupe to blend the food. Cook 3 added the remaining broth from the measuring cup, she estimated about 1/8 cup and blended the beef and noodle mixture until smooth. Cook 3 measured 5 scoops, using a # 6 scoop, into a metal pan, covered the pan with plastic wrap and placed the metal pan in a warmer. Cook 3 removed her gloves and washed her hands. Cook 3 retrieved a clean bowl for the robot coupe. She donned clean gloves, added previously prepared green beans with liquid, contained in a small metal serving table pan, to the robot coupe bowl. Cook 3 was unable to verbalize the amount of green beans and liquid she added to the robot coupe bowl. I just put the green beans in with the liquid from the beans. Cook 3 turned on the robot coupe to blend the beans until smooth, then added 2 tablespoons of thickener, measured with a measured tablespoon. Cook 3 turned on the robot coupe, blended the green beans, added 1 tablespoon of thickener and blended the green beans again. She indicated she didn't want the puree too thick or thin, she knew the right consistency by doing it for years, and how the food dripped off the spoon. In an interview on 8/29/22 at 12:01 PM, the Dietary Manager indicated recipes for preparing pureed foods were available in a binder. The binder was located on the preparation table near where the Dietary Manager was standing during the observation. In an interview on 8/29/22 at 4:28PM, Cook 4 indicated she had already pureed food for the evening meal. Cook 4 indicated, for the hall they were currently serving, she prepared 11 hotdogs. She indicated she added 11 hotdogs to the robot coupe, added about 8 ounces of water, I eyeballed it. Cook 4 indicated she made mashed potatoes, replacement for French fries on a pureed diet, added water and butter to potato flakes according to the instructions on the box. Cook 4 indicated she prepared the vegetable by adding a little amount of water, did not pay attention to the amount, see the right consistency. She indicated she knew the consistency was right when it looked like baby food, not too thick or thin. Cook 4 indicated a chart was available with different consistencies, she used it sometimes. A current recipe, titled beef and noodles pureed thick, was received from the Dietary Manager on 8/29/22. The recipe indicated 20 #8 scoop portions. Ingredients included beef and noodles 20 8-ounce ladle, low sodium beef base 1 1/3 tablespoon, hot water 1-quart 1/2 cup, food thickener 1 cup. Instructions included .1. Measure portions requires from the regular prepared recipe. 2. Place in food processor and process until fine in consistency. 3. Combine hot broth and thickener and gradually add while processing, until a smooth consistency. All broth may not be required. 4. Scrape down sides of processor with a rubber spatula and process for 30 seconds. Allow mixture to thicken 60 seconds: it will be thick enough to hold its own shape A current recipe, titled Mashed Potatoes Instant Prep (Granule) USDA, was received from the Dietary Manager on 8/29/22 at 12:15 PM. The recipe indicated 50 #8 scoop portions. Ingredients included hot water 3 1/2 quart, skim milk 1-quart 3/4 cup, potato granules 2 pound 1 ounce, unsalted butter 3/4 cup, salt 1 tablespoon. Instructions included .1. Pour water and milk into mixer bowl. 2. Add instant potato granules, margarine or butter, and salt. 3. Mix 1/2 minute to moisten potatoes. Beat an additional 1 minute until fluffy. (Use of a mixer is recommended) . A specific recipe for pureed mashed potatoes was not provided. A current recipe, titled Beans Green Canned Pureed Thick, was received from the Administrator on 8/30/22 at 3:22 PM. The recipe indicated 1 #16 scoop portion. Ingredients included canned green beans 1/2 cup, margarine 1 1/4 teaspoon, food thickener 3/8 teaspoon. Instructions included . 1. Remove portions required from the regular prepared vegetable (drain liquid). 2. Add drained vegetables with melted margarine to food processor and process until smooth in texture. 3. Add a food thickener. Process briefly until mixed, scraping sides of bowl . A current recipe, titled Hot Dog [NAME] Island Pureed Thick, was received from the Administrator on 8/30/22 at 3:22PM. The recipe indicated 1 each portion. Ingredients included [NAME] beef 5# 1 each, canned chili without beans 1 tablespoon, shredded mild cheddar cheese 2 tablespoon, hot water 1/3 cup 1 tablespoon, beef base 3/8 teaspoon, food thickener 1 1/4 teaspoon, pureed bread 2 2/3 slice. Instructions included . 1. Gather ingredients to prepare pureed sandwich. 2. Add meat/cheese/condiments etc. (exclude bread) to a food processor and process until fine in consistency. 3. Add base to hot water and gradually add to mixture while processing to a smooth homogenous consistency. 4. Add food thickener and process briefly until mixed. Scrape down sides of processor with a rubber spatula and process for 30 seconds . Note: Measurements of liquid and food thickener may be adjusted to achieve desired consistency. A current recipe, titled Vegetable Blend Mixed Pureed Thick, was received from the Administrator on 8/30/22. The recipe indicated 1 #16 scoop portion. Ingredients included mixed vegetable blend 1/2 cup, margarine 1 1/4 teaspoon, food thickener 3/8 teaspoon. Instructions included . 1. Remove portions required from the regular prepared vegetable (drain liquid). 2. Add drained vegetables with melted margarine to food processor and process until smooth in texture. 3. Add a food thickener. Process briefly until mixed, scraping sides of bowl . In an interview on 8/30/22 at 2:47 PM, the Administrator indicated there was no specific policy regarding how to prepare pureed food, that was included in the therapeutic diet policy which indicated follow the recipe. She indicated the recipe is not exact science, staff looked at the consistency of the food. The Administrator indicated the facility had no choking issues or taste issues with residents on pureed diets. She indicated 2 staff members check the taste, quality, and homogenous consistency. 17 residents received pureed diets, extra portions were made for those receiving large portions, double protein. She indicated a recipe was followed to make the food for the whole facility then food was taken to puree for those on a pureed diet. The Dietary Manager was present during the interview but did not speak. In an interview on 9/1/22 at 9:08AM, the Chief Executive Officer indicated she had spoken with the dietary staff. She indicated they had measured the beef and noodles, added liquid to thicken and hold shape. She provided a recipe, titled Beef and Noodles Pureed Thick, highlighted instructions .3. Combine hot broth and food thickener and gradually add while processing, until a smooth consistency. All liquid may not be required . it will be thick enough to hold its own shape . In an interview on 9/1/22 at 10:42 AM, the Dietician indicated staff should follow the spreadsheet instructions (recipe) when preparing pureed food, make sure to have the right serving size, and amounts. Food amounts and specific amounts of liquid were on the spreadsheets in a binder. Staff were to look at the texture of the food when done but follow the recipe. The Dietician indicated some foods, beef and noodles for example, had some flexibility in adding liquid due to the type of food but staff should still be following a recipe. He indicated nutritional value of the food could be altered if too much or too little liquid is added. Staff should follow the spreadsheets as written. A current policy, titled Therapeutic Diets, dated 11/21/2021, was received from the Administrator on 8/30/2022 at 8:32 AM. The policy included a policy statement .Therapeutic diets shall be prescribed by the attending physician . Policy interpretation and implementation included . 1. Mechanically altered diets, as well as diets modified for medical or nutritional needs, will be considered therapeutic diets. This includes mechanical soft and pureed textures as well as honey, nectar, and pudding thick liquids. 2. A therapeutic diet must be prescribed by the resident's attending physician. The physician's diet order should match the terminology used by food services. 4. Routine menus (without therapeutic purpose) are planned by the Food Service Manager and approved by a Registered Dietician for nutritional adequacy. The regular menu will be modified by the Registered Dietician for therapeutic diets, with input from the Dietary Manager for feasibility of kitchen production. 7. Residents on therapeutic diets will not receive extra or reduced portions or modifications that are not part of the diet, unless approved by the attending physician in conjunction with the Clinical Dietician . The policy did not include how pureed food is to be prepared. 1.3-21(a)(3)