Every finding on record at Caroleton Healthcare Center

Based on interview and record review, the facility failed to have complete and accurate documentation for the use of an antibiotic and failed to accurately document a resident's refusal of wearing heel boots and refusal of fingernail care for 3 of 34 residents reviewed for complete and accurate documentation (Resident 1, Resident 3 and Resident 32). Findings include:1. Review of the record for Resident 1 on 04/22/2026 at 12:21 p.m., indicated the resident's diagnosis included, but was not limited to, pneumonia (infection that inflames the air sacs in one or both lungs, causing them to fill with fluid or pus). The physician's order for Resident 1, dated 1/20/26, indicated the resident was ordered ceftaiaxone (antibiotic) 1 gram intravenously every 24 hours for pneumonia. The infection surveillance criteria report for Resident 1, dated 1/20/26 at 11:13 a.m., indicated for pneumonia all three criteria 1a, 1b, and 1c must be met. Resident 1 was marked for 1a - for chest x-ray demonstrate probable pneumonia, 2a - new or worsening cough, new or increased sputum production and new or changed lung exam abnormalities and 1c- was not marked for any of the symptoms. The significant change Minimum Data (MDS) assessment for Resident 1, dated 3/5/26, indicated the resident had an acute short hospital stay. The resident was severely impaired for daily decision making. During an interview with the infection control nurse on 04/23/2026 at 1:08 p.m., she indicated the facility utilized the McGeer criteria (standardized surveillance to identify and monitor for infections) for the use of antibiotics. The infection control nurse indicated she would look for the documentation that Resident 1 met the criteria for antibiotic use on 1/20/26. During an interview with the infection control nurse on 4/23/26 at 2:23 p.m., she indicated she forgot to document 1c for mental status change and decline in Activities of daily living for Resident 1 on the 1/20/26 infection control criteria report. 2. The clinical record for Resident 3 was reviewed on 4/24/2026 at 12:48 PM. The medical diagnoses included, but were not limited to, partial traumatic amputation of two or more toes and damage to the nerves from complications of diabetes. The admission MDS Assessment, dated 3/10/2026, indicated Resident 3 was cognitively impaired and did not reject care. Resident 3 was dependent on staff for hygiene needs, turning, and transferring. Resident 3 had a non-removable dressing, surgical wounds, and dressings to areas other than feet. A care plan, dated 3/11/2026, indicated Resident 3 had delirium and confusion. The interventions included, but were not limited to, observing behaviors including types of behaviors, frequency, and interventions utilized to help manage behaviors.A care plan, dated 3/11/2026, indicated Resident 3 had skin impairments. The interventions included, but were not limited to, to utilize pressure reducing heel boots while in bed.During an observation, on 4/23/2026 at 1:50 p.m., Licensed Practical nurse (LPN) 5 offered Resident 3 to put on his heel boots while in bed. Resident 3 refused to use heel boots and requested to float his heels with a pillow instead. Behavior monitoring documentation for 4/23/2026 (after the observation of the resident's refusal) indicated Resident 3 did not have any refusals of care. 3. The clinical record for Resident 32 was reviewed on 04/22/2026 at 12:37 PM. The medical diagnoses included, but were not limited to, stroke and alcohol induced dementia. An annual MDS, dated [DATE], indicated Resident 32 was cognitively impaired, did not refuse care, and was dependent on staff for grooming and hygiene needs. A care plan, initiated on 10/24/2020 and revised on 2/18/2026, indicated Resident 32 was at risk for skin alterations. The interventions included, but were not limited to, keeping Resident 32's fingernails short. A care plan, dated 7/29/2021 and revised on 2/18/2026, indicated Resident 32 had a mood disorder. The interventions included, but were not limited to, observing behaviors including types of behaviors, frequency, and interventions utilized to help manage behaviors.Review of the behavior management log for Resident 32, completed on 4/21/2026, indicated Resident 32 had one episode of refusals of care for 4/1/2026 through 4/21/2026. During an observation on 4/21/2026 at 10:56 AM, Resident 32 was sitting in the dining room. Resident 32's fingernails were long, jagged, and cracked on both hands.During an interview and observation, on 4/22/2026 at 12:05 PM, Resident 32's care was observed with Certified Nursing Assistant (CNA) 4. Resident 32 had long, jagged nails on both hands with brown debris underneath the fingernails on the left hand. CNA 4 touched Resident 32's hand and he immediately swatted at her. CNA 4 indicated Resident 32 refused nail care on almost every shower day, including every time CNA 4 gave Resident 32 a bed bath that month. When Resident 32 refused, CNA 4 would pass it on in report so staff could reapproach. During an interview, on 4/22/2026 at 2:00 PM, Director of Nursing (DON) indicated Resident 32 refused care, including nail care, often.During an interview, on 4/23/2026 at 2:20 PM, Assistant Director of Nursing (ADON) indicated resident behaviors should be documented on their behavior management logs within the electronic medical record. A policy entitled, Behavior Management, was provided by the DON, on 4/23/2026 at 1:57 PM. The policy indicated to document behaviors within the clinical record. 410 IAC (Indiana Administrative Code) 16.2-3.1.50(a)(1)410 IAC (Indiana Administrative Code) 16.2-3.1.50(a)(2)

Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) while providing catheter care and during a pressure ulcer treatment for 2 of 5 residents reviewed for infection control (Resident 4 and Resident 3). Findings include:1. During an observation and interview with Resident 4 on 4/21/2026 at 10:56 a.m., the resident indicated he had his catheter prior to coming to the facility. Resident 4 indicated staff did not wear a gown when providing catheter care but did wear gloves. The resident was observed to have an EBP sign at the doorway and EBP equipment hanging on the door (gowns and gloves). During an observation and interview on 4/22/26 at 12:34 p.m., Qualified Medication Aide (QMA) 3 and Certified Nursing Assistant (CNA) 7 came into Resident 4's room and applied gloves. There was no hand hygiene prior to the staff putting on their gloves. QMA 3 and CNA 7 did not put on a gown during care. QMA 3 obtained a wash basin and washcloths, lowered the head of the resident's bed down and raised the bed up with the bed remote control, removed Resident 4's incontinent brief and used a wet soapy washcloth to clean the resident. QMA 3 then took the soapy washcloth and cleaned the resident's catheter tubing. CNA 7 took off her gloves and took the soiled linen in a plastic bag out of the room. QMA 3 removed her gloves and applied another pair of gloves on and drained the resident's catheter bag into a urinal without performing hand hygiene. QMA 3 and CNA 7 indicated they kind of remembered the facility training them on wearing gown during care of a catheter. QMA 3 indicated she would normally wear a gown when providing catheter care but did not this time. Review of the record for Resident 4 on 4/22/26 at 1:15 p.m., indicated the resident's diagnosis included, but was not limited to, urinary tract infection (UTI). The plan of care for Resident 4, dated 1/7/26, indicated the resident required EBP for indwelling medical device of a foley catheter. The interventions were appropriate Protective Personal Equipment (PPE) would be utilized during high contact care such as providing personal hygiene, changing a brief and related to catheter care. 2. During an observation, on 4/23/2026 at 1:50 PM, Licensed Practical Nurse (LPN) 5 completed wound care for Resident 3's multiple wounds. When changing the dressings to Resident 3's left knee wound, LPN 5 had the Assistant Director of Nursing (ADON) remove scissors from LPN 5's pocket. The scissors were not cleaned prior to being used to cut the xeroform (a non-adhering primary wound dressing). LPN 5 removed the soiled dressing to Resident 3's left knee. LPN 5 was observed not changing her gloves or perform hand hygiene between removing and cleaning the resident's left knee wound and re-applied a clean dressing. LPN 5 then addressed the resident's pressure area to the left heel. LPN 5 removed the resident's soiled dressing and cleaned the resident's wound. LPN 5 did not perform hand hygiene when she changed her gloves and then re-applied a new dressing to Resident 3's left heel. The clinical record for Resident 3 was reviewed on 4/24/2026 at 12:48 PM. The medical diagnoses included, but were not limited to, partial traumatic amputation of two or more toes and damage to the nerves from complications of diabetes. The admission MDS Assessment, dated 3/10/2026, indicated Resident 3 was cognitively impaired. A pressure care plan, dated 3/9/2026 and reviewed 4/17/2026, indicated Resident 3 had pressure ulcers. An intervention, dated 3/25/2026, indicated for Resident 3 to provide wound care as indicated.A wound care report, dated 4/22/2026, indicated Resident 3 had a blister to the left knee, one diabetic foot ulcer on the left foot, three diabetic foot ulcers on the right foot, and pressure injuries to the left heel, left lateral foot, and right lateral foot. During an interview, on 4/23/2026 at 2:20 PM, ADON indicated she would expect hand hygiene to be performed before the procedure, each time LPN changed her gloves, and after the procedure. ADON expected scissors to be cleaned before being used on a clean dressing procedure. A policy entitled, Standard Precautions, was provided by the DON, on 4/23/2026 at 1:57 PM. The policy indicated hand hygiene should be performed after glove removal and after contact with residents' wound dressings. 410 IAC (Indiana Administrative Code) 16.2-3.1-18(a) 410 IAC (Indiana Administrative Code) 16.2-3.1-40(a)(2)410 IAC (Indiana Administrative Code) 16.2-3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to perform hand hygiene and change gloves when providing catheter (a tube that is inserted into the bladder, allowing urine to drain freely) care for 1 of 2 residents reviewed for catheter (Resident 4). Findings include:During an observation and interview with Resident 4 on 4/21/2026 at 10:56 a.m., Resident 4 indicated he had his catheter before being admitted to the facility. Resident 4 indicated he had been diagnosed with a urinary tract infection a few times since being at the facility. The resident had an indwelling catheter bag (a sterile, closed-drainage container connected to an indwelling catheter) hanging on the side of his bed. During an observation and interview on 4/22/26 at 12:34 p.m., Qualified Medication Aide (QMA) 3 and Certified Nursing Assistant (CNA) 7 went into Resident 4's room and applied gloves. There was no hand hygiene prior to the staff putting on their gloves. QMA 3 obtained a wash basin and wash clothes, lowered the head of the resident's bed down and raised the bed up with the bed remote control and removed Resident 4's incontinent brief that had a small amount of red substance on it. QMA 3 exposed the resident's genital area and used a wet soapy washcloth to clean the area and then rinsed and dried the area. QMA 3 then took the soapy washcloth and cleaned the catheter tubing. QMA 3 and CNA 7 applied a clean incontinent brief and incontinent pad. CNA 7 took off her gloves and took the soiled linen in a plastic bag out of the room. QMA 3 removed her gloves and donned another pair of gloves on and drained the resident's catheter bag into a urinal without preforming hand hygiene. QMA 3 and CNA 7 indicated they normally would complete hand hygiene and change their gloves during catheter care, but they were nervous and did not do it. Review of the record for Resident 4 on 4/22/26 at 1:15 p.m., indicated the resident's diagnoses included, but were not limited to, urinary tract infection (UTI) and urinary retention (the inability to fully or partially empty the bladder, causing urine to remain in the bladder even when one feels the need to urinate). The quarterly Minimum Data Set (MDS) assessment for Resident 4, dated 1/6/26, indicated the resident was cognitively intact for daily decision making. The resident had an indwelling catheter. The physician's order for Resident 4, dated 4/21/26, indicated the resident was ordered Sulfamethoxazole-Trimethoprim (antibiotic) 1 tablet by mouth every 12 hours for a UTI for 10 days. The catheter care policy provided by the Director of Nursing (DON) on 4/23/26 at 12:17 p.m., indicated catheter associated urinary tract infections was the most common adverse event associated with indwelling urinary catheters. The risk of bacteremia in residents with indwelling catheters was 3 to 36 times more likely that residents without an indwelling catheter. Catheter care at the bedside was performed to promote cleanliness and dignity. Catheter care included, but were not limited to, raise the residents bed to waist level before providing care, perform hand hygiene and apply gloves. Remove your gloves and perform hand hygiene. 410 IAC (Indiana Administrative Code) 3.1-4(a)(2)

Based on observation, interview, and record review, the facility failed to follow the physician's order for the correct size indwelling catheter (a tube that is inserted into the bladder, allowing urine to drain freely) for 1 of 35 residents reviewed to receive care and services that meet professional standards (Resident 4). Findings include:1. During an observation on 4/22/26 at 12:34 p.m., Qualified Medication Aide (QMA) 3 and Certified Nursing Assistant (CNA) 7 provided Resident 4 with catheter care. Resident 4 had a size 22 French catheter in place (a large-diameter medical tube measuring approximately 7.33 millimeters in external diameter). During an interview with Licensed Practical Nurse (LPN) 6 on 4/22/2026 at 12:50 p.m., the LPN indicated the nurse was responsible to ensure Resident 4 had the correct catheter size in place. LPN 6 reviewed Resident 4's physician order and indicated he was supposed to have a size 20 French catheter in place (medium to large diameter medical tube measuring approximately 6.66 millimeters in external diameter). LPN 6 indicated Resident 4's catheter was last changed on 4/19/26. During an interview with LPN 6 on 4/22/2026 at 1:11 p.m., the LPN indicated she was unable to find a size 20 French catheter in the facility's medical supplies. Review of the record for Resident 4 on 4/22/26 at 1:15 p.m., indicated the resident's diagnoses included, but were not limited to, urinary tract infection and urinary retention (inability to fully or partially empty the bladder, causing urine to accumulate). The plan of care for Resident 4, dated 1/6/26, indicated the resident was at risk for urinary complications related to urinary retention and an indwelling catheter. The interventions included, but were not limited to, change the indwelling catheter as ordered by the physician. The physician's order for Resident 4, dated 4/15/26, indicated the resident was to have a catheter size 20 with continuous drain. The quarterly Minimum Data Set (MDS) assessment for Resident 4, dated 1/6/26, indicated the resident was cognitively intact for daily decision making. The resident had an indwelling catheter. According to the American Urology Association 2024, Catheters come in sizes that measure the outside circumference in millimeters (mm), which is called the French (Fr) size. The larger the French size, the greater the catheter circumference. The French size as well as the recommended filling volume of the catheter's retention balloon (in cc or mL) is listed on the plastic cuff of the cathetersidearm (the arm of the Foley where the balloon is inflated). Make sure you have the right type and size Foley catheter kit, then open it up. 410 IAC (Indiana Administrative Code) 3.1-35(g)(1)

Based on observation, interview, and record review, the facility failed to assist a dependent resident with fingernail care and facial hair removal for 1 of 2 residents reviewed for Activities of Daily Living (ADL) (Resident 47). Findings include:During an observation and interview with Resident 47 on 4/21/2026 at 12:38 p.m., the resident had a full beard and long fingernails with black substance underneath on both hands. Resident 47 indicated he did not prefer to have a beard and liked to be clean shaven. The resident indicated no staff had offered to shave him since he was admitted to the facility. Resident 47 indicated when he was at home, he used an electric razor to trim his facial hair and then a disposable razor to cut his facial hair. The staff did trim his fingernails sometimes. During an observation on 4/22/26 at10:25 a.m., Resident 47 was sitting in the front lobby by the nursing station in a wheelchair. The resident had moderately long fingernails on both hands, with black substances and had a full long beard. During an observation on 4/22/2026 at 12:10 p.m., Resident 47 was eating lunch in the main dining room. The resident had moderately long fingernails on both hands, with black substances under the nails and had a full long beard. During an observation on 4/23/2026 10:24 a.m., Resident 47 was sitting in his wheelchair by the dining room. The resident had moderately long fingernails on both hands, with black substances and had a full long beard. Review of the record for Resident 47 on 4/23/2026 at 10:26 a.m., indicated the resident's diagnoses included, but were not limited to, Parkinson disease (a chronic, progressive neurological disorder that occurs when nerve cells in the brain die or become impaired), muscle weakness, and need for assistance with personal care. The admission Minimum Data Set (MDS) assessment for Resident 47, dated 3/20/26, indicated the resident was cognitively intact for daily decision making. Resident 47 had no behaviors of rejecting care. The resident required substantial to maximal staff assistance with personal hygiene. The plan of care for Resident 47, dated 4/7/26, indicated the resident required assistance with ADL Self Care Performance related to weakness, pain to left knee with activity tolerance limitations, and Parkinson's disease process. The interventions included, but were not limited to, the resident required substantial to maximal staff assistance with personal hygiene. During an interview with the Director of Nursing (DON) on 04/23/2026 at 1:55 p.m., the DON indicated it was the responsibility of the Certified Nursing Assistant's (CNA's) to ensure Resident 47's fingernails were trimmed and cleaned and his facial hair was shaven. The routine resident care policy, provided by the DON on 4/23/26 at 1:57 p.m., indicated resident care was not necessarily medically or clinically based but was necessary for quality of life to promote dignity. The facility would promote resident centered care by attending to the total medical, nursing, physical, emotional, mental and social needs and honor resident lifestyle preferences while in the care of the facility. The routine care provided by the CNA would provide assistance with personal care. 410 IAC (Indiana Administrative Code) 3.1-38(a)(3)(D)410 IAC (Indiana Administrative Code) 3.1-38(a)(3)(E)

Based on observation, interview, and record review, the facility failed to implement tubular (tubi) compression bandage on both arms as ordered by the physician for a resident who was experiencing arm edema (swelling) for 1 of 2 residents reviewed for general skin condition (Resident 4). Findings include:During an observation and interview with Resident 4 on 4/21/2026 at 11:00 a.m., the resident had edema (swelling caused by excess fluid trapped in the body's tissues) of the lower arms of both arms. The resident indicated he did not know what caused his arms to swell. During an observation and interview with Resident 4 on 4/22/2026 at 12:15 p.m., the resident had tubular sleeves on both arms. Resident 4 indicated staff were supposed to take the tubular sleeves off at night and put them on in the morning. During an observation and interview with Resident 4 on 4/23/2026 at 10:21 a.m., the resident's tubular sleeves were not in place on either arm. Resident 4 indicated he had never refused to wear the tubular sleeves and the tubular sleeves gave him some relief from his arms swelling. Resident 4's bilateral lower arms were swollen (abnormally enlarged, rounded, or puffed up due to fluid accumulation). During an observation on 4/23/26 at 11:45 a.m., Resident 4 was eating lunch in his room. Resident 4 did not have his tubular sleeves in place; the resident's lower bilateral arms were swollen. Review of the record for Resident 4 on 4/22/26 at 1:15 p.m., indicated the resident's diagnosis included, but were not limited to, bilateral arm edema. The physician recapitulation for Resident 4, dated April 2026, indicated the resident was ordered tubi grip to bilateral arms every day and evening shift for edema to be applied in the morning and off at bedtime (original order date 1/21/26). The quarterly Minimum Data Set assessment (MDS) for Resident 4, dated 1/6/26, indicated the resident was cognitively intact for daily decision making. The resident had no behavior of refusal of care. The resident required substantial to maximal staff assistance with upper body dressing. The plan of care for Resident 4, dated 1/22/26, indicated the resident was to have tubi grip to bilateral arms every day and evening shift for edema, to be applied in the morning and off at bedtime. During an interview with the Director of Nursing (DON) on 4/23/26 at 1:56 p.m., the DON indicated the nurse was responsible for applying Resident 4's tubular sleeves. The physician order policy provided by the DON on 4/23/26 at 12:17 p.m., indicated the facility would provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the resident. The licensed nurse would accurately document physician and provider orders as determined by the licensee's scope of practice. The nurse would be responsible for executing the physician's order. 410 IAC (Indiana Administrative Code) 3.1-37(a)

Based on interview, observation, and record review, the facility failed to implement interventions of heel boots and follow physician orders for treatment of a pressure area for 1 of 3 residents reviewed for pressure ulcers. (Resident 3)Findings include:The clinical record for Resident 3 was reviewed on 4/24/2026 at 12:48 PM. The medical diagnoses included, but were not limited to, partial traumatic amputation (sudden, unexpected [NAME] of a body part) of two or more toes, damage to the nerves from complications of diabetes (nerve damage caused by chronically high blood sugar levels), and abnormalities of mobility and gait.The admission Minimum Data Set (MDS) Assessment, dated 3/10/2026, indicated Resident 3 was cognitively impaired. the resident was dependent on staff for his hygiene needs, turning, and transferring. Resident 3 had a non-removable dressing, surgical wounds and dressings to areas other than feet.A pressure care plan, dated 3/9/2026 and reviewed 4/17/2026, indicated Resident 3 had pressure ulcers. An intervention, dated 3/17/2026, indicated for Resident 3 to utilize heel boots to bilateral feet while in bed.Hospital discharge orders, dated 3/8/2026, indicated Resident 3 to receive betadine to the left heel twice daily and to alleviate pressure at all times to bilateral heels with heel suspension boots.The nursing assessment for Resident 3's admission to the facility, dated 3/8/2026, did not indicate any skin impairment to the left heel but did indicate non-removable dressing to bilateral feet. A physician's order for Resident 3, dated 3/9/2026, indicated staff were to use betadine (broad-spectrum antiseptic used to treat and prevent infections) to the resident's left heel twice a day. A physician's order for Resident 3, dated 3/11/2026, indicated staff were to use bilateral heel boots for the resident while in bed. The March 2026 treatment administration record for Resident 3 indicated betadine had been applied to the resident's left heel twice a day from 3/9/2026 to 3/11/2026.The March 2026 treatment administration record and care plan for Resident 3 did not reflect the use of heel boots between 3/8/2026 and 3/11/2026.A wound care report, dated 3/25/2026, indicated Resident 3 had an unstageable pressure injury to the left heel. The measurements for Resident 3's pressure injury to the left heel were 2 centimeters (cm) by 5 cm with no depth. These were the first measurements of the resident's wound to the left heel. A wound care progress note, dated 3/25/2026, indicated the left heel pressure injury was discovered after removal of a non-removal dressing. Additional wounds to the bilateral feet were discovered at this time, including diabetic foot ulcers, a deep tissue injury to left lateral foot, and a Stage 1 pressure to the right lateral foot.During an interview, on 4/23/2026 at 3:00 PM, Assistant Director of Nursing (ADON) indicated Resident 3 admitted for rehabilitation, nursing services, and wound care after surgical intervention. Resident 3 admitted with a surgical wound to the left lateral knee and bilateral feet. At admission Resident 3 had non-removable dressing to bilateral feet covering the toes up to the mid-shin to knee on both legs. Due to the non-removable dressing, Resident 3's heels were not visible when admitted to the facility. The left heel was not visible until 3/25/2026 at the first dressing change.During an interview, on 4/24/2026 at 11:00 AM, ADON indicated staff would not have been able to apply betadine to Resident 3's left heel as signed on the treatment record between 3/9/2026 through 3/11/2026. Direct floor staff were responsible for providing care to Resident 3's wounds and implementing intervention, including the use of bilateral heel boots. It was the expectation of the facility to follow physicians order unless contraindicated. A policy entitled, Wound Care, was provided by the DON, on 4/23/2026 at 1:57 PM. The policy indicated residents will receive treatment as indicated for management and prevention of skin integrity issues.410 IAC (Indiana Administrative Code) 16.2-3.1-40(a)(1)410 IAC (Indiana Administrative Code) 16.2-3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to post the results of the most recent survey of the facility in a place readily accessible to residents, family members, and legal representatives of residents for 46 of 46 residents in the facility.A resident council meeting was held on 4/22/26 at 9:45 a.m. The following residents were present at the meeting: Residents 17, 18, 21, 36, 37, 41, 43, and 44. During the meeting the council indicated they were unaware of the location of the most recent survey results. On 4/22/26 at 10:14 a.m., an observation of the facility survey binder was made. The binder was located in a bin attached to the wall by the entrance to the facility. There was a sign, informing survey results availability posted above the survey binder. Neither the binder nor the sign were at wheelchair level. On 4/22/26 at 12:40 p.m., an observation of the survey binder and posting were made with Resident 18, the co-president of resident council, and the Executive Director (ED). The ED assisted Resident 18 in her wheelchair to the location of the survey binder. Resident 18 was unable to reach the binder without assistance and indicated she could not read the posting above it. An interview was conducted with the ED on 4/22/26 at 12:40 a.m., immediately after the above observation. She indicated she would have maintenance staff to move the survey binder and posting to a location more accessible to the residents. 410 IAC (Indiana Administrative Code) 16.2-3.1-3(b)(1)

Based on observation, interview, and record review, the facility failed to ensure food was kept at safe holding temperatures on the steam table, and failed to ensure dishes were stored dry for 2 of 4 observations and had the potential to affect all 47 residents in the facility. Findings include: On 2/26/24, at 9:14 a.m., Cook 3 was observed as she removed a tray of dishes from the dish machine, removed the dishes from the tray and immediately put them away while still wet. On 2/26/24 at 10:50 a.m., food temperatures were observed as taken, by Cook 3. The mashed potatoes were 117, then when rechecked were 115.8. The hamburgers were 131.8, and the hot dogs were 131.3. Cook 3 indicated foods are served at 130 (degrees) once they are on the steam table. Cook 3 began to plate the food for the noon meal and was stopped by the surveyor due to the low food temperatures of the mashed potatoes, hamburgers, and hot dogs. Cook 3 removed the steam table pans of mashed potatoes, hamburgers and hot dogs and reheated them on the range until the mashed potatoes reached 142, the hamburgers reached 137 and the hot dogs reached 137.5. Cook 3 said she took the food temperatures when the food was brought out and placed on the steam table, and the food sat, about 15 minutes on the steam table, before the temperatures were taken with the surveyor. On 2/28/24 at 1:30 p.m., with the Dietary Manager dishes were observed stored as clean. In 3 stacks of 19 total, 7 monkey dishes (small bowls) had moisture inside the bowls. On 2 trays, one with 10 cups and one with 15 cups, 3 had moisture inside the cups. In a stack of 7 plates, 1 had moisture. The Dietary Manager indicated they should let the dishes set and air dry before putting them away. A policy for Food: Preparation was provided by the Dietitian, on 3/1/24 at 10:31 a.m. The policy included, but was not limited to, Policy Statement: All foods are prepared in accordance with the FDA Food Code. Procedures: 4. The Dining Services Director/Cook(s) will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 [degrees] F (Fahrenheit) and/or less than 135 [degrees] F, or per state regulation A policy titled Warewashing was provided by the Dietitian, on 3/1/24 at 19:31 a.m., and included, but was not limited to, Policy statement: All dishware, serviceware, and utensils will be cleaned and sanitized after each use .4. All dishware will be air dried and properly stored. 3.1-21(i)(3)

Based on observation, interview and record review the facility failed to ensure Resident 13's portable oxygen tubing and storage bag was dated for 1 of 1 resident reviewed for respiratory care (Resident 13). Finding include; During an observation on 2/26/24 at 1:05 p.m., Resident 13's storage bag and tubing was not dated on portable oxygen. During an observation on 2/27/24 at 12:54 p.m., Resident 13's storage bag and tubing was not dated on portable oxygen. During an observation on 2/29/24 at 12:57 p.m., Resident 13's portable oxygen tubing/storage bag was not dated. During an observation and interview with CNA 2 on 2/29/24 at 2:22 p.m., verified Resident 13's portable oxygen tank tubing and storage bag was not dated. During an interview with the Director Of Nursing (DON) on 3/1/24 at 11:21 a.m., indicated Resident 13's portable oxygen tubing and storage bag should have been dated. Review of the record of Resident 13 on 3/1/24 at 11:45 a.m., indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease, asthma, acute respiratory failure with hypoxia and dependence ion supplemental oxygen. The physician order for Resident 13, dated March 2024, the resident was ordered oxygen 2 liters via nasal cannula to keep oxygen saturation above 90%. 3.1-47(a)(6)

Based on observations, interview, and record review, the facility failed to promote a resident's dignity by ensuring the use of a catheter drainage bag and have an order for the use of an indwelling urinary catheter for 1 of 3 residents reviewed for urinary catheters. (Resident 43) Findings include: The clinical record for Resident 43 was reviewed on 2/27/2024. The medical diagnosis included muscle weakness. An Admission Minimum Data Set Assessment, dated 12/13/2023, indicated that Resident 43 utilized an indwelling urinary catheter. Physician orders did not reflect the size of urinary catheter for Resident 43. A urinary catheter care plan, dated 12/15/2023, indicated to provide a privacy bag to Resident 43's drainage bag and he utilized a 16 Fr (French) catheter with a 10-milliliter balloon anchor. During an observation on 2/27/2024 at 10:39 a.m., Resident 43 was sitting in his wheelchair in the dining room with his urinary catheter drainage bag hanging under his wheelchair. A moderate amount of yellow urine was visible in the bag. During an observation on 2/27/2024 at 10:43 a.m., Resident 43 was sitting in his wheelchair in the dining room with his urinary catheter drainage bag hanging under his wheelchair. A moderate amount of yellow urine was visible in the bag. During an observation on 2/27/2024 at 1:20 p.m., Resident 43 was laying in bed and his catheter was noted to be a 22 Fr with a 30 mL balloon anchor. During an interview on 3/1/2024 at 11:20 a.m. with the Director of Nursing, she indicated that the size of his catheter had been changed to the 22 Fr with a 30 ml balloon after a recent surgical procedure. It was the expectation of the facility to utilize privacy bags and to have orders for the correct sizing and/or indication for use for urinary catheters. A physician's order for Resident 43's catheter size and indication of use was added to the clinical record on 2/29/2024. 3.1-41(a)(2)

Based on observation, interview and record review the facility failed to implement a fall intervention of a reacher to assist the resident with picking items off the floor for a resident who had a history of falls and was at risk for falls for 1 of 2 residents reviewed for accidents (Resident 20). Finding include: During an observation and interview with Resident 20 on 2/27/24 at 10:49 a.m., indicated he had a fall recently due to something slick on the floor. The resident had no reacher visible in his room. During an observation and interview on 2/27/24 at 12:59 p.m., the resident indicated he use to have a reacher to use to pick items up off the floor, but he had not seen it for awhile and was unsure where it was. The resident had no reacher visible in his room. During an observation on 2/28/24 at 10:35 a.m., Resident 20 did not have a reacher visible in his room. During an observation and interview with LPN 1 on 2/28/24 at 11:19 a.m., looked for Resident 20's reacher in his room and was unable to locate it. LPN 1 indicated she would request a reacher from therapy for the resident. Review of the record of Resident 20 on 2/27/24 at 1:01 p.m., indicated the resident's diagnoses included, but were not limited to, Parkinson's disease, diabetes, major depressive disorder, chronic pain disorder, chronic inflammatory demyelinating polyneuritis, muscle weakness and benign prostatic hyperplasia with lower urinary tract symptoms. The fall risk assessment for Resident 20, dated 12/21/23, indicated the resident was diminished safety awareness, used a walker for ambulation, impaired walking with difficulty rising from chair, head down, grasps furniture, minimal assist with gait belt, the resident had balance problems while walking, instability while turning. The resident had 3 or more predisposing conditions for risk of falls. The resident was identified as a fall risk. The care plan for Resident 20, dated 3/2/23, indicated the resident was at risk for falls related to gait/balance problems, history of falls, medications, safety awareness and weakness. The interventions included, but were not limited to, therapy to get me a reacher so that I can pick up items on the floor. The Annual Minimum Data Set (MDS) assessment for Resident 20, dated 2/13/24, indicated the resident was moderately impaired for daily decision making. The resident utilized a walker for mobility device. The State Optional MDS assessment for Resident 20, dated 2/13/24, indicated the resident required extensive assistance of one person for transfers and extensive assistance of two people for toileting needs. The resident was on a scheduled pain medication regimen, received PRN (as needed), did not receive non medication interventions for pain, The progress note for Resident 20, dated 2/22/24 at 7:15 a.m., indicated the nurse was called to the resident's room by a CNA. The resident was observed laying on the floor in front of his lift chair beside his bed. The resident had candy wrappers all over the floor by his feet. The resident indicated he stood up to go to his bed and slipped. The Interdisciplinary Team (IDT) progress note for Resident 20, dated 2/23/24 at 12:31 p.m., indicated the resident had an unwitnessed fall. The root cause of the incident was the resident was up without assistance and the floor was cluttered. During an interview with the Director Of Nursing (DON) on 2/28/24 at 1:25 p.m., indicated all nursing staff were responsible to ensure Resident 20's fall intervention of a reacher was in place. The fall policy provided by the DON on 2/29/24 at 10:00 a.m., indicated the facility would provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Fall prevention and management was the process of identifying risk factors that minimize the potential for falls and also a process to manage a resident's care if a fall occurs. The facility would attempt to put an intervention in place to prevent further falls. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a homelike environment by not maintaining walls in good repair for 5 rooms observed in the facility. (Room North 1, North 4, North 5, South 2, and South 11) Findings include: An observation was conducted of Room North 4 on 11/29/22 at 10:50 a.m. There was chipped paint observed on the wall. An observation was conducted of Room North 1 on 11/29/22 at 10:33 a.m. There was peeling paint observed on the wall with angled blinds that were not covering the entirety of the window. An observation was conducted of Room South 11 on 11/29/22 at 11:02 a.m. There was peeling paint on the wall. An observation was conducted of Room North 5 on 11/29/22 at 11:21 a.m. There was chipped paint observed on the wall. An interview was conducted with the Director of Nursing (DON) on 11/30/22 at 3:24 p.m. indicated Room South 11 had peeling paint and missing paint in the room. The problem with the walls has been ongoing that needed fixed. There were multiple rooms that had missing paint. An environmental tour conducted with the Maintenance Director (MD), on 12/1/22 at 11:45 a.m., indicated Room North 4 had chipped paint. Room North 1 was observed with chipped paint and bended blinds. There was missing trim noted behind on of the beds in Room North 1. Room South 11 had peeling paint. Room South 2 had peeling paint. The MD indicated there had been a difficult time with getting residents out of their rooms to conduct sanding and painting over the affected areas. It was on the list of items to be completed. An interview conducted with the Executive Director (ED), on 12/1/22 at 3:07 p.m., indicated there was no policy in regard to general environment. She noticed that there was missing paint in some of the rooms. Her expectations are to ensure residents have a homelike environment. 3.1-19(f) 3.1-19(f)(5)

Based on interview and record review, the facility failed to administer antibiotics for urinary tract infections (UTI) at the duration ordered per physician for 2 of 7 residents reviewed for unnecessary medications. (Resident 8 and 32) Findings include: 1. The clinical record for Resident 8 was reviewed on 11/30/2022 at 2:45 p.m. The medical diagnoses included, but were not limited to, dementia and chronic kidney disease. A UTI care plan, dated 10/06/2020, indicated that Resident 8 was at risk for UTI's and to administer medications as ordered. A urinalysis with culture and sensitive, dated 10/24/2022, indicated that Resident 8 had a UTI that was sensitive for minocycline (an antibiotic) and a handwritten order from nurse practitioner for minocycline 100 milligram (mg) twice a day for 5 days. Review of the October 2022 Medication Administration Records (MAR) for Resident 8 indicated she received minocycline 100 mg starting on 10/25/2022 through 10/31/2022 for a total of 12 doses over 7 days. An Interdisciplinary Team (IDT) note for Resident 8, dated 12/2/2022, indicated the aforementioned order was a medication error due to transcription error. 2. The clinical record for Resident 32 was reviewed on 12/1/2022 at 10:00 a.m. The medical diagnoses included, but were not limited to, Alzheimer's dementia and UTI. A UTI care plan, date revised on 11/22/2022, indicated that Resident 32 had a UTI and to administer antibiotics as ordered. A hospital discharge note, dated 9/13/2022, indicated for Resident 32 to have Macrobid (an antibiotic) 100 mg every 12 hours for 3 days for a fill quantity of 6 capsules. The September 2022 MAR for Resident 32 indicated she received Macrobid 100 mg starting on 9/13/2022 through 9/17/2022 for a total of 7 doses over 4 days. An IDT for Resident 32, dated 12/2/2022, indicated the aforementioned order was a medication error due to a transcription error. An interview with DON on 12/1/2022 at 4:15 p.m., indicated the antibiotics were administered in excessive duration/dose and medication error reports would be initiated for Resident 8 and Resident 32. A policy entitled, Physician Orders, was provided by the Director of Nursing on 12/2/2022 at 9:30 a.m. The policy indicated, .The purpose off this policy is to provide guidance for licensed nurses and licensed therapist to accurately document physician and provider orders .The nurse will transcribe the order into [the electronic medical record] . 3.1-48(a)(1) 3.1-48(a)(2)

Based on observation, interview and record review the facility failed to provide effective interventions to prevent skin tears and bruising for 1 of 3 residents reviewed for non- pressure skin condition (Resident 26). Finding include: During an observation on 11/29/22 at 11:09 a.m., Resident 26 was sitting in the dining room, the resident had multiple discolorations to the right arm. The resident had arm protectors in place on both arms that were large and falling off the resident's arms. Review of the record of Resident 26 on 11/29/22 at 2:55 p.m., indicated the resident's diagnoses included, but were not limited to, type 2 diabetes, chronic kidney disease, dementia, psychotic disturbance, anxiety, stiffness of joints and mood disturbance. The Quarterly Minimum Data Set (MDS) assessment for Resident 26, 11/18/22, indicated the resident was moderately cognitively impaired. The resident was total assistance of two people for transfers and did not ambulate. The plan of care for Resident 26, dated 10/6/22, indicated the resident had potential for skin integrity, bruising and skin tears. The resident had fragile skin, history of bruising to mouth related to jerking movements associated with Parkinson disease. The resident had poor safety awareness and bumped into objects frequently and was impulsiveness. The interventions included, but were not limited to, skin sleeves to bilateral upper extremities on at all times and pad side rails. The non skin assessment for Resident 26, dated 11/29/22, indicated the resident had a skin tear to his right forearm measuring 2 centimeter (cm) by 2 cm. During an observation on 11/30/22 at 10:58 a.m., Resident 26 was sitting in the dayroom asleep in his high back wheelchair. The resident had on a protective sleeve on right arm and was too large for the resident's arm, the left protective sleeve was laying on the ground underneath the resident's wheelchair. The resident's side rails on his bed were not padded. During an observation and interview with the Director Of Nursing (DON) on 11/30/22 at 3:15 p.m., Resident 26 was laying in bed and one of his protective sleeves came off. The DON verified the protective sleeves were too big for the resident and his side rails on his bed were not padded. The DON indicated she would ensure to provide the resident with the appropriate size of protective sleeves. The DON indicated the resident's side rails had been padded at one time and she was unsure what happened. The DON would have maintenance staff pad the side rails on the resident's bed. The skin care and wound management policy provided by the DON on 11/30/22 at 4:15 p.m., indicated the facility strived to prevent resident kin impairment and promote the healing of existing wounds. The facility would identify and implement interventions to prevent and treat potential skin integrity issues. The facility would evaluate for consistent implementation of interventions and effectiveness at clinical meetings. 3.1-37

Based on interview and record review, the facility failed to ensure a staff member followed the facility's policies regarding abuse prohibition, specific to an allegation of verbal abuse from a staff member towards a resident for 1 of 4 residents reviewed for abuse. (Resident C and CNA 3) Findings include: The clinical record of Resident C was reviewed on 10-3-22 at 11:17 a.m. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her most recent Minimum Data Set (MDS) assessment, dated 7-28-22, indicated Resident C has a moderate level of cognitive impairment, but is able to understand what is communicated to her and to be able to be understood by others. It indicated she requires extensive assistance of one to two persons for bed mobility, toileting and hygiene care and she is non-ambulatory and requires the use of a wheelchair for mobility. In an interview with Resident C on 10-3-22 at 1:15 p.m., she indicated CNA 3 had recently yelled at her. I was in bed and wanted help to get up, so I put my [call] light on and she came in and when I asked to have her help me get up, she let loose with her cussing and yelling at me. She indicated a staff nurse came in almost immediately and ensured CNA 3 left her room. She indicated she has not seen CNA 3 since that time. On 9-30-22 at 1:25 p.m., the Director of Nursing (DON) provided a copy of a state reportable event, dated 9-11-22. It indicated on 9-11-22 at 9:05 a.m., [Name of CNA 3] allegedly spoke in a raised tone to [name of Resident C]. In a follow-up to the initial report, dated 9-15-22, it indicated CNA 3 was immediately removed from the facility and suspended, pending the outcome of the investigation. Notifications were made to Resident C's family, the Executive Director, the DON, attending physician and local police department. It indicated Resident C was followed closely for 72-hours for any psycho-social concerns, with no concerns identified. The facility conducted interviews with all reliably-interviewable residents and skin assessments of the same with no new concerns identified. It indicated the allegation of verbal abuse was substantiated, related to CNA 3 using a raised voice with the resident during a verbal disagreement with Resident C. It indicated the CNA's employment was ended prior to 9-15-22. In an interview with LPN 4 on 10-3-22 at 10:20 a.m., she indicated on the morning of 9-11-22, she was seated at the nurse's station and heard 2 women screaming and I immediately ran down to where the screams were coming from. As I was walking down the hall, [name of CNA 3] was walking toward me and saying that she was not going to snap to it just when she [Resident C] snaps. She indicated she then entered Resident C's room to check on her and the resident seemed upset. She told me she had asked [name of CNA 3] to get her up for the day and [CNA 3] started yelling at her that she was busy with somebody else and left her room. She indicated she then located CNA 3 and told her she would not be taking care of CNA 3. She indicated she then notified the DON of the situation and was informed to have CNA 3 to write out a statement of the events and then to have CNA 3 leave the facility. She indicated her impression of Resident C was she seems to be pretty sharp with some occasional short term memory issues. An associated progress note, dated 9-11-22 at 10:54 a.m., written by LPN 4 indicated, This nurse heard resident and staff member yelling at each other from [room number of Resident C] while [LPN 4] was at nurse's station. I went down there and staff member said, 'She wants me to snap just like that and I'm not gonna snap just like that. I'm in the middle of helping someone.' I went to the resident who said, 'I'm not gonna take that from her. I asked to get up to go outside and she got an attitude like she always does. I've had problems with her before and I'm not gonna put up with it. I'm sorry to get that way but I'm tired of it.' Staff member was removed from the area. DON and ED [Executive Director] notified. Staff member sent home at this time. Resident monitored for negative psychosocial effects and will continue to be. Convergence [medical provider] notified. No N.O.'s [new orders]. Message left to update family. A review of CNA 3's most recent training/education for abuse prohibition indicated she had received trainings on 1-14-22, 4-28-22, 7-11-22 and 8-11-22. On 9-30-22 at 11:00 a.m., the Social Services Designee (SSD) provided a copy of the facility's current policy and procedure, entitled, Indiana Abuse & Neglect & Misappropriation of Property, with a revision date of 10-27-2021. This policy indicates, Verbal Abuse [definition]: In Indiana, oral, written, and/or gestured language that includes disparaging and/or derogatory terms to the residents or their families, either directly or within their hearing. This may include resident to resident verbal threats of harm, but excludes random statements of a cognitively impaired resident such as repetitive name calling or nonsensical language. Verbal abuse includes any staff to resident episodes .It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. It is the intent of this facility to prevent the abuse, mistreatment, or neglect of residents or the misappropriation of their property, corporal punishment and/or involuntary seclusion and to provide guidance to direct staff to manage any concerns or allegations of abuse, neglect or misappropriation of their property .An employee who is alleged or accused of being a party to abuse, neglect misappropriation of property, will be immediately removed from the area(s) of the resident care, interviewed by facility leadership for a written statement and not left alone .After completing the statements, the employee(s) will be asked to vacate the facility until further investigation of the incident is completed. This Federal tag relates to Complaint IN 453. 3.1-28(a)

Based on interview and record review, the facility failed to ensure an allegation of staff to resident verbal abuse did not occur and failed to ensure an allegation of resident to resident verbal abuse did not occur for 3 of 4 residents reviewed for abuse. (Residents C, D and E) Findings include: 1. The clinical record of Resident C was reviewed on 10-3-22 at 11:17 a.m. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her most recent Minimum Data Set (MDS) assessment, dated 7-28-22, indicated Resident C has a moderate level of cognitive impairment, but is able to understand what is communicated to her and to be able to be understood by others. It indicated she requires extensive assistance of one to two persons for bed mobility, toileting and hygiene care and she is non-ambulatory and requires the use of a wheelchair for mobility. In an interview with Resident C on 10-3-22 at 1:15 p.m., she indicated CNA 3 had recently yelled at her. I was in bed and wanted help to get up, so I put my [call] light on and she came in and when I asked to have her help me get up, she let loose with her cussing and yelling at me. She indicated a staff nurse came in almost immediately and ensured CNA 3 left her room. She indicated she has not seen CNA 3 since that time. On 9-30-22 at 1:25 p.m., the Director of Nursing (DON) provided a copy of a state reportable event, dated 9-11-22. It indicated on 9-11-22 at 9:05 a.m., [Name of CNA 3] allegedly spoke in a raised tone to [name of Resident C]. In a follow-up to the initial report, dated 9-15-22, it indicated CNA 3 was immediately removed from the facility and suspended, pending the outcome of the investigation. Notifications were made to Resident C's family, the Executive Director, the DON, attending physician and local police department. It indicated Resident C was followed closely for 72-hours for any psycho-social concerns, with no concerns identified. The facility conducted interviews with all reliably-interviewable residents and skin assessments of the same with no new concerns identified. It indicated the allegation of verbal abuse was substantiated, related to CNA 3 using a raised voice with the resident during a verbal disagreement with Resident C. It indicated the CNA's employment was ended prior to 9-15-22. In an interview with LPN 4 on 10-3-22 at 10:20 a.m., she indicated on the morning of 9-11-22, she was seated at the nurse's station and heard 2 women screaming and I immediately ran down to where the screams were coming from. As I was walking down the hall, [name of CNA 3] was walking toward me and saying that she was not going to snap to it just when she [Resident C] snaps. She indicated she then entered Resident C's room to check on her and the resident seemed upset. She told me she had asked [name of CNA 3] to get her up for the day and [CNA 3] started yelling at her that she was busy with somebody else and left her room. She indicated she then located CNA 3 and told her she would not be taking care of CNA 3. She indicated she then notified the DON of the situation and was informed to have CNA 3 to write out a statement of the events and then to have CNA 3 leave the facility. She indicated her impression of Resident C was she seems to be pretty sharp with some occasional short term memory issues. An associated progress note, dated 9-11-22 at 10:54 a.m., written by LPN 4 indicated, This nurse heard resident and staff member yelling at each other from [room number of Resident C] while [LPN 4] was at nurse's station. I went down there and staff member said, 'She wants me to snap just like that and I'm not gonna snap just like that. I'm in the middle of helping someone.' I went to the resident who said, 'I'm not gonna take that from her. I asked to get up to go outside and she got an attitude like she always does. I've had problems with her before and I'm not gonna put up with it. I'm sorry to get that way but I'm tired of it.' Staff member was removed from the area. DON and ED [Executive Director] notified. Staff member sent home at this time. Resident monitored for negative psychosocial effects and will continue to be. Convergence [medical provider] notified. No N.O.'s [new orders]. Message left to update family. A review of CNA 3's most recent training/education for abuse prohibition indicated she had received trainings on 1-14-22, 4-28-22, 7-11-22 and 8-11-22. 2. The clinical record of Resident D was reviewed on 10-3-22 at 12:37 p.m. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His most recent Minimum Data Set (MDS) assessment, dated 8-10-22, indicated he was moderately cognitively impaired and had verbal behaviors towards others and other unspecified behaviors toward others. A copy of a state reportable event, dated 9-1-22, indicated on 9-1-22 at 8:07 p.m., Residents D and E, who were roommates, allegedly had a verbal disagreement with no physical contact was made. It indicated the residents were immediately separated, an investigation was initiated with notification made to the Executive Director (ED), Director of Nursing (DON), families and attending physician. Resident D was moved to another room. A follow-up report was filed on 9-7-22, which indicated the residents were no longer roommates, care plans for each resident were updated and psycho-social follow-up was conducted with each resident. In an interview on 10-3-22 at 2:12 p.m., with CNA 5, she recalled working with Resident D on the evening of 9-1-22. She recalled she was assisting Resident D from the dining room to his room, which he shared with Resident E. He started calling [name of Resident E] a son of a b---h and that he didn't want to be in the room with that a-----e, before we even got to his room. He kept calling [name of Resident E] names. We, me and [name of CNA 6], kept them separated and went and got the [name of LPN 7]. She indicated Resident D was relocated into a different room in the facility at that time. She reported while she and Resident D were out in the hallway with Resident D still yelling at Resident E, Resident E called one of his daughters on his phone to tell her what was going on. CNA 5 indicated Resident E, was very upset about the situation. CNA 5 indicated she has worked at the facility for several years. I have worked here about 6 years. She indicated Resident D had problems with a roommate before, kind of the same thing. Calling him names and being very rude. 3. The clinical record of Resident E was reviewed on 10-3-22 at 12:55 p.m. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His most recent Minimum Data Set (MDS) assessment, dated 8-22-22, indicated he is cognitively intact, always understands what is said or communicated and occasionally may not be understood. A copy of a state reportable event, dated 9-1-22, indicated on 9-1-22 at 8:07 p.m., Residents D and E, who were roommates, allegedly had a verbal disagreement with no physical contact was made. It indicated the residents were immediately separated, an investigation was initiated with notification made to the Executive Director (ED), Director of Nursing (DON), families and attending physician. Resident D was moved to another room. A follow-up report was filed on 9-7-22, which indicated the residents were no longer roommates, care plans for each resident were updated and psycho-social follow-up was conducted with each resident. In an interview on 10-3-22 at 2:12 p.m., with CNA 5, she recalled working with Resident D on the evening of 9-1-22. She recalled she was assisting Resident D from the dining room to his room, which he shared with Resident E. He started calling [name of Resident E] a son of a b---h and that he didn't want to be in the room with that a-----e, before we even got to his room. He kept calling [name of Resident E] names. We, me and [name of CNA 6], kept them separated and went and got the [name of LPN 7]. She indicated Resident D was relocated into a different room in the facility at that time. She reported while she and Resident D were out in the hallway with Resident D still yelling at Resident E, Resident E called one of his daughters on his phone to tell her what was going on. CNA 5 indicated Resident E, was very upset about the situation. CNA 5 indicated she has worked at the facility for several years. I have worked here about 6 years. She indicated Resident D had problems with a roommate before, kind of the same thing. Calling him names and being very rude. In an interview with Resident E on 10-3-22 at 1:05 p.m., he recalled the incident with Resident D from approximately one month ago. He indicated Resident D was his roommate at that time. He indicated prior to this incident, there had been no other negative encounters. He was in the hall and started yelling and cussing at me. Don't know why he did it. He indicated the nursing staff did not return him into their shared room at that time and has not seen him since. He indicated Resident D's comments were hurtful at the time, but did not cause him any significant problems. On 9-30-22 at 11:00 a.m., the Social Services Designee (SSD) provided a copy of the facility's current policy and procedure, entitled, Indiana Abuse & Neglect & Misappropriation of Property, with a revision date of 10-27-2021. This policy indicates, Verbal Abuse [definition]: In Indiana, oral, written, and/or gestured language that includes disparaging and/or derogatory terms to the residents or their families, either directly or within their hearing. This may include resident to resident verbal threats of harm, but excludes random statements of a cognitively impaired resident such as repetitive name calling or nonsensical language. Verbal abuse includes any staff to resident episodes .It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. It is the intent of this facility to prevent the abuse, mistreatment, or neglect of residents or the misappropriation of their property, corporal punishment and/or involuntary seclusion and to provide guidance to direct staff to manage any concerns or allegations of abuse, neglect or misappropriation of their property .An employee who is alleged or accused of being a party to abuse, neglect misappropriation of property, will be immediately removed from the area(s) of the resident care, interviewed by facility leadership for a written statement and not left alone .After completing the statements, the employee(s) will be asked to vacate the facility until further investigation of the incident is completed. This Federal tag relates to Complaint IN 453. 3.1-27(b)

Based on interview and record review, the facility failed to ensure staff members did not report for duty within 24 hours after suspected Norovirus symptoms of nausea, vomiting and diarrhea had subsided for 12 of 15 facility staff members reviewed for an outbreak of suspected Norovirus in the facility with a facility census of 45 of which 6 residents had displayed symptoms of suspected Norovirus between the dates of 3-25-21 and 3-28-21. (Business Office Manager or BOM, CNA 5, 8 and 15, QMA 7 and 18, Housekeeper 6, 13 and 14, LPN 10 and 16, and Dietary Staff 12) Findings include: On 3-29-21, the facility submitted a reportable incident to the Indiana Department of Health (IDOH) regarding 10% (percent) or more of their resident population and staff having symptoms of vomiting and diarrhea. A follow-up to this report was submitted to IDOH on 4-1-21 which indicated 13% of the residents and 29% of the staff members was identified to have symptoms of nausea, vomiting and diarrhea .No new residents or staff has exhibited [these symptoms] since 3-29-21.] In an interview on 4-8-21 at 9:40 a.m., with the Executive Director, she indicated during the time period of 3-21-21 through 3-29-21, the facility experienced some type of gastrointestinal infection in which 6 residents and 16 staff experienced of a very short-lived, anywhere from maybe one shift to 24 hours of nausea, vomiting and some diarrhea. Seems like it was the residents on the south hall that had the bug, but the staff on the north end of the building that got it. She indicated the facility was in contact with the county health dept, the State Health Dept and the State IP [Infection Preventionist]. In an interview with the Director of Nursing (DON) on 4-9-21 at 11:39 a.m., she indicated she is one of three IP's for the facility. She indicated upon further review of the Indiana State Department of Health [MEDICATION(S)] Disease Case Report Worksheet, it was discovered one of the staff members listed on the worksheet did not meet the actual criteria for suspected Norovirus and was to be deleted, leaving 15 staff members on the worksheet. In continued interview on 4-9-21 at 1:00 p.m., the DON indicated she was out of the facility during this time. The IP that week was [name of RN 3] and she is on vacation this week. I was able to reach her and she did tell me that initially, she didn't realize that we were in the midst of an outbreak until the weekend of 3-27-21 and 3-28-21. Review of the employees listed on the Indiana State Department of Health [MEDICATION(S)] Disease Case Report Worksheet, indicated the following employees returned to work less than 24 hours after suspected Norovirus symptoms of nausea, vomiting and diarrhea had subsided: 1. BOM (business office manager) became symptomatic with nausea, vomiting and diarrhea on 3-22-21 at an unknown time, with symptoms resolved on 3-24-21 and returned to work on 3-25-21 for the day shift. 2. CNA 5 called in sick with nausea, vomiting and diarrhea on the morning of 3-21-21, with symptoms resolved on 3-22-21 at an unknown time. Her work schedule indicated she was off on 3-20-21, called in sick on 3-21-21 and returned to work at 2:00 p.m. on 3-22-21. 3. Housekeeper 6 became symptomatic with nausea, vomiting and diarrhea on 3-23-21, with symptoms resolved on 3-25-21 at an unknown time. Her work scheduled indicated she was off work by 3-23-21 at 1:00 p.m., was off on 3-24-21, worked 3-25-21 and was off on 3-26-21 through 3-31-21. 4. QMA 7 became symptomatic with nausea, vomiting and diarrhea on 3-24-21, with symptoms resolved on 3-25-21 at an unknown time. Her work scheduled indicated she called in sick on 3-23-24 and 3-24-21, was scheduled off on 3-25-21 and returned to work on 3-26-21. Her shifts were identified as 6:00 a.m. to 6:00 p.m. and/or 6:00 a.m. to 2:00 p.m. 5. CNA 8 called in sick with nausea, vomiting and diarrhea on the morning of 3-25-21, with symptoms resolved on 3-26-21 at an unknown time. Her work schedule indicated she worked day shift on 3-24-21, called in sick on 3-25-21 and returned to her day shift schedule on 3-27-21. 6. LPN 10 became symptomatic with nausea, vomiting and diarrhea on 3-25-21, during a scheduled day off, called in on 3-26-21, with symptoms resolved on 3-27-21 and returned to work on 3-27-21. Review of her work schedule 7. Dietary Staff 12, became symptomatic with nausea, vomiting and diarrhea on the morning of 3-26-21 with symptoms resolved the evening of 3-26-21 and returned to work on 3-27-21. In an interview on 4-8-21 at 11:32 a.m., with Dietary Staff 12, she indicated she was scheduled to work 3-26-21, from 10:00 a.m. to 6:30 p.m., but called in for an upset stomach, vomiting and headache. She indicated she began feeling much better by late afternoon on 3-26-21 and returned to work on Saturday, 3-27-21, for her 10:00 a.m. to 6:30 p.m. shift. 8. Housekeeper 13, became symptomatic with nausea, vomiting and diarrhea 3-27-21, with symptoms resolved 3-28-21 at an unknown time. Her work schedule indicated she worked day shift on 3-25-21, was off on 3-26-21 and returned to work on 3-27-21, was off on 3-28-21 and returned to work on 3-29-21. 9. Housekeeper 14, became symptomatic with nausea, vomiting and diarrhea 3-26-21 with symptoms resolved 3-27-21 at an unknown time. Her work schedule indicated she was off on 3-25-21, was off on 3-25-21, worked on 3-26-21, was off 3-27-21 and returned to work on 3-28-21. 10. CNA 15, became symptomatic with nausea, vomiting and diarrhea 3-27-21 with symptoms resolved 3-28-21 at an unknown time. Her work schedule indicated she worked on the day shift on 3-25-21, was off on 3-26-21 and called in sick on 3-27-21 and returned to work on 3-28-21. 11. LPN 16, became symptomatic with nausea, vomiting and diarrhea 3-27-21 with symptoms resolved 3-28-21 at an unknown time. Her work schedule indicated she worked her shift of 7:00 a.m. until 7:00 p.m. on 3-26-21, was scheduled off on 3-27-21 and 3-28-21 and and returned to work on 3-29-21 at 7:00 a.m. 12. QMA 18, became symptomatic with nausea, vomiting and diarrhea 3-27-21 with symptoms resolved 3-28-21 at an unknown time. Her work schedule indicated she worked 6:00 a.m. until 6:00 p.m. on 3-26-21. She was scheduled off on 3-27-21 and returned to work on 3-28-21 at 6:00 a.m. In a telephone interview on 4-9-21 at 9:58 a.m., with a State Epidemiologist, she indicated the terms gastroenteritis and Norovirus are often used interchangeably, but for an unknown status of nausea, vomiting and diarrhea, it is acceptable to use the term, suspected Norovirus. She indicated the current Retail Food Establishment Sanitation Requirements manual for Indiana (2004) indicates for situations, such as in nursing homes with a population of potentially vulnerable persons, the manual indicates for any staff cases of nausea, vomiting & diarrhea, the staff person should not return to work for a minimum of 24 hours after symptoms have resolved. She indicated this information could be found at 410 IAC 7-24-121(a)(1) and 410 IAC 7-24-121(a)(4)(A) 4-9-21 at 9:55 a.m. The Executive Director provided a copy of a policy entitled, Employee Health Work Exclusion, # IC 1091-01 with a revision date of 5-1-17. This policy indicated, A single point-of-contact is established for calling off for work by the director of nursing. The point-of-contact employee will then receive employee call offs from work and document as per facility standard. In the event the HCP [healthcare personnel] is calling off work due to their own illness, the contact will direct the employee to call the IP/designee for symptom tracking for potential infections and provide the appropriate contact information to the employee. The employee will contact the IP/Designee for self-illness related call offs. This process is established to: Reduce confusion for the HCP with a self-illness related call off for whom to report an illness; Provide a specialized trained nurse for symptom documentation to determine potential infections based on signs and symptoms for caregivers who may have been infectious prior to the on-set of symptoms .The IP/Designee will assist the employee to determine if presenting signs/symptoms indicate an infection based on the McGeers Criteria; If an infection is indicated, the IP/Designee will create an employee surveillance record and recommend non-resident contact .The IP/Designee will determine when the HCP may return to work based on CDC, APIC guidelines for the particular infection and the facility human resources guidelines .Certain diagnosis [sic] will exclude HCP [healthcare personnel] from working directly with residents for care until resolved. Exclusion diagnosis [sic] include but are not limited to .Diarrheal disease(s): Restrict from resident care and food handling: Norovirus: 48 hours after symptoms resolve. Gastroenteritis: 24 hours after symptoms resolve. On 4-9-21 at 9:55 a.m., the Executive Director provided an undated copy of a CDC (Centers of Disease Control) handout, entitled, Key Infection Control Recommendations for the Control of Norovirus Outbreaks in Healthcare Settings. This handout was included with other infection control policies provided at this time. It indicated, In the absence of clinical laboratory diagnostic or in the case of delay in obtaining laboratory results, use Kaplan's clinical and epidemiological criteria to identify a norovirus gastroenteritis outbreak. Kaplan's Criteria [includes]: vomiting in more than half of symptomatic cases, and Mean (or median) incubation period of 24 to 48 hours, and Mean (or median) duration of illness of 12 to 60 hours, and No bacterial pathogen isolated from stool culture .Exclude ill personnel from work for a minimum of 48 hours after the resolution of symptoms . This deficiency relates to Complaint IN 585. 3.1-18(b)(1)(a) 3.1-18(b)(1)(b) 3.1-18(b)(1)(c) 3.1-18(b)(6) 3.1-18(k) 3.1-21(i)(2) 410 IAC 7-24-121(a)(1) 410 IAC 7-24-121(a)(4)(A)

Based on interview and record review, the facility failed to ensure a dietary staff member did not report for duty within 24 hours after suspected Norovirus symptoms of nausea, vomiting, diarrhea and headache had subsided for 1 of 1 dietary members with suspected Norovirus, with a facility census of 45. (Dietary Staff 12) Findings include: On 3-29-21, the facility submitted a reportable incident to the Indiana Department of Health (IDOH) regarding 10% (percent) or more of their resident population and staff having symptoms of vomiting and diarrhea. A follow-up to this report was submitted to IDOH on 4-1-21 which indicated 13% of the residents and 29% of the staff members was identified to have symptoms of nausea, vomiting and diarrhea .No new residents or staff has exhibited [these symptoms] since 3-29-21. Review of the Indiana State Department of Health [MEDICATION(S)] Disease Case Report Worksheet, indicated one (1) dietary staff member experienced the symptoms of vomiting, nausea and diarrhea, with an onset date identified of 3-26-21 and a resolution date of symptoms identified as 3-27-21. The work schedule for Dietary Staff 12 indicated she had last worked on 3-23-21, from 10:00 a.m. to 6:30 p.m. and returned to work on 3-27-21, from 10:00 a.m. to 6:30 p.m. In an interview on 4-8-21 at 11:32 a.m., with Dietary Staff 12, she indicated she was scheduled to work 3-26-21, on 10:00 a.m. to 6:30 p.m., but called in for upset stomach, vomiting and headache. She indicated she began feeling much better by late afternoon on 3-26-21 and returned to work on Saturday, 3-27-21, for her 10:00 a.m. to 6:30 p.m. shift. In a telephone interview on 4-9-21 at 9:58 a.m., with a State Epidemiologist, she indicated the terms gastroenteritis and Norovirus are often used interchangeably, but for an unknown status of nausea, vomiting and diarrhea, it is acceptable to use the term, suspected Norovirus. She indicated the current Retail Food Establishment Sanitation Requirements manual for Indiana (2004) indicates for situations, such as in nursing homes with a population of potentially vulnerable persons, the manual indicates for any staff cases of nausea, vomiting and diarrhea, the staff person should not return to work for a minimum of 24 hours after symptoms have resolved. She indicated this information could be found at 410 IAC 7-24-121(a)(1) and 410 IAC 7-24-121(a)(4)(A) 4-9-21 at 9:55 a.m. The ED provided a copy of a policy entitled, Employee Health Work Exclusion, with a revision date of 5-1-17. This policy indicated, Certain diagnosis [sic] will exclude HCP [healthcare personnel] from working directly with residents for care until resolved. Exclusion diagnosis [sic] include but are not limited to .Diarrheal disease(s): Restrict from resident care and food handling: Norovirus: 48 hours after symptoms resolve. Gastroenteritis: 24 hours after symptoms resolve. Preventing Norovirus Outbreaks, (June 2014) was retrieved on 4-8-21 from the Centers of Disease Control (CDC) website. This article included a poster entitled, Ways to prevent norovirus outbreaks from food contamination. This poster specified, Stay home when sick. Food service workers should stay home when sick with vomiting or diarrhea and for at least 48 hours after symptoms stop. This deficiency relates to Complaint IN 585. 3.1-21(i)(2) 410 IAC 7-24-121(a)(1) 410 IAC 7-24-121(a)(4)(A)

Based on observation, interview and policy review, the facility failed to ensure one of five staff donned gloves before entering a resident room and performed hand hygiene after removing PPE (Personal Protection Equipment), and failed to ensure eight of 10 direct care staff on two of two COVID-19 observation areas donned gloves in proper sequence according to CDC (Centers for Disease Control) guidelines. Findings include: During an interview on 12/15/20 at 9:00 AM, the Administrator stated two direct care staff had been confirmed positive for COVID-19 on 12/14/20. All 46 residents in the facility were placed on droplet precautions on two of two resident care areas. The two resident care areas were described as Yellow Zones. 1. On 12/15/20 at 11:50 AM, Nursing Assistant (NA) 1 was observed preparing to enter room [ROOM NUMBER]. NA1 was wearing a mask and face shield. NA1 donned gloves and then donned an isolation gown. NA1 failed to ensure the cuffs of the gloves were extended to cover the wrist of the isolation gown. 2. On 12/15/20 at 12:05 PM, NA2 was observed preparing to enter room [ROOM NUMBER]. NA2 was wearing a mask and face shield. NA2 donned gloves and then donned an isolation gown. NA2 failed to ensure the cuffs of the gloves were extended to cover the wrist of the isolation gown. 3. On 12/15/20 at 12:10 PM, the Maintenance Director (MD) was observed preparing to enter room [ROOM NUMBER]. The MD was wearing a mask and face shield. The MD donned an isolation gown and did not don gloves before entering the room. The MD handed a package to the resident with ungloved hands. The MD removed the isolation gown and pushed it into an overflowing isolation container for trash with ungloved hands. The isolation trash container was overflowing, and the MD pushed the discarded PPE down into the container. The MD did not wash her hands or use hand sanitizer after discarding the gown then reached into the clean storage of gowns on the door of the room. During the observation the MD stated, I contaminated the clean gowns and I'll have to throw them out. I usually wear gloves, but I was nervous and didn't think about it. 4. On 12/15/20 at 12:15 PM, NA3 was observed preparing to enter room [ROOM NUMBER]. NA3 was wearing a mask and face shield. NA3 donned gloves and then donned an isolation gown. NA3 failed to ensure the cuffs of the gloves were extended to cover the wrist of the isolation gown. 5. On 12/15/20 at 12:20 PM, the Physical Therapy Aide (PTA) was observed preparing to enter room [ROOM NUMBER]. The PTA was wearing a mask and face shield. The PTA donned gloves and then donned an isolation gown. The PTA failed to ensure the cuffs of the gloves were extended to cover the wrist of the isolation gown. 6. On 12/15/20 at 12:22 PM, the Director of Rehabilitation (DOR) was observed preparing to enter room [ROOM NUMBER]. The DOR was wearing a mask and face shield. The DOR donned gloves and then donned an isolation gown. The DOR failed to ensure the cuffs of the gloves were extended to cover the wrist of the isolation gown. 7. On 12/15/20 at 2:00 PM, Licensed Practical Nurse (LPN) 1 was observed preparing to enter room [ROOM NUMBER]. LPN1 was wearing a mask and face shield. LPN1 donned gloves and then donned an isolation gown. LPN1 failed to ensure the cuffs of the gloves were extended to cover the wrist of the isolation gown. 8. On 12/15/20 at 3:10 PM, Registered Nurse (RN) 2 was observed preparing to enter room [ROOM NUMBER]. RN2 was wearing a mask and face shield. RN2 donned gloves and then donned an isolation gown. RN2 failed to ensure the cuffs of the gloves were extended to cover the wrist of the isolation gown. During a phone interview on 12/16/20 at 1:10 PM, NA 1 stated, I knew I messed up yesterday with the PPE. I realized it as soon as I put the gloves on first. During a phone interview on 12/16/20 at 1:20 PM, LPN 1 stated, I always put the gown on first, I guess I got confused. During a phone interview on 12/16/20 at 1:40 PM, NA 2 stated, I was trained to put the gloves on first, I guess I was nervous yesterday. I usually put gloves on first. During a phone interview on 12/16/20 at 1:50 PM, NA 3 stated, I realized I did it wrong as soon as I did it. I'll start putting the gown on first. During a phone interview on 12/16/20 at 1:55 PM, the PTA stated, I usually put on gloves first but I'm nervous by nature and when I'm being watched I get really nervous. During a phone interview on 12/16/20 at 2:03 PM, the DOR stated, I put my gloves on first because the cuff of the gown covers my gloves. I guess I have it backwards. During an interview on 12/15/20 at 1:20 PM, the Director of Nursing (DON) stated the facility staff were trained on PPE use following CDC guidelines. The DON provided a copy of the CDC poster titled, Sequence for putting on and safely removing personal protective equipment. The DON stated the CDC poster was used by the facility for staff training related to PPE use. Review of the CDC poster titled, Sequence for putting on and safely removing personal protective equipment used by the facility for training purposes, indicated, 1. Gown . 2. Mask or Respirator . 3. Goggles or face shield .and 4. Gloves-extend to cover wrist of isolation gown .wash hands or use an alcohol-based hand sanitizer immediately after removing all PPE. Review of Use of PPE while in the facility dated 11/30/20 indicated, Yellow Quarantined/Observation area .Full PPE will be used while working on the COVID designated area .including masks, gloves, gowns and eye covers .gowns must be disposed of when exiting the resident room. Review of Hand Hygiene revised on 10/31/18 ndicated, Hand hygiene: the cleaning of hands by using either handwashing with soap and water, antiseptic hand rub that is, alcohol-based sanitizer .when to perform hand hygiene .for care between patients .after contact with inanimate objects including medical equipment in the immediate vicinity of the resident.