Every finding on record at Community Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to timely initiate physician's orders for 1 of 2 residents reviewed for skin conditions. (Resident 23) Findings include: The clinical record for Resident 23 was reviewed on 4/20/26 at 8:30 a.m. The resident's diagnosis included, but was not limited to, chronic peripheral venous insufficiency (condition that prevented blood from returning to heart and caused blood to pool in lower extremities) A Quarterly Minimum Data Set (MDS) Assessment, completed 3/25/26, indicated the resident had moderately impaired cognition and had no foot problems. A physician's order, dated 4/15/26, indicated the resident's right foot was to be wrapped in kerlix (type of gauze dressing) daily. The order was discontinued on 4/17/26. A care plan, initiated 4/16/26, indicated Resident 23 had an open blister on his right foot. He had intermittent edema (swelling) of his feet. He had a history of refusing treatments and labs at times. The goal was for the wound to heal without complications. A Skin and Wound note, dated 4/17/26, indicated Resident 23 had been seen for a new skin issue of a large blister on the top of his right foot that extended to the right great toe and was suggestive of cellulitis. The blister had opened and the area around the wound was edematous (swollen), had redness, was warm and tender to touch. It was recommended to reach out to the primary care physician for an oral antibiotic (medication to treat infection). The wound on the top of the right foot was to be treated with Xeroform (a type of wound dressing) and secured with an ABD pad (thick, absorbent dressing) and kerlix gauze. The wound dressing should have been changed every other day and as needed. A physician's order, dated 4/17/26, indicated the resident was to receive linezolid (antibiotic) 600 milligrams (mg) every 12 hours for 10 doses. Resident 23's clinical record did not contain an order for the Xeroform wound dressing. The April 2026 Medication Administration Record (MAR) indicated Resident 23 did not receive linezolid 600 mg on 4/17, 4/18, 4/19, and 4/20/26 at 7:00 a.m.On 4/20/2026 at 11:16 a.m., Resident 23 was observed in the hallway. The resident's right foot had an unraveling kerlix dressing with tan colored drainage visible on the top of the dressing. On 4/21/26 at 10:34 a.m., Resident 23 was observed in his room. The resident had a clean kerlix dressing on his right foot.A physician's order, dated 4/21/26, indicated the resident was to have right foot wound cleansed and covered with xeroform, covered with an ABD and wrapped in kerlix. The wound dressing was to be changed every other day and as needed. During an interview on 4/21/2026 at 11:34 a.m., Licensed Practical Nurse (LPN) 2 indicated the resident had received a dose of linezolid that morning. LPN 2 removed Resident 23's linezolid medication from the medication cart. The linezolid had been dispensed by the pharmacy on 4/17/26 and 2 of the 10 doses dispensed had been given. LPN 2 was unsure why only 2 doses had been administered. During an interview on 4/22/26 at 11:42 a.m., the Regional Director of Clinical Services indicated Resident 23's antibiotic and wound treatment should have been started when ordered by the physician. On 4/22/26 at 11:42 a.m., the Regional Director of Clinical Services provided the Skin Management Program, dated May 2022, that read .Alterations in skin integrity will be reported to the MD/NP [sic] .Treatment orders will be obtained from the MD/NP [sic] . 410 IAC (Indiana Administrative Code) 16.3.1-37

Based on interview and record review, the facility failed to timely address residents' missing eyeglasses, ensure an ophthalmologist appointment was made and eye drops were administered as ordered for 2 of 3 residents reviewed for vision services. (Residents 8 and 10) Findings include:1.The clinical record for Resident 8 was reviewed on 4/20/26 at 8:30 a.m. The diagnosis included but was not limited to: dry eye syndrome (eyes do not produce enough tears). A Quarterly Minimum Data Set (MDS) Assessment, dated 3/31/26, indicated Resident 8 was cognitively intact. An eye visit report, dated 11/14/25, indicated Resident 8 has lost her eyeglasses. The eye doctor had recommended a new set of bifocals upon approval. An interview was conducted with Resident 8 on 4/20/26 at 8:42 a.m. She indicated she needed eyeglasses. She did have some, but they have been missing for a while. An interview was conducted with Certified Nursing Assistant (CNA) 3 on 4/22/26 at 10:24 a.m. She indicated Resident 8 did wear eyeglasses, but the eyeglasses were unable to be found. An interview was conducted with the Administrator on 4/23/26 at 8:52 a.m. She indicated she had spoken to the Social Services Director (SSD). The SSD reported Resident 8's eyeglasses were missing. She was unaware the eyeglasses were missing until that day. 2. The clinical record for Resident 10 was reviewed on 4/20/26 at 7:30 a.m. The diagnosis included but was not limited to: schizoaffective disorder (a chronic mental mood disorder with hallucinations and delusions.) A Quarterly MDS Assessment, dated 3/25/26, indicated Resident 10 was cognitively intact. A physician's order, dated 4/20/26, indicated the staff were to make an ophthalmology (specialized eye services) consultation. A physician's order, dated 4/20/26, indicated Resident 10 was to receive brimonidine eye drops in both eyes twice a day. An interview was conducted with Resident 10 on 4/20/26 at 7:57 a.m. He indicated he was supposed to have cataract eye surgery. He was unsure when it was scheduled. An eye visit report, dated 2/4/26, indicated the provider had recommended Resident 10 to have cataract surgery. The provider ordered ophthalmology consultation and brimonidine eye drops were to be administered to the resident in both eyes twice a day. The resident had lost his eyeglasses. New bifocals would be delivered upon approval. An interview was conducted with the Regional Director of Clinical Services (RDCS) on 4/22/26 at 11:00 a.m. She indicated Resident 10 had asked the nurse on 4/20/26 about his cataract surgery. The eye visit report was reviewed. The recommendations for ophthalmology consultation, and the brimonidine eye drops that had been ordered on 2/4/26 were missed. A Vision services policy was provided by the RDCS on 4/22/26 at 11:43 p.m. It indicated, .Policy. It is the policy of this facility to ensure that residents are provided with vision and hearing services as needed.Nursing provides for proper care of glasses,. 410 IAC (Indiana Administrative Code) 16.3-3.1-39(a)(1)

Based on observation, interview, and record review, the facility failed to provide fluids at the bedside for 1 of 2 residents reviewed for hydration. (Resident C) Findings include:The clinical record for Resident C was reviewed on 4/21/2026 at 9:58 a.m. The diagnoses included, but were not limited to, dementia, anxiety, and hypothyroidism (the thyroid gland fails to produce enough hormones, slowing metabolism). A physician's order, dated 5/1/25, indicated Resident C had a regular diet order with thin liquids. During an observation on 4/20/26 at 7:39 a.m., Resident C had a small clear cup of pink liquid sitting on a table across the room from Resident C's bed. During an observation on 4/21/26 at 10:27 a.m. and 2:13 p.m., Resident C did not have any fluids in her room or at her bedside. Resident C's bedside table was adjacent to her bed with a pillow lying on top. An observation of Resident C on 4/21/26 at 12:40 p.m., indicated she could independently hold a cup and drink through a straw without difficulties. During an observation on 4/23/26 at 9:50 a.m., Resident C had no fluids in her room or at her bedside. A Significant Change Minimum Data Set (MDS) assessment, dated 4/1/26, indicated Resident C was moderately cognitively impaired and required substantial/maximal assist with eating. A plan of care, dated 4/25/25, indicated Resident C had potential for tiredness and weakness due to the diagnosis of anemia. The interventions included, but were not limited to, encourage fluids. A plan of care, dated 4/25/25, indicated Resident C was at risk for fluid imbalance due to dementia and hypothyroidism. The interventions included, but were not limited to, encourage fluids. During an interview with Licensed Practical Nurse (LPN) 2 on 4/23/26 at 9:56 a.m., indicated staff should be passing ice waters and she did not know why Resident C did not receive any ice water that morning. LPN 2 indicated waters were passed to residents every shift and as needed. Certified Nursing Assistants (CNAs) were assigned to pass waters, but any staff member can pass water if needed. A Hydration Management policy was provided by the Senior Administrator on 4/23/26 at 11:00 a.m. It indicated .Policy: It is the policy of American Senior Communities to ensure that each resident is offered sufficient fluid intake to maintain proper hydration.Procedure: 9. Fresh water or other preferred beverages will be passed to all residents on each shift.10. A variety of additional fluids will be offered at various times throughout each shift. 410 IAC (Indiana Administrative Code) 3.1-46

Based on observation, interview, and record review, the facility failed to follow a physician's order to change humidified oxygen for 1 of 2 residents reviewed for respiratory care. (Resident C) Findings include:The clinical record for Resident C was reviewed on 4/21/2026 at 9:58 a.m. The diagnoses included, but were not limited to, chronic respiratory failure, chronic obstructive pulmonary disease (a progressive lung disease that restricts airflow), and anxiety. A plan of care, dated 4/25/25, indicated Resident C had the potential for impaired gas exchange due to chronic obstructive pulmonary disease. The interventions included, but were not limited to, administer oxygen as ordered. A Significant Change Minimum Data Set (MDS) assessment, dated 4/1/26, indicated Resident C was moderately cognitively impaired and received oxygen therapy. During an observation on 4/20/26 at 7:40 a.m., Resident C had an empty bottle of humidified oxygen, dated 4/13/26, hooked up to her oxygen concentrator. The April 2026 Medication Administration Record (MAR) indicated Resident C had a new bottle of humidity hung 4/19/26 between 11:00 p.m. to 7:00 a.m. A physician's order, dated 3/26/26, indicated staff were to change the resident's oxygen tubing and humidity once a day on Sunday. During an observation on 4/20/26 at 10:33 a.m., Resident C had a new humidity bottle, dated 4/19/26, hooked up to her oxygen concentrator. During an interview with Licensed Practical Nurse (LPN) 2 on 4/21/26 at 10:33 a.m., they indicated the LPN did not know who hung the new bottle of humidity or why it was dated 4/19/26 when it was hung on 4/20/26. LPN 2 indicated they normally would put the correct date and initials on a new bottle hung. During an interview with the Minimum Data Set (MDS) assessment Nurse on 4/21/26 at 10:45 a.m., they indicated they went in to change the oxygen humidity bottle on 4/20/26 with LPN 4 because they noticed it was empty and she must have put the wrong date on the bottle. During an interview with the Regional Director of Clinical Services on 4/23/26 at 9:38 a.m., indicated on Sunday 4/19/26, the unit manager should have changed the humidified oxygen bottle as it was ordered on the MAR or as needed. Her expectation was that staff follow physician orders. This Citation relates to intake 2808585410 IAC (Indiana Administrative Code) 3.1-47(a)(6)

Based on observation, interview, and record review, the facility and the facility-contracted pharmacy failed to ensure an excessive dose of a medication was not administered to a resident for 1 of 5 residents reviewed for unnecessary medications (Resident B).Findings include: The clinical record for Resident B was reviewed on 4/20/26 at 10:12 a.m. The resident's diagnoses included, but were not limited to, diabetes and morbid (severe) obesity due to excess calories. A Quarterly Minimum Data Set (MDS) Assessment, completed 2/16/26, indicated Resident B was cognitively intact. A care plan, last reviewed 1/16/26, indicated the resident was at risk for adverse effects of hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar) related to the use of glucose (blood sugar) lowering medications and a diagnosis of diabetes. The goal was for the resident not to experience hyperglycemia or hypoglycemia. The interventions included, but were not limited to, observe for signs and symptoms of hyperglycemia and hypoglycemia, monitor blood sugar as ordered, and administer medications as ordered. A physician's order, dated 12/2/25, indicated the resident was to receive Ozempic (medication given once a week to improve blood sugar control) 0.5 milligram (mg) subcutaneously (injected into the subcutaneous tissue) every Tuesday. This order was discontinued on 1/27/26. A physician's order, dated 1/20/26 with a start date of 1/27/26, indicated the resident was to receive Ozempic 1 mg/dose (4mg/3ml); 4 mg subcutaneously every Tuesday.A physician's progress note, dated 1/20/26, indicated Resident B's Ozempic was to be increased to 4 mg weekly. The first dose was to be given on 1/27/26.A pharmacy review, conducted 2/4/26, did not contain recommendations about Resident B's Ozempic dosage.The February 2026 Medication Administration Record (MAR) indicated Resident 23 had received Ozempic 1 mg/dose (4mg/3ml); 4 mg subcutaneously on 2/3, 2/17, and 2/24/26.A pharmacy review, conducted 3/5/26, did not contain recommendations about Resident 23's Ozempic dosage. The March 2026 MAR did not contain documentation that Resident B had received her scheduled dose of Ozempic on 3/3 and 3/10/26. The March 2026 MAR did indicate the resident had received Ozempic 1 mg/dose (4mg/3ml); 4 mg subcutaneously on 3/24 and 3/31/26.During an interview on 4/20/26 at 10:12 a.m., Resident B indicated she had not been getting her scheduled shots on Tuesdays. The April 2026 MAR did not contain documentation that Resident B had received her scheduled dose of Ozempic on 4/7/26. The resident had received the scheduled dose of Ozempic on 4/14/26. The 4/21/26 dose indicated had not been given and a note indicated awaiting pharmacy.During an interview on 4/23/26 at 1:26 p.m., Pharmacy Technician (PTC) 5 indicated the resident's Ozempic had been refilled by the pharmacy on 2/17/26 and four doses had been sent. The Ozempic had also been refilled on 4/9/26 and four doses had been sent to the facility. The facility should have had the Ozempic available to be given.On 4/23/24 at 1:30 p.m., the facility medication room refrigerator was observed with Licensed Practical Nurse (LPN) 4. LPN 4 indicated the facility medication refrigerator did not contain Resident B's Ozempic medication. Ozempic was normally stored in the medication refrigerator.During an interview on 4/23/26 at 2:10 p.m., the Director of Nursing (DON) indicated Resident B had been receiving 4 mg of Ozempic as ordered by the Nurse Practitioner.During an interview on 4/23/26 at 2:15 p.m., Registered Pharmacist (RP) 7 indicated the pharmacy had received an order for Ozempic 1 mg/dose (4mg/3ml); 4 mg subcutaneously and had clarified the order with Nurse Practitioner (NP) 8 on 1/30/26. The clarified Ozempic order was for the resident to receive 1 mg of Ozempic every Tuesday. The pharmacy had sent an Ozempic multidose pen that contained 4 one milligram doses on 4/9/26. The maximum dose of Ozempic was two milligrams weekly. The pharmacy would not have filled the prescription for Ozempic 4 mg weekly as it would have exceed the maximum dosage.During an interview on 4/23/26 at 2:20 p.m., the Administrator indicated NP 8 did not work at the facility and the facility was unaware of who NP 8 was and the facility did not have an order on record for Resident B to receive Ozempic 1 mg weekly. The Ozempic physician's order the facility had been following for 4 mg weekly.During an interview on 4/23/26 at 2:29 p.m., NP 6 indicated she had increased Resident B's Ozempic on 1/20/26. NP 6 could not recall the amount of Ozempic ordered but would not have intended to order an inappropriate dose. The Ozempic.injection, for subcutaneous use Medication Guide, dated October 2025, was retrieved from Ozempic.com website on 4/24/26 at 2:00 p.m. The Ozempic Medication Guide read .2.2 Recommended Dosage.The maximum recommended dosage is 2 mg once weekly. This citation was related to Intake 2808585 410 IAC (Indiana Administrative Code) 16.3.1-25(i)

Based on interview and record review, the facility failed to ensure a physician's order was clearly written for 1 of 5 residents reviewed for resident records. (Resident B)Findings include: The clinical record for Resident B was reviewed on 4/20/26 at 10:12 a.m. The resident's diagnoses included, but were not limited to, diabetes and morbid (severe) obesity due to excess calories. A Quarterly Minimum Data Set (MDS) Assessment, completed 2/16/26, indicated Resident B was cognitively intact. A physician's order, dated 1/20/26 with a start date of 1/27/26, indicated the resident was to receive Ozempic 1 mg/dose (4mg/3ml); 4 mg subcutaneously every Tuesday.A physician's progress note, dated 1/20/26, indicated Resident B's Ozempic was to be increased to 4 mg weekly. The first dose was to be given on 1/27/26.The March 2026 MAR did not contain documentation that Resident B had received her scheduled dose of Ozempic on 3/3 and 3/10/26. The March 2026 MAR did indicate the resident had received Ozempic 1 mg/dose (4mg/3ml); 4 mg subcutaneously on 3/24 and 3/31/26. The April 2026 MAR did not contain documentation that Resident B had received her scheduled dose of Ozempic on 4/7/26. The resident had received the scheduled dose of Ozempic on 4/14/26. The 4/21/26 dose indicated had not been given and a note indicated awaiting pharmacy. During an interview on 4/23/26 at 2:10 p.m., the Director of Nursing (DON) indicated Resident B had been receiving 4 mg of Ozempic as ordered by the Nurse Practitioner.During an interview on 4/23/26 at 2:15 p.m., Registered Pharmacist (RP) 7 indicated the pharmacy had received an order for Ozempic 1 mg/dose (4mg/3ml); 4 mg subcutaneously and had clarified the order with Nurse Practitioner (NP) 8 on 1/30/26. The clarified Ozempic order was for the resident to receive 1 mg of Ozempic every Tuesday. The pharmacy had sent an Ozempic multidose pen that contained 4 one milligram doses on 4/9/26. The maximum dose of Ozempic was two milligrams weekly. The pharmacy would not have filled the prescription for Ozempic 4 mg weekly as it would have exceed the maximum dosage.During an interview on 4/23/26 at 2:20 p.m., the Administrator indicated NP 8 did not work at the facility and the facility was unaware of who NP 8 was and the facility did not have an order on record for Resident B to receive Ozempic 1 mg weekly. The Ozempic physician's order the facility had been following for 4 mg weekly.During an interview on 4/23/26 at 2:29 p.m., NP 6 indicated she had increased Resident B's Ozempic on 1/20/26. NP 6 could not recall the amount of Ozempic ordered but would not have intended to order an inappropriate dose. The Ozempic.injection, for subcutaneous use Medication Guide, dated October 2025, was retrieved from Ozempic.com website on 4/24/26 at 2:00 p.m. The Ozempic Medication Guide read .2.2 Recommended Dosage.The maximum recommended dosage is 2 mg once weekly.This citation was related to Intake 2808585410 IAC (Indiana Administrative Code) 16.3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to maintain a resident's room in good repair contributing to a subsequent allegation of a resident for 1 of 3 residents reviewed for safe and clean environment. (Resident D)Findings include:The clinical record for Resident D was reviewed on 12/11/25 at 10:41 a.m. His diagnoses included, but were not limited to: major depressive disorder, cirrhosis of liver, liver transplant, severe alcohol dependence, and chronic kidney disease. The unedited 11/16/25, 7:33 a.m. nurse's note indicated, I was called to the first floor after a phone call from the police asking if there is problem. I replied that I would investigate. Upon reaching the first floor [name of Resident D] was yelling and accusing a new CNA [Certified Nursing Assistant] of pushing him. She did not. The plumbing broke and spilled water on the floor. This was apparently the trigger of his anger The investigative file into the allegation of staff to resident abuse involving Resident D and CNA (Certified Nursing Assistant) 2 was provided by the DNS (Director of Nursing Services) on 12/11/25 at 9:48 a.m. The file included the 11/17/25 documented interview with Resident D conducted by the SSD (Social Services Director.) It indicated Resident D reported that Sunday morning (11/16/25) nursing staff came into his shared room to get his roommate dressed for the day. Their normal routine was to turn on the water so that it could warm up. Staff left the water running unattended and moments later, water started to flood from the wall and around the bottom of the sink. Staff came in promptly to address the wet floors and provide the appropriate signage to be careful due to wet floors. Resident D indicated he told CNA 2 she should not have left the water unattended causing flooding on the floors. Resident D stated that CNA 2 asked him, Who are you talking to like that, and pushed him out of the way and exited his room. An interview was conducted with CNA 2 on 12/11/25 at 12:24 p.m. She indicated she currently worked at the facility as a CNA and was still within her first 90 days of employment. The morning of 11/16/25, she assisted Resident D's roommate with incontinence care, which involved running the water in the sink. She turned the water off prior to exiting the room. About an hour later, a co-worker informed her that there was water all over the floor in Resident D's room. CNA 2 retrieved a towel and went into the room to clean up the water. After entering the room, Resident D accused her of causing the water on the floor. Resident D thought she was responsible, because she was the last person in the room to use the sink. CNA 2 stated, I swear I don't remember leaving the water on. CNA 2 informed Resident D she did not leave the water running in the room and walked away. She did not ask him who he was talking to like that or push him out of the way to exit the room. When Resident D jumped off his bed, he flopped into his wheelchair, which wasn't locked, so it went backwards. Then Resident D immediately accused her of pushing him. CNA 2 was standing near the door at this time, like six feet away, from Resident D. She was in the room for less than two minutes.An interview and observation were conducted with Resident D in his room on 12/11/25 at 12:46 p.m. There was a small sink in the room against the wall. The drainpipe coming from the sink, leading into the wall, was easily visible. The wall to the right of the sink had ripples, bubbles, and peeling paint leading from the bottom of the wall up 4 feet, as well as missing baseboard. The bottom right part of the wall was dark in color. Resident D indicated the bubbles in the wall were from water damage. The sink did not overflow. It was the drain return pipe leading into the wall that leaked. He'd told the maintenance director about it a thousand times, and filled out a work order for it eight months ago. When the drainpipe leaked, water went into the hallway as well. The maintenance director doesn't do anything. When the CNAs came into his room to assist his roommate with incontinence care, the first thing they did was turn the water on, as it took a while for the water to warm. The plumbing can't take running water for too long. After the water ran from the room, it would then run down the hallway and staff had to put out the yellow wet floor sign. Staff had to use a bunch of towels, so no one slipped on the water. This occurrence happened routinely, about once a month. He was worried about the potential of breathing in mold as he believed his immune system was compromised. The water had been leaking, and the wall had looked like this since he'd lived in the room. The census tab of the electronic health record indicated Resident D began residing in his room on 3/2/25. On 12/11/25 at 1:04 p.m., an interview and observation of Resident D's room were conducted with the HS (Housekeeping Supervisor,) as the Maintenance Director was unavailable. The HS indicated he noticed the condition of Resident D's wall before. It looked like structural damage to him, but he was unsure what was happening. The facility was supposed to begin renovations sometime after Thanksgiving (11/27/25,) but they hadn't yet begun. The Resident's Rights policy was provided by the DNS on 12/11/25 at 2:02 p.m. It indicated, The Resident has a right to prompt efforts by the Facility to resolve grievances .This Citation relates to Intake 2667249.3.1-19(f)(5)

Based on interview and record review, the facility failed to report an allegation of staff to resident abuse to the ED (Executive Director) and IDOH (Indiana Department of Health) timely for 1 of 3 residents reviewed for abuse. (Resident D)Findings include: The clinical record for Resident D was reviewed on 12/11/25 at 10:41 a.m. His diagnoses included, but were not limited to: major depressive disorder, cirrhosis of liver, liver transplant, severe alcohol dependence, and chronic kidney disease. The 11/16/25, 7:00 a.m. nurse's note indicated, This writer was notified by a CNA that resident was cursing at her and yelling out false Accusations at approx [approximately] 5 am, situation began because of leaking water, staff was removed from res [resident's] room assignment and this writer instructed the staff to contact the ED [Executive Director] and DNS [Director of Nursing Services,] CNA [Certified Nursing Assistant] spoke with DNS and DNS reported the situation to the ED, statements were written and left in ED office, Nurse on night shift was aware of situation and spoke with the resident. MD was notified, res has no listed Emergency Contact. Will cont [continue] to monitor. Res currently in good spirits and talking nicely to the staff, he is requesting his colostomy supplies be re-ordered when next order is processed, resident states.An interview was conducted with CNA (Certified Nursing Assistant) 2 on 12/11/25 at 12:24 p.m. She indicated she currently worked at the facility as a CNA and was still within her first 90 days of employment. The morning of 11/16/25, she assisted Resident D's roommate with incontinence care, which involved running the water in the sink. She turned the water off prior to exiting the room. About an hour later, a co-worker informed her that there was water all over the floor in Resident D's room. CNA 2 retrieved a towel and went into the room to clean up the water. After entering the room, Resident D accused her of causing the water on the floor. Resident D thought she was responsible, because she was the last person in the room to use the sink. CNA 2 stated, I swear I don't remember leaving the water on. CNA 2 informed Resident D she did not leave the water running in the room and walked away. She did not ask him who he was talking to like that or push him out of the way to exit the room. When Resident D jumped off his bed, he flopped into his wheelchair, which wasn't locked, so it went backwards. Then Resident D immediately accused her of pushing him. CNA 2 was standing near the door at this time, like six feet away, from Resident D. She was in the room for less than two minutes. The investigation file into the above allegation of staff to resident abuse involving Resident D and CNA (Certified Nursing Assistant) 2 was provided by the DON (Director of Nursing) on 12/11/25 at 9:48 a.m. The file included the 11/20/25 follow-up incident report. It indicated the incident date and time was on 11/17/25 at 11:01 a.m. It was reported to IDOH on 11/17/25 by the ED (Executive Director.] The file included the 11/17/25 documented interview with Resident D conducted by the SSD (Social Services Director.) It indicated Resident D reported that Sunday morning (11/16/25) nursing staff came into his shared room to get his roommate dressed for the day. Their normal routine was to turn on the water so that it could warm up. Staff left the water running unattended and moments later, water started to flood from the wall and around the bottom of the sink. Staff came in promptly to address the wet floors and provide the appropriate signage to be careful due to wet floors. Resident D stated he told CNA 2 she should not have left the water unattended causing flooding on the floors. Resident D stated that CNA 2 asked him, Who are you talking to like that, and pushed him out of the way and exited his room. An interview was conducted with the DNS on 12/11/25 at 1:16 p.m. She indicated she reported the allegation to the ED on 11/16/25, the day it occurred. The ED was unavailable in the facility for interview.An interview was conducted with the RDCS (Regional Director of Clinical Services) on 12/11/25 at 12:24 p.m. She indicated the allegation should have been reported to the ED and IDOH immediately. It was her understanding the ED reported to IDOH immediately upon finding out about the allegation, which wasn't until 11/17/25. The Abuse Prohibition, Reporting, and Investigation policy was provided by the RDCS on 12/11/25 at 12:50 p.m. It indicated, Identification: Abuse includes: 1. Staff to resident abuse of any type.Types of abuse: 1. Verbal abuse.4. Physical abuse.Resident Abuse - Staff member, volunteer, or visitor: .2. Any individual who witnesses abuse, or has suspicion of abuse, shall immediately notify the charge nurse of the unit, which the resident resides and to the Executive Director.4. The Executive Director and/or Director of Nursing will be immediately notified of the report and the initiation of the investigation. Reporting/Response: 1. All abuse allegations must be reported to the Executive Director immediately. Failure to report will result in disciplinary action, up to and including immediate termination. 2. The Executive Director will ensure that if the alleged violation involves abuse or results in serious bodily injury, it must be reported immediately but no later than 2 hours to the Long-Term Care Division of the Indiana State Department of Health via the Gateway Portal.This Citation relates to Intake 2670919.3.1-28(c)

Based on observation, interview, and record review the facility failed to provide incontinent care timely for a dependent resident for 1 of 3 residents reviewed for Activities of Daily Living (ADL) assistance (Resident F). Finding include:Review of the clinical record of Resident F on 12/10/25 at 11:08 a.m., indicated the resident's diagnoses included, but were not limited to, heart failure, peripheral vascular disease, diabetes, muscle weakness, anxiety disorder and major depressive disorder. The plan of care for Resident F, dated 8/18/25, indicated the resident required assistance with ADL's. The interventions included, but were not limited to, assist with grooming, hygiene, toileting and incontinent care as needed. The resident concern/grievance form for Resident F, dated 11/10/25, indicated the resident's concern was she would turn on her call light to be provided incontinent care and the incontinent care was not provided in a timely manner resulting in the resident sitting in her own waste. The resident indicated this happened often. The grievance was marked resolved on 11/15/25 and indicated Resident F indicated care had gotten better, but there still were times it happened. The grievance was completed by the admission Coordinator. The quarterly Minimum Data Set (MDS) assessment for Resident F, dated 11/18/25, indicated the resident was cognitively intact for daily decision making. The resident was consistent and reasonable. The resident had no behaviors of rejection of care. The resident was dependent on staff for toileting. The resident was always incontinent of urine and frequently incontinent of bowels. During an interview and observation with Resident F on 12/10/25 at 11:32 a.m., the resident indicated it was disrespectful to her when staff did not answer her call light and would leave her wet and dirty. The resident indicated it hurt her feelings and it made her cry. The staff left her in urine and bowel movement for hours. The resident indicated she had a cell phone and timed how long it took for staff to provide care to her. The admission Coordinator came and seen her every morning and the resident did report these concerns to her. The resident indicated she was currently lying in urine and had been for an hour. The resident activated her call light. CNA 3 and the Assistant Director of Nursing Services (ADNS) came in and provided Resident F with incontinent care. The resident's brief was urine soaked and two cloth incontinent pads were also soaked in urine. During an interview with the admission Coordinator on 12/10/25 at 1:35 p.m., indicated she was Resident's F care companion and she visited her every morning. The admission Coordinator indicated she did fill out a grievance for Resident F related to not getting incontinent care timely. The admission Coordinator indicated after the grievance was filed Resident F continued to report to her that her call light was not answered timely and incontinent care was not provided timely. The admission Coordinator indicated she always reported Resident F's concerns in morning meeting. During an interview with the Director of Nursing Services (DNS) on 12/11/25 at 1:00 p.m., the DNS indicated it was the facilities expectation that when residents were incontinent of urine or bowel movement, incontinent care should be provided immediately. This Citation relates to Intake 2667249. 3.1-38(a)(3)(A)

Based on observation, interview and record review, the facility failed to transport a resident in wheelchair in a safe manner and failed to provide adequate monitoring for a resident who exited the facility without a responsible party for 2 of 3 residents reviewed for accidents (Resident F and Resident B). Findings include:1. Review of the clinical record of Resident F on 12/10/25 at 11:08 a.m., indicated the resident's diagnoses included, but were not limited to, heart failure, peripheral vascular disease, diabetes, muscle weakness, anxiety disorder and major depressive disorder. The quarterly Minimum Data Set (MDS) assessment for Resident F, dated 11/18/25, indicated the resident was cognitively intact for daily decision making. The resident was consistent and reasonable. The resident utilized a wheelchair for transportation and was dependent on staff for transport in the wheelchair. The resident did not ambulate. The progress note for Resident F, dated 9/20/25 at 2:13 p.m., indicated the resident complained of right foot pain. The resident's right foot was swollen and painful to the touch. An physician's order was received for the resident to obtain an x-ray of the right foot. The radiology report for Resident F, dated 9/21/25, indicated there was no fracture to the right foot. The witness statement, dated 10/18/25, indicated CNA 4 admitted pushing Resident F in the wheelchair in September 2025 and accidently hit the resident's foot on the door entry when trying to turn into the resident's room. The witness statement from Resident F, dated 10/18/25, indicated in September 2025, CNA 4 was pushing her in the wheelchair and accidentally rammed her foot into the wall when she was turning the wheelchair into the resident's room. During an interview with the Director Of Nursing Services (DNS) on 12/11/25 at 10:37 a.m., indicated Resident F had complained of pain of her legs and feet in October 2025 and called emergency services. The resident returned to the facility with a fractured right toe. The DNS indicated she started an investigation. Resident F reported to her that in September 2025, CNA 4 was pushing her down the hallway and hit her right foot on the wall when she was turning into the resident's room. The DNS indicated she talked to CNA 4 and the CNA indicated she accidently hit the resident's right foot on the wall when transporting her in the wheelchair. CNA 4 reported it to the Unit Manager. The Unit Manager had an x-ray completed and there was no fracture. The DNS indicated she did not do any safety training with the staff or implement in interventions to prevent an accident like this to happen again. During an interview with the DNS on 12/11/25 at 11:23 a.m., the DON indicated the facility did not have a accident policy. During an interview with the Regional Director Of Clinical Services on 12/11/25 at 12:50 p.m., indicated the facility did not have a policy on transporting residents in wheelchairs. During an interview with the DNS on 12/11/25 at 1:00 p.m., indicated the facilities expectations for staff transporting dependent residents in their wheelchair was to transport the residents in a safe and slow manner down the hallway and to watch their surroundings and make ensure there was enough clearance/room when going around corners. 2. The clinical record for Resident B was reviewed on 12/10/25 at 11:10 a.m. His diagnoses included, but were not limited to: schizoaffective disorder, bipolar type, post-traumatic stress disorder, and anxiety. He was readmitted to the facility on [DATE] after an in-patient psychiatric hospitalization. The Quarterly MDS (Minimum Data Set) assessment, dated 11/10/25, indicated he was cognitively intact. The physician's orders indicated he may go LOA (leave of absence) with responsible party and medications, effective 8/8/25. The 11/13/25, 2:30 p.m. nurse's note indicated, Resident observed in between front double doors with grocery bag in hand. Writer assisted resident back inside building. Resident stated he went to gas station for pop and chips. Writer informed resident he should not leave the building without staff due to safety and if he needs snacks the staff can get it for him. Weather was sunny and resident was dressed appropriately. No visible injuries noted. Writer assisted resident back to room for head to toe assessment no abnormalities noted. Full set of vitals completed and within normal limits. ED [Executive Director,] SSD [Social Services Director,] and Family notified. The IDT (Interdisciplinary Team) note, dated 11/14/25, written by the SSD, indicated, Description of behavior: Resident excited [sic] building to go to gas station to get snacks. Immediate interventions: Resident was assessed by staff and educated on following the loa policy. Also staff informed resident that facility will provide snacks. Assessment of potential correlation to root cause: Psychiatric conditions (depression, anxiety, psychosis, etc.) Dx of schizoaffective disorder bipolar type. Root cause of behavioral expression: Due to resident's dx [diagnosis] of schizoaffective disorder he has a behavioral expressions of impulsiveness. Describe preventative intervention relating to above root cause: Resident was assessed and given a Wanderguard for safety due to fluctuating Bims [brief interview for mental status.] Care plan updated and current interventions revised as applicable: Yes. Communication provided as to above intervention.: yes. An interview was conducted with the DNS and RDCS (Regional Director of Clinical Services) on 12/10/25 at 1:43 p.m. The DNS indicated she was present in the facility when Resident B returned to the facility on [DATE] after he was LOA without a responsible party. The RDCS indicated he was gone around 30 minutes. He had a BIMS of 15 and knew where he was going, but his physician did not think he should be LOA without a responsible party. The investigation file into Resident B's 11/13/25 LOA was provided by the RDCS on 12/10/25 at 12:30 p.m. It included an 11/14/25 progress note, written by Physician 5, Resident B's physician. It indicated, Informed today that the patient had left the facility but returned after he had purchased snack and a drink. It appears that the patient waited by the front door and slipped out when other visitors were leaving. It was not an incident in which he wandered out of the facility, it was intentional. Although he has a BIMS of 15, there are periods of time where that BIMS is not 15. He has dx of schizoaffective disorder and has episodes of cycling. During these periods of cycling, he is manic and behavior is unpredictable (has required several hospitalizations due to behaviors) and it is difficult to reason with him. He has hx [history] of impulsive behavior and poor decision making. I would NOT recommend patient have an independent LOA. I agree that a wanderguard should be placed for patient protection. I would be very concerned that if he were to leave again that his behavior could potentially put him at risk for injury. If he were to be outside of the facility alone and encountered a situation that was overwhelming, he could potentially be injured not just physically. His mental and emotional status needs to be protected as much as possible. If there was a responsible friend or family member who was willing to take him out, that would be acceptable. An interview was conducted with Resident B's guardian, Family Member 6, on 12/10/25 at 1:10 p.m. He indicated he was not okay with Resident B having left the facility alone on 11/13/25. He might take off somewhere, get hurt, get lost, anything. An observation of Resident B was made on 12/11/25 at 10:17 a.m. He was asleep and unavailable for interview. There was a wanderguard on his right ankle. The Leave of Absence policy was provided by the DNS on 12/11/25 at 9:48 a.m. It indicated, It is the policy of this facility that continuity of care and safety during resident Leave of Absence will be maintained. Leave of absence requires a physician's order.Procedure: .2. Nursing will obtain a physician's order for leave of absence with responsible person and medications, as appropriate.9. If the resident desires to leave the facility independently, please refer to the Independent LOA policy. The Independent Leave of Absence policy was provided by the DNS on 12/11/25 at 11:30 a.m. It indicated, Leave of absence requires a physician's order. This Citation relates to Intakes 2667249 and 2670004

Based on observation, interview, and record review the facility failed to provide oxygen as ordered by the physician and failed to maintain oxygen tubing and humidifier bottle in a sanitary manner for 1 of 1 random observation of oxygen use (Resident F). Review of the clinical record of Resident F on 12/10/25 at 11:08 a.m., indicated the resident's diagnoses included, but were not limited to, heart failure, peripheral vascular disease, diabetes, muscle weakness, anxiety disorder and major depressive disorder. The plan of care for Resident F, dated 8/18/25, indicated the resident had impaired gas exchange and utilized oxygen. The interventions included, but were not limited to, administer oxygen as ordered. The December 2025 physician order for Resident F, indicated she was ordered oxygen 3 liters per nasal cannula every shift and change tubing and humidity every week on Sunday. The quarterly Minimum Data Set (MDS) assessment for Resident F, dated 11/18/25, indicated the resident was cognitively intact for daily decision making. The resident was consistent and reasonable. During an interview and observation with Resident F on 12/10/25 at 11:32 a.m., the resident's oxygen tubing and humidifier bottle was lying on the floor, neither one had a date on it. The resident's oxygen was set a 3 liters. Resident F indicated someone was supposed to get her new oxygen tubing and humidifier bottle, but they had not yet. The resident indicated she had been waiting for an hour for her oxygen to be fixed. The resident indicated her oxygen concentrator had been broke a long time and the humidifier bottle always sat on the floor. The resident activated her call light. The Assistant of Nursing Services (ADNS) indicated the nurse was supposed to care for Resident F's oxygen tubing and humidifier bottle. The ADNS brought in new oxygen tubing and a new humidifier bottle and dated both. The ADNS indicated the resident's oxygen concentrator strap was broke to hold the humidifier water and she would attempt to find another oxygen concentrator. The ADNS was unable to find another oxygen concentrator and placed the humidifier bottle in a bag so it was not in direct contact with the floor. The ADNS checked Resident F's oxygen saturations and it was between 92-94 % without the oxygen in place, when the ADNS provided Resident F with her oxygen, the resident's oxygen saturation went up to 99%.During an interview with the Director Of Nursing Services (DNS) on 12/11/25 at 1:00 p.m., indicated it was the facilities expectation that staff would ensure residents were receiving oxygen as ordered by the physician and the tubing and humidifer bottle should be dated. This Citation relates to Intake 2667249. 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure 1 of 3 residents reviewed for receipt of physician-ordered medications received their ordered anti-convulsant (seizure prevention medications) and/or anti-anxiety medications as ordered for 3 consecutive days, resulting in an increase in the number of seizures and a hospitalization related to the increase in seizures. (Resident B) Findings include:The clinical record of Resident B was reviewed on 11-12-25 at 11:14 a.m. His diagnoses included, but were not limited to, traumatic hemorrhage of the cerebrum (brain bleed), seizures, general anxiety, impulse disorder, aphasia (does not speak/nonverbal). It indicated he was admitted to the facility on [DATE], from an area hospital. The most recent Minimum Data Set (MDS) assessment, dated 10-30-25, indicated the resident was severely cognitively impaired, was nonverbal, had no concerns with his short-term memory, but his long-term memory was affected. The current physician's order indicated the resident was to receive an anti-convulsant and anti-anxiety medications. He was dependent on the staff for most activities of daily living, such as bathing, toileting and physical movement and required the use of a wheelchair for mobility. A review of a progress note, from the attending Nurse Practitioner, dated 10-20-25, indicated Currently at neurological baseline but experiencing increased seizures due to lack of seizure medication administration since admission .Recommending transfer to ER [emergency room] for evaluation and treatment due to increased seizures and medication noncompliance. The Assessment/Plan portion of the note indicated Resident B's, Epilepsy, was not intractable .[had] increased seizure activity .[medications of] Phenobarbital, Ativan, Vimpat, Dilantin (not received since admission); Recommending transferring patient to ER for eval and treatment. A review of Resident B's progress notes, from 10-17-25 through 10-20-25, failed to acknowledge Resident B had not received any of the anti-convulsant medications or an anti-anxiety medication. The medication administration record (MAR) for the same time-period indicated the same medications, Phenobarbital, Ativan, Vimpat and Dilantin were unavailable for administration. The progress notes and the MAR failed to identify what steps, if any, had been taken to discover why the facility had not received the medications from the contracted pharmacy. The progress notes and MAR did not indicate any notifications had been made to the pharmacy, to the resident or resident's responsible party, the attending physician or facility administration regarding the lack of medication availability. A review of the physician's ordered medications for the resident not received were, specifically, Phenobarbital, Ativan, Vimpat and Dilantin. The resident's MAR was reviewed for the time period from 10-17-25 through 10-20-25, and indicated the following: - Phenobarbital 32.4 mg (milligrams) twice daily for seizures: 6 consecutive doses were not administered.- Phenobarbital 64.8 mg twice daily for seizures: 6 consecutive doses were not administered.- Ativan 2 mg three times daily for general anxiety: 7 consecutive doses were not administered. The morning dose, on 10-20-25, was documented as administered.- Vimpat 100 mg twice daily for seizures: 6 consecutive doses were not administered.- Dilantin 100 mg daily at bedtime for seizures: 3 consecutive doses were not administered.An additional medication, an anti-psychotic and identified for Resident B's use for general anxiety, olanzapine (Zyprexa) 10 mg twice daily was noted to have not been available for administration for five of six doses during the timeframe from 10-17-25 through 10-20-25. The MAR indicated Resident B was administered one dose of olanzapine 10mg on the admission evening of 10-17-25. In an interview with the Director of Nursing (DON), on 11-13-25 at 11:17 a.m., she indicated she learned about Resident B not having his anti-seizure or anti-anxiety meds until Monday morning, 10-20-25, when she read the Nurse Practitioner's note about him not receiving his meds and being sent out to the ER for evaluation for his increase in seizures during the night shift of 10-19-25 into 10-20-25. She shared her normal expectations for any new resident admission would be that each new admission/resident's meds should be received within 1-2 hours of admission. She indicated there has not been any formal investigation into this event at this point or any additional training or education for the nursing staff regarding lack of medications. She indicated her typical expectations for a resident not having meds available are to check the Omnicell (the facility's emergency drug device) for availability of the needed medications. If the meds are not available there, the nurse should then reach out to the MD to inform him/her the medication is unavailable [allowing] the MD the opportunity to write an order to hold or change the med to something different. The nurse should also reach out to the contracted pharmacy to stat [send emergently] the med out to the facility or discover what the holdup may be. The pharmacy should let the nurse know if there is an issue obtaining the med or if they might require a hard copy of the script. The nurse should also call me to let me know there is a problem in getting the meds for a resident. I might be able to give them some ideas as to what the next steps may be. The DON added the nursing staff should also be documenting what problems they have encountered with accessing the medications and what they have done to fix the problem. The DON indicated she was unable to locate any documentation that reflected any problems the facility had encountered accessing the meds. The DON indicated the facility does have a policy that addresses what staff are to do and who to notify regarding any missing medication doses. A progress note, dated 10-18-25 at 11:30 p.m., indicated Resident B had a seizure episode of approximately 2 minutes in length. A second progress note, dated 10-20-25 at 6:03 a.m., indicated on the night shift of 10-19-25 through the early morning hours of 10-20-25, Resident experienced five seizures, each lasting approximately 1-2 minutes .On-call provider and DON were notified and advised to continue close monitoring .provider informed via communication book .Will continue to monitor for further seizure activity and notify provider of any changes in condition. The next progress note, dated 10-20-25 at 11:16 a.m., indicated Resident B was in the process of being transferred to an area hospital for evaluation and treatment. In an interview with the DON, on 11-12-25 at 12:20 p.m., she indicated she was unable to locate any policies which referenced what nursing staff are to do in the event a medication is not available from the contracted pharmacy. In an interview with the Executive Director and Corporate Nurse, on 11-13-25 at 3:05 p.m., a policy for medication administration was requested. The Corporate Nurse indicated the facility does not have a specific policy on medication administration but does expect the staff to follow Standards of Practice. The Corporate Nurse indicated the facility does not have a particular policy on documentation, as the facility documents by exception. A request was made for the narcotic record for Resident B for the 10-20-25, administration of the morning dose of the lorazepam (Ativan). In an interview, on 11-13-25 at 5:13 p.m., with the ED and DON, the ED indicated the facility was unable to locate any documentation to substantiate the 10-20-25, morning dose of lorazepam (Ativan) was actually administered. The DON indicated the MAR may have been documented incorrectly. The DON indicated she was able to locate in-service education on the topic of medication administration, most recently provided by the facility for the nursing staff in the summer of 2025. This citation relates to Intake 4657181. 3.1-25(a)3.1-25(b)(2)3.1-25(b)(9)

Based on interview and record review, the facility failed to ensure a resident's choice was honored pertaining to selection of food items of their choice for 1 of 3 residents reviewed for resident rights. (Resident B) Findings include: The clinical record for Resident B was reviewed on 7/14/25 at 3:50 p.m. The diagnoses included, but were not limited to, encephalopathy (group of conditions that cause brain dysfunction), hemiplegia (loss of strength leading to paralysis on one side of the body), and dysphagia (difficulty swallowing). A Significant Change Minimum Data Set (MDS) assessment, dated 6/3/25, indicated Resident B had moderate cognitive impairment, required substantial/maximal assistance with toileting hygiene, and was always incontinent of bowel and bladder. A care plan, last revised 5/28/25, indicated Resident B required assistance with activities of daily living (ADLs) including eating and toileting. The approach included to provide assistance with eating as needed and assistance with toileting and/or incontinent care as needed related to Resident B being incontinent of bowel and bladder. An incident reported to the Indiana Department of Health (IDOH), dated 6/11/25, indicated it was reported that Certified Nurse Aide (CNA) 2 was rude to Resident B during dining service. The investigation file was reviewed, on 7/14/25 at 4:00 p.m., and contained the following statements:A typed statement that pertained to what CNA 2 was referring to regarding Resident B. The statement indicated, I told the resident he wasn't [sic] giving him any chocolate milk because it runs through him and nobody got time for that. A typed statement that pertained to what Resident B had indicated during a staff interview regarding the incident with CNA 2. Resident B indicated he recalled the interaction between CNA 2 and himself. He stated he asked for chocolate milk and CNA 2 declined as it would upset his stomach. A typed statement that pertained to what Licensed Practical Nurse (LPN) 3 had witnessed regarding CNA 2 and Resident B. LPN 3 indicated, I was in the dining room between the hours of 12:39pm [12:39 p.m.] - 12:45p [12:45 p.m.]. As I was passing meds [medications]. I heard [name of CNA 2] say to [name of Resident B] as he asked for chocolate milk, 'No, I'm not getting you no chocolate milk, it's gonna have you going up your back - I don't have time for that'. An interview conducted with the Executive Director (ED), on 7/14/25 at 4:18 p.m., indicated CNA 2 was educated on residents' choice and preferences. The ED believed CNA 2 was attempting to advocate for Resident B, but the staff needed to honor Resident B's preferences. A policy entitled Preferences for Daily Routine, revised 12/2015, was provided by the ED on 7/14/25 at 4:39 p.m. The policy indicated the purpose was to identify and develop a plan of care that reflects a resident's past and current daily customary routines. The information would be shared with the interdisciplinary team so that each department can address the residents' preferences. This citation relates to Complaint IN00462929. 3.1-3(u)(1)3.1-3(u)(3)

Based on observation, interview, and record review, the facility failed to timely implement a podiatry recommendation for 1 of 3 residents reviewed for foot care (Resident E).Findings include: The clinical record for Resident E was reviewed on 7/14/25 at 2:15 p.m. The resident's diagnosis included, but was not limited to, polyneuropathy (disorder of the nervous system).A physician's order, dated 9/25/24, indicated Resident E could be seen by the Podiatrist.On 7/14/25 at 2:45 p.m., Resident E was observed with the Director of Nursing (DON) in her room. She was lying in her bed, and her feet were observed to have thick, yellowing, crusty toenails on both big toes. Resident E indicated she had been seen by the Podiatrist recently.A Podiatry Group note, dated 6/14/25, indicated she had been seen by the Podiatrist and the nails on both feet had been debrided (reduced in size). There was a recommended new order of urea 40% cream (medication for dry skin and damaged nails) to all toenails daily for sixty days. The clinical record did not contain an order for urea 40% cream to be applied to Resident E's toenails daily for sixty days. During an interview on 7/14/25 at 4:15 p.m., the DON indicated when a resident had a podiatry recommendation it was normally given to her, and she processed the new order. The DON had not been made aware that Resident E had a recommended new order for urea cream. The urea cream should have been ordered. This citation relates to Complaint IN00463244.3.1-47(a)(7)

A. Based on observation, interview, and record review, the facility failed to ensure the kitchen was clean and in good repair, the staff contained their hair in the kitchen, and food was not open to air, labeled, dated and not expired. This had the potential to affect 54 of 54 residents that eat food prepared in the facility kitchen. B. Based on observation, interview, and record review, the facility failed to cover trash cans when not in use in the kitchen with the potential to affect 54 or 54 residents who receive food out of the facility kitchen. Findings include: A. On [DATE] at 6:25 p.m., the facility kitchen was observed with Dietary Aide (DA) 15. The walk- in refrigerator was observed to have a metal can of butterscotch pudding with a piece of plastic wrap covering the open can. The can did not contain a date on which it was opened. There was an undated plastic storage container of macaroni and cheese, an undated jar of beef base, an undated bottle of orange juice and grape juice which were half empty, an undated container of ranch and Caesar salad dressing, an undated jar of pickle relish, a bag of pre-made scrambled eggs with no date, an undated plastic storage container of peaches, plastic wrapped open containers of deli ham, American cheese, and deli turkey with no open dates. There was a package of pepperoni that was open to air with no open date. There was a tray containing small bowls of peaches and a tray containing small bowls of mandarin oranges which were open to air and undated. There was a tray containing a thawed ground beef roll with red liquid present on the tray that was undated. There was a tray with a bag of thawed chicken that was present with no date. The dry storage area was observed to have a storage bin of oats with no lid and a package of blueberry muffin mix labeled open [DATE] and use by [DATE]. The floor of the dry storage area had a sticky substance present on it. During an interview on [DATE] at 6:50 p.m., DA 15 indicated the kitchen floor had been that way since she started. She had worked at the facility for a week and a half. She was not sure why the food items were not covered. She had not been instructed on dating items. She had been shown how to use the date label maker. On [DATE] at 12:10 p.m., lunch service was observed in the facility kitchen. DA 17 was observed at the tray line setting up trays with silver wear and placing small bowls of grapes on trays. He had a growth of hair on his upper lip and chin. His beard net was around his neck and not covering his beard. DA 17 indicated his beard net should be in place over his facial hair while he was serving food. During an interview on [DATE] at 1:45 p.m., the Dietary Manager (DM) indicated items in the refrigerator should be labeled and dated with the date opened and a discard date. Food items should be covered while in the refrigerator. The items identified on [DATE] had been disposed of. The floor in the dry storage area was sticky. The staff had mopped the floor, and she was unsure why it was still sticky. Staff with facial hair should wear beard nets while preparing and serving food. On [DATE] at 2:58 p.m., the Corporate Executive Director provided the Food Storage Policy, last reviewed [DATE], which indicated .Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored at appropriate temperatures and by methods designed to prevent contamination .Leftover prepared foods and processed meats such as lunchmeat, are to be stored in covered containers or wrapped securely. The food must clearly be labeled with the name of the product, the date it was prepared, and marked to indicate the date by which the food shall be consumed or discarded. Leftover foods can be held at 41 degrees F [Fahrenheit] or less for no more than 3 days. The day the food was prepared shall be counted as Day 1 .Food items that are not considered potentially hazardous including, commercially prepared mayonnaise, salad dressing, mustard, ketchup, BBQ sauce, pickles, and pickle relish will be labeled when opened and, to ensure quality, used or disposed of within 90 days of the opening or per the use-by-date, whichever comes first. Follow the manufacturer's directions regarding the need to refrigerate after opening in order to preserve quality. The day the original container is opened shall be counted as day 1 .Dry Storage . All foods shall be covered or wrapped tightly, labeled, and dated. On [DATE] at 2:58 p.m., the Corporate Executive Director provided the Culinary Personal Hygiene Policy, last revised [DATE], which indicated .Culinary employees with facial hair must also wear a beard restraint . B. On [DATE] at 6:25 p.m., the facility kitchen was observed with Dietary Aide (DA) 15. The dry storage area was observed to have an unattended busing cart with a trash can attached to the end of the cart. The trash can had food waste visible and there was no lid on the trash can. On [DATE] at 12:20 p.m., the dry storage area was observed with the Dietary Manager (DM). An unattended busing cart with a trash can on the end was observed in the dry storage area. The trash can was uncovered and had food substances present in the can. The soiled dish area of the kitchen had an unattended trash can with food items present in the can. The lid to the trash can was sitting beside it. There were no staff using the trash can. During an interview on [DATE] at 1:45 p.m., the DM indicated she was unsure if the busing cart trash can had a lid, but the trash bag could have been removed prior to it being placed in the area. The trash can in the soiled dish area should have been covered when not in use. On [DATE] at 2:58 p.m., the Corporate Executive Director provided the Kitchen Safety Guidelines, last revised February 2025, which indicated .Plastic liners are to be used inside all trash containers and the containers are kept covered with lids . 3XXX,d+[DATE](i)(2) 3XXX,d+[DATE](i)(3) 3XXX,d+[DATE](i)(5)

Based on observation, interview, and record review, the facility failed to ensure residents' respect and dignity were maintained for 2 of 3 residents reviewed for dignity, 3 of 8 resident interviews in abuse investigations, and 3 residents randomly observed during dining. (Resident B, D, F, J, K, L, M, and N) Findings include: 1. The clinical record for Resident J was reviewed on [DATE] at 11:30 a.m. The diagnoses included, but were not limited to, cellulitis. The Admission Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident J was cognitively intact. An interview was conducted with Resident J on [DATE] at 11:18 a.m. She indicated the staff were disrespectful during care. The staff needed training to not rush during care. They were rushing and jerk you around. It was rough, but not abusive. 2a. The clinical record for Resident D was reviewed on [DATE] at 12:00 p.m. The diagnoses included, but were not limited to, depression. The Quarterly MDS assessment, dated [DATE], indicated Resident D was cognitively intact. 2b. The clinical record for Resident K was reviewed on [DATE] at 1:00 p.m. The diagnoses included, but were not limited to, hypertension. The Annual MDS assessment, dated [DATE], indicated Resident K was cognitively intact. An abuse investigation into a reportable incident, dated [DATE], was provided by the Corporate Executive Director on [DATE] at 10:55 a.m. The file included, but was not limited to, the following documentation: A statement by Resident D indicating the staff during care handled her roughly. A statement by Resident K indicated the staff were rough during care at times. On one occasion, it felt like the staff person was digging her nails in his skin during incontinent care. An interview was conducted with Resident K on [DATE] at 10:26 a.m. He indicated Certified Nurse Aide (CNA) 2 was having a bad day. She at times has had an attitude. There was a time, CNA 2 was wiping him so fast during incontinent care; she dug her nails in his skin. 52119 3. The clinical record for Resident F was reviewed on [DATE] at 3:54 p.m. The diagnoses included, but were not limited to, anxiety, panic disorder, post-traumatic stress disorder, depression, borderline personality disorder, and schizoaffective disorder. An MDS assessment, dated [DATE], indicated Resident F was cognitively intact. An interview was conducted with Resident F on [DATE] at 3:38 p.m. She indicated she was treated differently because she was more able-bodied . CNA 2 had a poor attitude and demeanor. She was not polite and never smiled. Resident F had to make her own bed because CNA 2 would not do it. She had a hard time getting laundry done because staff said she can do it herself. She was made to put her laundry in a bag and put it by the door by some staff and others told her differently. A grievance was filed by Resident F on [DATE]. She indicated CNA 2 always picked on her and told her to make her own bed. If Resident F didn't like the meal that was served or wanted seconds, CNA 2 told her to go get it herself and she didn't like taking care of a resident who can do things herself. Resident F would request ice water and CNA 2 would bring half a cup of water to upset her. CNA 2 knew Resident F had a history of mental illness and would pick on her to upset her. She reported CNA 2 several times in the past and requested that CNA 2 no longer care for her. An interview was conducted with CNA 2 on [DATE] at 9:52 a.m. She indicated she had received abuse training and resident rights training. She regularly took care of Resident F who didn't need assistance with anything and did her own ADLs (activities of daily living). CNA 2 would strip her bed, and the resident would make it. She also brought the resident ice and water when she asked. Their relationship was fine until several months ago when CNA 2 stopped doing hair and nails for the residents, but Resident F wanted CNA 2 to continue to bring beauty supplies. After this, Resident F would get flustered and aggravated due to her mental illness and make smart comments which CNA 2 would ignore. She wasn't sure if the resident asked to have a different CNA or if the facility re-assigned her to keep the peace. 51984 4. The clinical record for Resident B was reviewed on [DATE] at 12:00 p.m. The diagnoses included, but were not limited to, stroke. The Quarterly MDS assessment, dated [DATE], indicated Resident B was cognitively intact. During an interview with Resident B on [DATE] at 6:50 p.m., she indicated the staff would come in and yell at her because she pressed the call light at the wrong time. 40287 5a. The clinical record for Resident M was reviewed on [DATE] at 12:25 p.m. The diagnoses included, but were not limited to, dementia. 5b. The clinical record for Resident L was reviewed on [DATE] at 12:25 p.m. The diagnoses included, but were not limited to, dementia. 5c. The clinical record for Resident N was reviewed on [DATE] at 12:25 p.m. The diagnoses included, but were not limited to, dysphagia (inability to swallow). On [DATE] at 12:25 p.m., lunch service in the main dining room was randomly observed. Resident L, Resident M, and Resident N had facility tablecloths folded and tied around their necks while sitting and waiting for their meals. During an interview on [DATE] at 12:26 p.m., the Minimum Data Set Coordinator indicated she was unsure why table clothes were being used as clothing protectors. During an interview on [DATE] at 12:37 p.m., the Nurse Consultant indicated the facility had clothing protectors available to be used in the dining room. An interview was conducted with Nurse Consultant 13 on [DATE] at 1:04 p.m. She indicated the staff were expected to treat the residents respectfully. A policy titled Resident's Rights, dated ,d+[DATE], noted Each resident shall be treated with consideration, respect, and full recognition of his dignity, and individuality .the Resident has a right to a dignified existence, self-determination and communication with, and access to, persons and services inside and outside the Facility . This citation relates to Complaint IN00456672. 3XXX,d+[DATE](a) 3XXX,d+[DATE](t) 3XXX,d+[DATE](v)(1)

Based on observation, interview, and record review, the facility failed to ensure food was served at palatable temperatures for 4 of 4 residents reviewed for food and 14 of 54 residents that attend resident council. (Residents' B, D, 22, J, K, 33, 28, 13, 31, 4, G, H, 25, 23, E, 41, 6, and 48) Findings include: 1. The clinical record for Resident J was reviewed on 4/22/25 at 11:30 a.m. The diagnoses included, but were not limited to, cellulitis. The Admission Minimum Data Set (MDS) assessment, dated 3/24/25, indicated Resident J was cognitively intact. An interview was conducted with Resident J on 4/22/25 at 11:18 a.m. She indicated the food was served cold. 2. The April 2025 resident council minutes were provided by the Activities Director on 4/23/25 at 9:31 a.m. The resident attendees were the following: Residents' 6, 23, H, 33, 41, 13, 25, 28, and G. The council indicated the food temperatures were not appropriate. During a resident council meeting on 4/23/25 at 11:05 a.m., the council attendees were the following: Residents' K, 33, 28, 13, 31, 4, G, H, 25, 23, E and 48. The council indicated the food was served cold. 40287 3. The clinical record for Resident G was reviewed on 4/22/25 at 12:20 p.m. The diagnoses included, but were not limited to, liver transplant and major depressive disorder. A Quarterly MDS assessment, dated 3/24/25, indicated Resident G was cognitively intact. During an interview on 4/22/25 at 12:12 p.m., Resident G indicated the food was often served cold. He had received meals that were ice cold. He had filed grievances about the food, but it did not seem to get any better. 51984 4. The clinical record for Resident 22 was reviewed on 4/23/25 at 10:34 a.m. The diagnoses included, but were not limited to, acute respiratory failure. A Quarterly MDS assessment, completed 2/22/25, indicated she was cognitively intact. During an interview on 4/21/25 at 6:33 p.m., she indicated the eggs were awful and cold. 5. The clinical record for Resident D was reviewed on 4/24/25 at 4:08 p.m. The diagnoses included, but were not limited to, diabetes mellitus. A Quarterly MDS Assessment, completed on 3/5/25, indicated she was cognitively intact. During an interview on 4/21/25 at 7:21 p.m., she indicated meals were not consistent, sometimes they were good, and other times they were not. Resident D indicated breakfast was usually the best meal, and the rest go downhill from there. 6. The clinical record for Resident B was reviewed on 4/22/25 at 12:00 p.m. The diagnoses included, but were not limited to, stroke. A Quarterly MDS assessment, completed 1/20/25, indicated she was cognitively intact. During an interview with Resident B on 4/21/25 at 6:58 p.m., she indicated the food could use improvement. During an observation and interview on 4/24/25 at 12:45 p.m., the Regional Culinary Manager 3 (RCM 3) brought a test tray into the conference room. The temperatures were obtained by RCM 3, using the dietary department's thermometer. The tenderloin sandwich was 126.3 degrees Fahrenheit, the baked beans were 153 degrees Fahrenheit, and the pears were 50.7 degrees Fahrenheit. RCM 3 indicated the temperature for the tenderloin sandwich was below the proper holding temperature, and the pears were above the proper holding temperature. 3.1-21(a)(2) 3.1-21(i)(2)

Based on interview and record review, the facility failed to follow up on grievances for 2 of 2 residents reviewed for grievances. (Resident B and Resident 41) Findings include: 1. The clinical record for Resident B was reviewed on 4/22/25 at 12:00 p.m. The diagnoses included, but were not limited to, stroke. A Quarterly Minimum Data Set (MDS) assessment, completed 1/20/25, indicated she was cognitively intact. An interview was conducted with Resident B on 4/21/25 at 7:01 p.m. She indicated she had filed grievances and had not heard anything about a follow-up from the facility. Resident B indicated she was missing an arm sling, a backpack, a purse, and a box of crackers. An interview was conducted with the Social Services Consultant on 4/24/25 at 2:32 p.m. The Social Services Consultant indicated she could not find the grievances filled out by Resident B. Social Services Director (SSD) 4 indicated she spoke with Resident B and filled out grievances. SSD 4 indicated she did not know where the original grievances were located. 52119 2. The clinical record for Resident 41 was reviewed on 4/23/25 at 2:00 p.m. The diagnoses included, but were not limited to, borderline personality disorder. A Quarterly MDS assessment, dated 9/16/24, indicated the resident was cognitively intact. Resident 41 was interviewed on 4/22/25 at 10:31 a.m. He indicated that within the last year, he entered his room and found Resident H sitting on his bed. He got angry, yelled, and swore at him to get out of his bed. Resident H stood up and staff came in to assist him back to his own room. Resident 41 was mad because the resident had done this before, and wanted his sheets changed because of Resident H's incontinence. Staff told Resident 41 he cannot yell or swear at other residents, but he was upset at finding the resident in his room again. He told a CNA (certified nurse aide) and the Weekend Supervisor about the incident. The Weekend Supervisor was interviewed on 4/24/25 at 10:48 a.m. She indicated Resident 41 told her about the incident several weeks ago. He was upset about the incident because Resident H frequently wanders into other residents' rooms. The Weekend Supervisor asked if he wanted her to fill out a grievance and he said yes. She completed the grievance and placed it into a bag in the conference room for the Director of Nursing (DON) to look over on Monday, which was her usual procedure for grievance forms. The DON was interviewed on 4/24/25 at 12:47 p.m. She did not recall seeing the grievance form. She hadn't heard of any residents having issues with Resident H's wandering, because he was pleasant and easily redirected. The Executive Director (ED) and Social Services Consultant were interviewed on 4/24/25 at 11:56 a.m. They could not locate the grievance Weekend Supervisor had filled out regarding the incident with Resident H. The ED said Resident 41 was usually very serious about his grievances and was likely very upset that Resident H was incontinent and sat on his bed. However, staff changed his sheets at the time of the incident, so they considered the issue resolved. A policy titled Resident Concerns and Grievances, revised 1/2019, noted If a concern/grievance of any kind is noted, the Concern/Grievance form is used .The Executive Director/Grievance Official will sign off on all completed concerns/grievance forms, ensuring resident and/or family satisfaction .All concern forms are to be maintained on-site for a minimum of three years. 3.1-3(k) 3.1-3(l)

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse for 2 of 3 residents reviewed for abuse. (Resident 37 and Resident 42) Findings include: 1. The clinical record for Resident 42 was reviewed on 4/22/25 at 9:00 a.m. The diagnoses included, but were not limited to, stroke, major depressive disorder, physical debility, unsteadiness on her feet, and anxiety disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 3/16/25, indicated Resident 42 was moderately cognitively impaired. The resident had impairments with her upper and lower extremities on one side. She utilized a walker and wheelchair. She required substantial assistance with dressing but was able to sit to stand independently with no assistance. A behavior care plan, dated 10/4/24, indicated Resident 42 had exhibited verbal aggression towards staff and anxiousness. 2. The clinical record for Resident 37 was reviewed on 4/22/25 at 9:57 a.m. The diagnoses included, but were not limited to, schizoaffective disorder, bipolar disorder, anxiety disorder, and post-traumatic stress disorder. The Quarterly MDS assessment, dated 3/24/25, indicated Resident 37 was cognitively intact. The resident did not have any impairments with his upper or lower extremities. He utilized a walker and a cane. He was independent and did not need assistance with dressing and walking. A behavior care plan, start date of 4/17/25, indicated Resident 37 had been refusing medications and lab draws. A behavior care plan, start date of 4/17/25 with a revision date of 4/22/25, indicated Resident 37 had exhibited behaviors of self-pleasuring in common areas and sexually inappropriate behaviors with staff and a female peer. The interventions, but were not limited to, Ensure resident's safety . Provide resident with privacy to self pleasure himself . Remove from immediate area to further evaluate needs. A nursing note, dated 4/17/25, indicated Resident 37 had refused all meds during shift, resident tearful during shift, attempting to hug and kiss staff member, resident not easily directed, resident pulling out his penis and asking staff members to look at him, resident stated 'look at me' while resident pulled on his penis while lying in bed, resident asked to pull curtain and not pull out penis in front of staff, resident continued to jerk at his penis. writer pulled resident's curtain to give resident privacy, new and worsening event opened, DON [Director of Nursing] notified, MD [Medical Director] notified via MD binder of residents med refusal and behaviors. A nursing note, dated 4/18/25, indicated Resident refused all medication this shift, the writer went back the second time and found resident masturbating, gave resident some room and went back and resident was requesting for hug and kisses from writer . A behavior note, dated 4/19/25, indicated the resident was exhibiting behaviors of grabbing staff and kissing them on the neck. The resident was educated on the inappropriate behavior. The resident becoming aggressive towards staff in his attempt to touch/kiss them and he is pulling out his private parts and asking staff to look while he plays with himself. The medical provider was made aware of the increase in behaviors. A behavior note, dated 4/20/25 at 1:49 p.m. indicated the resident attempted to inappropriately touch the staff members. The resident was educated regarding the inappropriate behavior and redirection was provided. A nursing progress note, dated 4/20/25 at 4:35 p.m., indicated Resident 37 had gone into Resident 42's room and touched and kissed her inappropriately. Resident 37 was sent to the emergency room for evaluation. A reportable incident to the Indiana Department of Health, dated 4/20/25 at 3:07 p.m., indicated Resident 37 had entered Resident 42's room and touched her chest. The investigation for the reportable incident between Resident 37 and Resident 42 was provided by the Corporate Executive Director on 4/23/25 at 10:55 a.m. The file included, but was not limited to, the following documentation: A typed statement by the Social Services Director, dated 4/21/25, indicated .This a.m. I spoke with [Resident 37] to get more information on what happened 4/20/25 with him and a female peer [Resident 42]. Resident was laying across his bed on him [sic] stomach. Resident refused to look at the writer or sit up. Resident did not answer the writer's questions and told writer to get out of his room using profane language. After two more attempts, the resident continued on demanding that the writer leave the room. The writer excused herself and allowed resident to have space to himself. A typed statement by the Social Services Director, dated 4/22/25, indicated Resident 42 had stated Resident 37 had attempted to touch her and requested to have sexual relations. She refused. Resident 42 had indicated she does feel safe and not in danger. The resident denied any psychological distress from the incident. An observation and interview were conducted of Resident 37 in his room on 4/21/25 at 6:33 p.m. The resident was observed in bed with a blanket over his head. The resident was pleasant but had refused an interview. During that time, there was no observation of a staff person present by the resident's room nor in the resident's room providing one on one supervision. An observation and interview were conducted with Resident 42 on 4/22/25 at 11:44 a.m. The resident was observed in her room, dressed, and sitting in her wheelchair by her bed. She indicated Resident 37 had attempted to rape her a few days ago. Resident 37 had ambulated into her room and started touching her. She was clothed, but he was trying to remove her breast from her bra and touch her vagina. The staff came into her room and removed Resident 37 from her room. The resident had never done that before. Resident 42 indicated she felt safe in the facility with no concerns. An interview was conducted with the Business Office Manager on 4/23/25 at 3:40 p.m. She indicated, on 4/20/25, she had observed one of the Certified Nurse Aides (CNAs) bringing Resident 37 to the conference room. CNA 2 had reported she was going to get the nurse. Resident 42 had inappropriately touched Resident 37. An interview was conducted with the Corporate Executive Director on 4/23/25 at 3:56 p.m. She indicated a staff person should always be present while providing one on one supervision. Resident 37 should not have been left alone at any time on the evening of 4/21/25. An interview was conducted with CNA 2 on 4/24/25 at 9:44 a.m. She indicated she was the CNA that had brought Resident 42 to the conference room. On Sunday, 4/20/25, she overheard Resident 42 yelling out in the hallway, Someone help me! She and two other staff members had gone into the resident's room and observed Resident 42 sitting in her wheelchair using her arms pushing Resident 37 away from her. He was touching her breast. The residents were clothed. Resident 37 was redirected away from the resident and out of the room. She took Resident 42 to the conference room and reported the incident to the Weekend Supervisor (WS) 8. During that time, Resident 42 was highly upset and afraid. An interview was conducted with WS 8 on 4/24/25 at 10:49 a.m. She indicated a CNA had reported Resident 42 was brought into the conference room. It had been witnessed regarding Resident 37 inappropriately touching Resident 42. During an interview with Resident 42, she had reported to the WS 8 that Resident 37 had ambulated in her room and climbed on top of her while she was in her wheelchair. He put his hands on her vagina and breast while kissing her neck. Three CNAs came into the room and removed Resident 42 from her room. During that time, Resident 42 was crying and upset during the interview. The WS 8 indicated after receiving the report that she notified the Executive Director (ED), Director of Nursing (DON), and the police department. Resident 42 and Resident 37 were immediately placed on one-on-one supervision. After police arrival, Resident 37 was sent to the hospital for a psychiatric evaluation. He later returned to the facility and was placed back on-one-on one supervision. An interview was conducted with CNA 22 on 4/24/25 at 2:50 p.m. She indicated she was one of the three staff members that had observed the incident between Resident 37 and Resident 42. She heard a sound in the hallway like a baby crying. She and two other staff members rushed into Resident 42's room. Resident 42 was sitting in her wheelchair crying and Resident 37 was rubbing on her breast and vagina. The residents were clothed at that time. CNA 22 had to remove Resident 37's hands off Resident 42. He then was redirected out of her room. After, the residents were placed on one-on-one supervision until the police and ambulance arrived. Resident 37 was sent out to the hospital. An abuse policy was provided by the Executive Director on 4/22/25 at 8:55 a.m. It indicated, .Policy: It is the policy of [Name of corporation] to provide each resident with an environment that is free from abuse . [Name of corporation] will not permit residents to be subjected to abuse by anyone . other residents . Definitions/Examples of Abuse . Sexual abuse - nonconsensual sexual contact of any type with a resident. Examples may include but not be limited to fondling, touching, rubbing . kissing 3.1-27(a)(1)

Based on interview and record review, the facility failed to maintain evidence that an allegation of abuse was thoroughly investigated for 2 of 3 residents reviewed for abuse (Resident 37 and Resident 42). Findings include: 1. The clinical record for Resident 42 was reviewed on 4/22/25 at 9:00 a.m. The diagnoses included, but were not limited to, stroke, major depressive disorder, physical debility, unsteadiness on her feet, and anxiety disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 3/16/25, indicated Resident 42 was moderately cognitively impaired. The resident had impairments with her upper and lower extremities on one side. She utilized a walker and wheelchair. She did need substantial assistance with dressing but was able to sit to stand independently with no assistance. 2. The clinical record for Resident 37 was reviewed on 4/22/25 at 9:57 a.m. The diagnoses included, but were not limited to, schizoaffective disorder, bipolar disorder, anxiety disorder, and post-traumatic stress disorder. The Quarterly MDS assessment, dated 3/24/25, indicated Resident 37 was cognitively intact. The resident did not have any impairments with his upper or lower extremities. He utilized a walker and a cane. He was independent and did not need assistance with dressing and walking. A Nursing Progress Note, written by Weekend Supervisor (WS) 8 at 4/20/25 at 4:30 p.m., indicated Resident 42 had reported that a male resident (Resident 37) had entered her room without permission and attempted to touch and kiss her inappropriately. The Power of Attorney, Physician, Executive Director, and the Director of Nursing Services had been notified. An interview was conducted with the Weekend Supervisor (WS) 8 on 4/24/25 at 10:49 a.m. She indicated a CNA (certified nurse aide) had reported Resident 42 was brought into the conference room. It had been witnessed, Resident 37 inappropriately touching Resident 42. During an interview with Resident 42, she had reported to WS 8 that Resident 42 had ambulated in her room and climbed on top of her while she was in her wheelchair. He put his hands on her vagina and breast while kissing her neck. Three CNAs came into the room and removed Resident 37 from her room. During that time, Resident 42 was crying and upset during the interview. WS 8 indicated after receiving the report, she notified the Executive Director (ED), Director of Nursing (DON), and the police department. Resident 42 and Resident 37 were immediately placed on one-on-one supervision. After the police arrival, Resident 37 was sent to the hospital for a psychiatric evaluation. He later returned to the facility and placed back on one-on-one supervision. She had spoken with the DON and the ED when the incident happened. On 4/25/25 at 9:12 a.m., the Executive Director (ED) provided the completed investigation file for the reportable incident between Resident 37 and Resident 42. The completed investigation file did not include a statement from WS 8. During an interview on 4/25/25 at 2:45 p.m., the Corporate Executive Director (CED) indicated that WS 8 had reported the incident to the ED and DON. The incident between Resident 37 and 42 had been reported to the Indiana Department of Health. She did not believe there was an actual written statement, but WS 8 had written progress notes about the incident in each of resident's medical records. An abuse policy was provided by the Executive Director on 4/22/25 at 8:55 a.m. It indicated, .Policy: It is the policy of [Name of corporation] to provide each resident with an environment that is free from abuse . [Name of corporation] will not permit residents to be subjected to abuse by anyone . other residents . Definitions/Examples of Abuse . Sexual abuse - nonconsensual sexual contact of any type with a resident. Examples may include but not be limited to fondling, touching, rubbing . kissing . Investigation .Resident to Resident Abuse .4. The staff member in charge will initiate the investigation immediately 5. The executive Director will be notified immediately of the report and the initiation of the investigation . Statements will be taken from individuals witnessing the incident . Resident Abuse- Staff member, volunteer, or visitor .The investigation will include . facts and observations by involved employees . facts and observations by witnessing employees . facts and observations from others who might have pertinent information . Facts and observations by the supervisor or individual whom the initial report was made . 3.1-28(d)

Based on interview and record review, the facility failed to monitor and address a resident's pain for 1 of 3 residents reviewed for wounds. This resulted in a resident admitted to the hospital with severe pain. (Resident C) Findings include: The clinical record for Resident C was reviewed on 1/20/22 at 2:30 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Significant change MDS (Minimum Data Set) assessment dated [DATE] indicated Resident C was cognitively intact. A care plan dated 9/20/21 indicated Resident [C] is at risk for pain related to: CA [cancer] of bone and kidney, GERD, [CONDITION(S)], [CONDITION(S)] [[CONDITION(S)]], amp [amputation] L [left] foot, amp R [right] great toe, DJD [[CONDITION(S)] joint disease], vit [vitamin] D deficiency, gangrene right foot .Approach .Administer meds as ordered, assist with positioning to comfort, document effectiveness of PRN [as needed] medications, notify MD [medical doctor] if pain is unrelieved and/or worsening, observe for adverse effects of pain medication, including but not limited to, over sedation, constipation, skin rash, nausea/vomiting, loss of appetite, change in mental status, stomach upset, document abnormal findings and notify MD, observe for nonverbal signs of pain: changes in breathing, vocalizations, mood/behavior changes, eye change expression, sad/worried face, crying, teeth clenched, changes in posture. Offer nonpharmacological interventions such as quiet environment, rest, shower, back rub, reposition. A care plan for Resident C dated 11/29/21 indicated he had an [CONDITION(S)] (infection) in his right foot. The interventions were the following: administered medications as ordered, Notify MD of worsening or no change in symptoms, observe for increase or change in symptoms. A skin integrity care plan dated 11/29/21 indicated .Assess for pain, treat as ordered, Notify MD of unrelieved/worsening pain, .observe for signs of infection: redness, pain, drainage, malodorous drainage, fever, increase in size/depth of wound .wound location: right foot (amputation of 1st, 2nd, 3rd digit). A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The January 2022 Medication Administration Record indicated Resident C received his scheduled 100 mcg [MEDICATION(S)] patch to his left chest on 1/5/22. The resident's next scheduled [MEDICATION(S)] patch was due to be administered on 1/8/22. The MAR did not indicate he had received the 1/8/22, [MEDICATION(S)] patch nor any PRN pain medication on 1/8/22 or 1/9/22. A January 2022 controlled substance record indicated Resident C received on 1/8/22 at 6:00 p.m., 5 milligrams (3 tablets total of 15 milligrams) of PRN oxycodone for pain. The resident's clinical record did not include a pain assessment before or after administration of the PRN oxycodone on the evening of 1/8/22. A nursing progress note dated 1/9/22 dated 10:42 a.m., indicated writer [Registered Nurse 5] noted EMT [Emergency Medical Technician] entering the building, when asked they stated they were called to room [Resident C]. Upon evaluation resident stated he called 911 because he wanted to go to hospital as he wasn't feeling his best. Transport transferred resident to stretcher and transported resident to hospital per his request. Hospital records dated 1/9/22, indicated Resident C arrived to the emergency department at 10:28 a.m., with complaints of pain to toe of right foot and anxiety. The resident was anxious, fidgeting, couldn't hold still, jerking. with intractable pain. He has .significant comorbidities including [CONDITION(S)] with metastatic bone disease, chronic kidney disease .reports severe pain in the right 5th digit .He was given [MEDICATION(S)] in the ED [emergency department] followed by [MEDICATION(S)] continued to have severe pain and restlessness. With his recent history, I was asked to admit the patient for further workup and pain control. Upon my assessment the patient is writhing in pain very uncomfortable appearing and reports he feels like he is having a panic attack and can not sit still. Reportedly this has been ongoing for many hours. He tells me that he lives in a rehab facility and does not feel that he has been getting his pain medications as prescribed and tells me he is having bone cancer pain and his arms and neck. Upon further review of his chart he is suppose to be on [MEDICATION(S)] patch, oxycodone IR [immediate-release], [MEDICATION(S)]. He had a [MEDICATION(S)] patch noted to the left side of his chest that appeared very old and was barely attached and it appeared the date was placed on 1/5/22 however could not really see the written date. Patient reports he did not think it had been replaced in a few days. This was removed and new patch was placed. He was also give his oxycodone and a dose of [MEDICATION(S)] and was then resting much more comfortably and was calm. I spoke to the patient's wife who reports .she is concerned because he has had significant pain and does not think he is getting his pain medications as prescribed .Podiatry consult note dated 1/9/22 at 1:40 p.m. indicated .Pain crisis 10/10 pain, cannot sit still. hx [history] of bone cancer . The discharge note dated 1/10/22 indicated the resident's principal problem included but was not limited to: .R [right] toe pain - no evidence of acute pathology. Likely related to uncontrolled widespread pain from bony metastatic disease .Metastatic [CONDITION(S)] (cancer) to bone .Subacute [CONDITION(S)] of right foot .Chronically on opiate therapy - poorly managed at ECF [extended care facility] . Hospitization course indicated resident .was suffering intractable pain related to bony metastatic disease from renal [CONDITION(S)] in conjunction with some likely opiate withdrawal . An interview was conducted with Resident C on 1/21/22 at 3:26 p.m. He indicated his wife called 911 on the morning of 1/9/22, to transfer him to the hospital to have his pain addressed. There are days he doesn't receive his medications by the facility's staff. He had not received his scheduled pain patch. The day he went to the hospital, I felt like the staff didn't want to be bothered or know what to do with me. He was unable to recall if he had requested or received any pain medication that night, but when I do request, it takes an hour to get any medications that is if they come back at all. During the night of 1/8/22, he was anxious and in a lot of pain. It had continued all night into the morning. The pain had gotten so bad it had caused him to have a panic attack. The hospital staff was able to calm him down by giving him some pain medication to get his pain under control. An interview was conducted with the Executive Director on 1/21/22 at 3:22 p.m. She indicated Registered Nurse 5 was unavailable. Resident C should have received his scheduled [MEDICATION(S)] patch on 1/8/22. She was unsure the reason the resident had not received the [MEDICATION(S)] patch. The resident's pain should have been assessed by staff every shift in the hot charting tab in the resident's clinical record. The resident's record does not indicated staff have been conducting pain assessments every shift. The resident's MAR did not indicate the resident received any PRN pain medication on 1/8/22, however the controlled substance form for his PRN oxycodone pain medication indicated he had received 15 milligrams of oxycodone on the evening of 1/8/22. The staff should have assessed Resident C's pain after the administration for effectiveness of the PRN pain medication. A Pain Management policy dated 10/2020, was provided by the Executive Director on 1/21/22 at 3:00 p.m. It indicated .Policy: Its is the policy of American Senior Communities to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being, including pain management .Procedures: 1. Residents are assessed for pain upon admission, weekly and during medication administration as outlined below. 2. The following will be used when assessing pain Nursing Admission Observation, Weekly Summary, IDT Pain Interview .Ongoing nursing assessments can also be documented in matrix progress notes or matrix vitals. 3. Interviewable Resident - Pain medications will be prescribed and given based upon the intensity of the pain as follows using the verbal descriptive, numerical scale (1-10) .Mild = (1-2), Moderate = (3-5), Severe = (6-8), Very Severe, Horrible = (9-10) .7. Residents receiving routine pain medication should be assessed each shift by the charge nurse during rounds and/or medication pass. 8. Documentation of administration of ordered PRN pain medication will be initialed on the Medication Administration Record (MAR). 9. Additional information including, but not limited to reasons for administrations, and effectiveness of pain medication will be documented on the Medication Administration Record (MAR), or on the facility specific pain management flow sheet . This Federal tag relates to Complaint IN 865. 3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident was successfully transported to [MEDICAL TREATMENT] appointments and follow-up on resident's condition after not receiving [MEDICAL TREATMENT], that resulted in a change in condition and hospitalization , for 1 of 2 residents reviewed for [MEDICAL TREATMENT]. (Resident C) Findings include: The clinical record for Resident C was reviewed on 12/9/19 at 1:00 p.m. The [DIAGNOSES REDACTED]. An Annual Minimum Data Set (MDS) assessment, dated 11/26/19, indicated a Brief Interview for Mental Status was conducted for Resident C, and she was cognitively intact. A [MEDICAL TREATMENT] care plan, dated 3/8/17, indicated the following, .Resident is receiving [MEDICAL TREATMENT] and is at risk for complications such as fluid imbalance, bleeding or infection .Approach .Observe for symptoms of fluid volume deficit such as [MEDICAL CONDITION], orthostatic [MEDICAL CONDITION], dizziness, thirst, dry mucous membranes, weight loss, nausea, muscle cramps. Document findings and notify MD (Medical Doctor) and [MEDICAL TREATMENT] center .Treatment as ordered A physician order, dated 10/24/18, indicated Resident C had [MEDICAL TREATMENT] on Monday, Wednesday, and Fridays. A document titled Hemo [MEDICAL TREATMENT] Weekly Review, dated 11/29/19, indicated Resident C did not receive [MEDICAL TREATMENT] on 12/2/19. The reason was related to no transportation. An interview conducted with Unit Manager 10, on 12/9/19 at 1:48 p.m., indicated Resident C did not attend [MEDICAL TREATMENT] on 12/2/19 due to no transportation. She contacted (name of transportation company) and they had to recertify her. A progress note, dated 12/2/19 at 2:27 p.m., indicated the following, .Writer received a call from pharmacy regarding resident's critically high Creatinine level of 9.0. Level reported to NP (Nurse Practitioner) in facility at time. No new orders received A progress note, dated 12/3/19 at 11:03 a.m., indicated the following, .Summary of Session .The therapist met with the resident in her room. She was sitting in her wheelchair and dressed appropriately. The resident advised that transportation had not come to get her yesterday for [MEDICAL TREATMENT] and that she was feeling very tired. The resident looked very tired and was struggling to pronounce her words. A chart review shows that the resident's creatinine level is very high also There were no further progress notes that indicated follow-up was conducted for Resident C's missed [MEDICAL TREATMENT] appointment and her change in condition noted on the 12/3/19 progress note. A progress note, dated 12/4/19 at 6:10 a.m., indicated the following, .Responded to resident call light. Upon arrival resident c/o (complained of) R (right) leg pain. Repositioned R (right) leg and offered PRN (as needed) pain medication. Resident stated she felt nauseated and would like to go to the hospital Hospital records, dated from 12/4/19 to 12/6/19, indicated Resident C had a potassium level of 9.5 (normal 3.5 - 5.0) and fluid overload secondary to missed [MEDICAL TREATMENT]. Resident C's weight decreased from 323 pounds to 296 pounds at the hospital. Resident C received [MEDICAL TREATMENT] two days in a row while at the hospital. An interview conducted with the Executive Director (ED), on 12/9/19 at 2:18 p.m., indicated there was no documentation that could be found in the clinical record related to Resident C's condition due to missing [MEDICAL TREATMENT] on 12/2/19. A policy titled [MEDICAL TREATMENT] Care, revised 11/2017, was provided by the ED on 12/9/19 at 2:18 p.m. The policy indicated the following, .Ongoing assessment and oversight of the resident before, during, and after [MEDICAL TREATMENT] treatments, monitoring for complications, implementing appropriate interventions, and using appropriate infection control practice .Ongoing communication and collaboration with the [MEDICAL TREATMENT] facility regarding [MEDICAL TREATMENT] care and services .Facility must assist resident to ensure that arrangements are provided to secure transportation to and from [MEDICAL TREATMENT] appointments .Procedure .10. The physician will be notified of any unusual findings and/or change in condition based upon the assessments This Federal tag relates to Complaint IN 841. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a resident was free from abuse resulting in psychosocial harm for 1 of 3 residents reviewed for abuse. (Resident #C) Findings include: The clinical record for Resident #C was reviewed on 1/19/16 at 12:30 p.m. The [DIAGNOSES REDACTED]. The 12/11/15 Quarterly MDS (minimum data set) assessment indicated Resident #C had a BIMS (brief interview for mental status) score of 15, the highest possible score, indicating Resident #C was cognitively in tact. The investigative file for a 12/28/15 incident involving Resident #C was provided by the Executive Director (ED) on 1/19/16 at 12:05 p.m. The Follow-Up Incident Report submitted to the Indiana State Department of Health indicated, Resident states CNA (Certified Nursing Assistant) has asked her for months if she wanted hot dog. Resident states CNA grabbed himself and then she knew CNA was referencing his penis as hot dog. Resident immediately assessed for further clinical needs. ED, MD, APS (Adult Protective Services), Ombudsman notified. CNA suspended pending the outcome of an investigation. Social Services began assessments to identify if other residents were affected and initiated 3-day follow up of resident involved. Resident referred to psych (psychological) services to identify if further follow up if (sic) needed .No injury noted .CNA suspended pending the outcome of an investigation to ensure no further contact with resident Facility investigation confirmed need to terminate employment with CNA (name of CNA #7) upon completion of investigation. Resident has been followed by Social Services and has exhibited no signs or symptoms of distress. Resident has been referred to Psych services to assess need for further follow up. The 12/29/15 CNA #3 and CNA #4 written statement, written by CNA #3 and signed by CNA #3 and CNA #4 indicated, I (names of CNA #3 and CNA #4) came on shift which was 12/27/15 going into 12/28/15 Monday morning 2:45. (Name of CNA #7) walks up and say (sic) Merry Christmas to (names of CNA #3 and CNA #4). We all started having short talk and (name of CNA #7) started talking bout (sic) hotdogs and I (name of CNA #3) said go on (name of CNA #7) with that hotdog talk. Then he ask (sic) (name of CNA #4) bout (sic) hotdog and then asked (name of Resident #C) and (name of Resident #C) said I got a husband. I don't need your hot dog and stop talking to me that way cause (sic) I know what you mean. You say it again and I am turning you in to the administration. Then he started acting like he didn't understand what (name of Resident #C) was saying. So we told the nurse (names of LPN #9 and LPN #6) and told them (name of Resident #C) said she was going to turn him, meaning (name of CNA #7) in in the morning. The first person we sent (sic) Monday morning was (name of Staff Scheduler). We told her. Cause (sic) (name of Resident #C) said it offended her and made her uncomfortable (sic) she also stated when asked what hot dog he grabbed himself and that's when she clicked, and told him no one wants your nasty stinking hotdog and then he turned and left and didn't say anything the rest of (sic) night or the next day. Never witness (sic) the grab, but heard the rest. He also say this to lots of people bout (sic) hot dog. The 12/27/15 Resident #C statement indicated, An aide name (name of CNA #7) keep (sic) asking me for months do I want hotdog. Said I got hotdog. I didn't relize (sic) he was talking about his (expletive). I thought it was an Africian (sic) food for weeks until he grab (sic) himself. Then I knew it was his penis. I told his (sic) got to get the (expletive) away from me with his nasty stinky (expletive) (expletive). Don't nobody want it or him, an (sic) told 2nd floor, one of the nurses what he said. It was scary. The 12/28/15, 8:15 a.m. Unit Manager (UM) #5 written statement indicated, Writer clocked in for work. Resident (room number of Resident #C) came to me and stated that (name of CNA #7) CNA asked her if she wanted to see his hot dog. Resident asked him what was on it and staff grab (sic) his private part. Writer reported to CEC (Clinical Education Coordinator), DNS (Director of Nursing Services) and ED. Will continue to observe. The undated LPN #6 written statement was provided by the CEC on 1/19/16 at 3:09 p.m. It indicated, On Sunday, 12/28 @ around 6:30 a.m., my CNA (name of CNA #3) notified me that the CNA upstairs (name of CNA #7) was downstairs and talking to her, (name of CNA #4) and patient (name of Resident #C) about wanting a hot dog & grabbed his penis. I notified the DON (aka DNS) and scheduler (name of Staff Scheduler). I checked on the patient who was unharmed, asked the patient what happened who said the male CNA grabbed his penis and asked if she wanted a hot dog. The patient seemed calm & not upset about situation. Skin assessment normal. DON told me to make CNA leave due to accusation. CNA was leaving for the shift at this time. The 12/28/15 Staff Scheduler written statement indicated, This morning around 7:15 a.m. (names of CNA #4 and CNA #3) told me that (name of Resident #C), a resident here, stated a staff member member made sexual and inappropriate conversation with her. (Names of CNA #4 and CNA #3) stated that (name of Resident #C) said the staff (name of CNA #7) asked her if she wanted a hot dog. And she (name of Resident #C) said yes, he grabbed his crotch and she said no and told him to leave her room. The 1/20/16 CNA #7 written statement indicated, I had work (sic) with CNA (name of CNA #4) at another facility and we are friends. A while ago, I came down stairs and I saw (name of CNA #4) and another CNA eating something with biscuit (sic), and she said do you want some, (sic) is hot dog, it tastes good, and I said hot dog, I never heard of that, what is it? And they laughed and said it make (sic) out of pork, not really from dog. From that day at any time they saw me, they asked me do you want hot dog. It was joke (sic) and we were saying back and forth to each other and we laugh about it. On 12/28/15 at 5:30 a.m., I came down stairs to chart and I saw (name of CNA #4) and CNA down hallway and joking and say do you got hot dog. They laughed and we just talk friendly, and there was no resident around, and when get (sic) done with my charting and went home A telephone interview was conducted with CNA #3 on 1/19/16 at 2:19 p.m. CNA #3 indicated about 5:00 a.m., on 12/28/15, CNA #7 asked her (CNA #3) 'do you like hot dogs?'. CNA #3 indicated she told him not to start with that. CNA #3 indicated she'd heard CNA #7 say hot dog before, but never to a resident. CNA #3 indicated CNA #7 asked Resident #C 'do you like hot dogs?'. Resident #C looked at him and said, 'No, I dont. I have a husband. Don't bring that to me. I know what you're talking about.' CNA #3 indicated Resident #C started cussing and telling CNA #7 she didn't want his nasty hot dog. CNA #3 indicated she did not see CNA #7 grab himself. CNA #3 indicated Resident #C was upset and said she was going to report it. CNA #3 indicated she, along with CNA #4 told 2 nurses right away. CNA #3 indicated Resident #C was looking crazy because she (Resident #C) said she'd been raped before. CNA #3 indicated Resident #C just kept saying she was going to report his (expletive), because he had no business talking to her like that, and she was uncomfortable. CNA #3 indicated her written statement may have been inaccurate regarding the incident occurring at 2:45, and meant to write 5:45 a.m. An interview was conducted with CNA #4 on 1/20/16 at 1:31 p.m. CNA #4 indicated she, CNA #3, and Resident #C were in the hallway and CNA #7 asked Resident #C 'you want hot dog?' CNA #4 indicated Resident #C took it to mean a real hot dog, but when she realized what he meant, she got mad. CNA #4 indicated, From my perspective, he was talking about his private. CNA #4 indicated Resident #C was really upset, and that she and CNA #3 had to calm her down. CNA #4 indicated Resident #C told CNA #7 if she wanted a hotdog, she had a husband, and didn't need CNA #7's (expletive) hot dog. CNA #4 indicated she and CNA #3 told LPN #6 immediately. CNA #4 indicated she and CNA #3 stayed with Resident #C until she calmed down because they knew she had [MEDICAL CONDITION]. CNA #4 indicated, We didn't want her to worry herself into a [MEDICAL CONDITION], so we had to calm her. CNA #4 indicated CNA #7 indicated 'me got hot dog' before, but this was the first time she'd heard him say it to a resident. CNA #4 indicated, To be in the caregiving field, you just don't say those things. An interview was conducted with Resident #C on 1/19/16 at 3:34 p.m. She indicated CNA #7 said something she didn't like, and he was fired the same day. She indicated he asked her, 'You want my hot dog?'. She indicated she never paid attention to it until he grabbed himself, and that was when she figured out what he meant by 'hot dog'. She indicated CNA #7 had been saying it for about a week to her. She indicated afterwards she felt nervous, insulted, and like she needed to get help right away. She indicated CNA #3 and CNA #4 stayed with her until CNA #7 left the area. She indicated she told CNA #7, Don't nobody want your nasty stankin' (expletive) (expletive). She indicated she informed CNA #7 she was going to report him. Resident #C indicated she was proud of the way the facility handled everything. She indicated she was sexually abused as a child, so CNA #7's statements and actions really shook me up. Resident #C indicated she pictured CNA #7 grabbing himself, in her head, for a couple of weeks after the incident. She indicated she prayed at night for the next couple of days for God to keep her safe and not let it happen again. She indicated she never had to go through anything like that before at the facility. She indicated when CNA #7 grabbed himself, he made a humping motion. Resident #C made a fist, placed it at her pubic area, and began motioning back and forth to display what she observed from CNA #7. Resident #C indicated she spoke with her therapist about the situation. Resident #C's 1/12/16 Psychotherapy Progress Note, written by Licensed Clinical Social Worker (LCSW) #8, indicated her symptom behavior reflective of psychiatric problems were: anxiety/rumination, agitation, sad/hopelessness/helpless and tearful. It indicated the description of the session as: utilized poor expressive/receptive verbal reasoning, and poor general feeling of well-being. It indicated, If I sleep 4 hours, I'm doing good. I'm scared to fall asleep. I might have nightmares about sex. The comments section of the note indicated, 'I'm just sad today. Life sucks. I don't care anymore.' Pt was in good spirits last week. The Barriers section of the note indicated, Low self esteem, compares herself to others . A telephone interview was conducted with LCSW #8 on 1/20/16 at 11:31 a.m. LCSW #8 indicated she'd been working with Resident #C for over a year and tried to see her once a week, but sometimes it was every other week. LCSW #8 indicated Resident #C told her about the incident involving CNA #7. LCSW #8 indicated Resident #C was upset about it in that Resident #C felt like why didn't she catch that, and was kind of down on herself. LCSW #8 indicated the reason for that was she was supposed to be in a safe place. The facility was her home, so it would be totally unexpected for that to happen, so she was down on herself for not picking up on it. LCSW #8 indicated Resident #C was molested as a child and had nightmares about her dad, especially close to her [MEDICATION NAME] (antipsychotic medication) shot being due. LCSW #8 indicated Resident #C was already tormented by her child hood, so this guy at the facility doing this would trigger nightmares and more fear. LCSW #8 indicated Resident #C seemed shocked that CNA #7 would say that, and (Resident #C) felt like it was so obvious what he meant, how could she (Resident #C) not pick up on that. The 12/31/15, 1:16 p.m., IDT (Interdisciplinary Team) Note indicated, IDT met to review to discuss residents status [REDACTED]. Resident expressed she is happy living in facility and comfortable here. Resident also voiced her appreciation with the immediate reaction and actions taken by staff as a result of event, and is happy with the outcome. Resident states she is not in any psychological, mental, emotional or physical distress as result of the 12/27/15 event Resident cont (continues) to attend several activities on a daily basis. Resident has experienced no change in diet or consumptions. Residents normal sleep pattern has not been affected. Resident shows no s/sx (signs/symptoms) of distress. Resident cont to deny ay pain or discomfort. Will cont to F/U (follow up) with resident. In attendance: DNS, ED, SSD, Activities Director, CDM (Certified Dietary Manager), and UM (Unit Manager). An interview was conducted with the ED, DNS, and Social Services Director (SSD) on 1/19/16 at 1:49 p.m. The ED indicated she determined the allegation took place and employee #7 needed terminated. The ED indicated she thought the conversation started out as a conversation between coworkers and became something that he could involve the resident in. The ED indicated she did not know if CNA #7 had intent to verbally abuse her. The ED indicated it was undetermined whether CNA #7's statements were disparaging and derogatory. A telephone interview was conducted with CNA #7 on 1/20/16 at 11:02 a.m. He indicated it became a laughing matter that he didn't know what a hot dog was. He indicated he was talking to another CNA around 5:30 a.m., on 12/28/15, and no resident was around. He indicated he did not make any gestures. The 1/7/16 Employee Record for CNA #7 indicated, Above employee utilized profane language & inappropriate conduct toward resident .Action taken from this discussion/investigation: Termination. Final Written Warning Violations: Horseplay, disruptive or unruly behavior, creation of unreasonable noise, or use of profane language. The Abuse Prohibition, Reporting, and Investigation policy and procedure was provided by the ED on 1/19/16 at 12:05 p.m. It indicated, Abuse is the willful infliction of injury, unseasonable confinement, intimidation or punishment with resulting physical harm or pain, or mental anguish. The policy defined willful as, the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm. It indicated, Verbal abuse - oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing, regardless of their age, ability to comprehend, or disability. Examples would include, but are not limited to: threats of harm, saying things to frighten a resident, . It indicated, Sexual Abuse-sexual harassment, sexual coercion, or sexual assault .Examples: .gestures .harassment, seduction, coercion .Mental Abuse-Verbal or nonverbal infliction or anguish, pain, or distress that results in psychological or emotional suffering. 1. Staff to resident-any episode .Examples: humiliation, harassment, threats of punishment or deprivation, bullying .(Name of corporate facility) will not permit residents to be subjected to abuse by anyone, including employees . This Federal tag relates to complaint IN 842. 3.1-27(b)