Every finding on record at Envive of Beech Grove

Based on interview and record review, the facility failed to ensure a new physician's order was clarified timely for 1 of 5 residents reviewed. (Resident B) Finding includes:The clinical record for Resident B was reviewed on 8/6/26 at 10:11 a.m. The diagnoses included, but were not limited to, epilepsy, diabetes, and congestive heart failure.A physician's order, started on 4/18/26 and discontinued on 4/21/26, indicated lacosamide (anti-seizure medication) 50 milligrams (mg), administer three tablets orally twice daily for seizures.A progress note, dated 4/18/26 at 1:57 p.m., indicated a pharmacy alert for a drug to drug interaction between lacosamide 50 mg and carvedilol (medication used to treat high blood pressure) 25 mg had been identified by the pharmacy. During an interview on 8/6/26 at 12:35 p.m., the Regional Nurse indicated the nurse should have ensured the physician's order for lacosamide had been clarified and the medication had been administered. On 8/6/26 at 1:00 p.m., the facility was unable to provide a policy regarding physician notification for medication clarifications by survey exit.This citation relates to Intake 3012355.410 IAC (Indiana Administrative Code) 16.2-3.1-35(g)(1)

Based on observation, interview, and record review the facility failed follow the menus prepared in advance for 1 of 1 dining observations. Findings include: On 12/10/25 at 1:00 p.m., observed posted menu on the wall, outside of the main dining room. The menu indicated scalloped potatoes were to be served on 12/10/25 during lunch time. During a dining observation on 12/10/25 at 1:10 p.m., the following was observed: - Resident 44, Resident 24, Resident 29, and Resident 42's lunch plate was observed to include mashed potatoes, the plate did not include the listed scalloped potatoes as indicated on the posted menu. - At that time, Resident 42's a family member indicated the meals Resident 42 received on his meal tray did not match the posted menu. During an interview on 12/19/25 at 1:00 p.m., the Administrator indicated he was not aware of the discrepancy and indicated the posted menu should match the served meal. On 12/12/25 at 9:12 a.m., the Executive Director provided a policy titled Kitchen operations: Meal Service and Distribution, dated December 2022, and indicated it was the current policy being used by the facility. A review of the policy indicated Procedures .3. Residents' meals are distributed promptly with supervision provided as needed. Staff should check resident name and room number to verify correct information, and check items on the tray against the tray ticket to assure all necessary items are provided. 3.1-20(i)(2)

Based on observation, interview, and record review, the facility failed to ensure food was served in a sanitary manner for 1 of 3 kitchen observations. A refrigerator food item was not covered, and a perishable food item was not discarded by the use-by-date. Findings include: During the initial facility tour with the Executive Director (ED) on 12/9/25 at 9:45 a.m., the resident snack pantry, located near the resident dining room area, was observed. The following was observed inside the resident snack pantry refrigerator:-One plastic gallon container of Country Fresh white milk was located on the shelf of the refrigerator door. The milk container contained a grayish colored thick substance that covered the bottom of the container. Similar substances were observed inside the container that was adhered to the sides of the container. Near the top of the milk container, the manufacturer's pre-printed Use By Date: 11/30/25 was observed.-One medium sized plastic pan was observed on the top shelf of the refrigerator unit. The pan was approximately ten percent full of applesauce. The pan was partially covered with a loose fitted plastic wrap. The plastic wrap was torn in half which resulted in the majority of the pan to be un-covered. During an interview on 12/9/25 at 9:50 a.m., the ED indicated the milk container should have been discarded by the use by date and the applesauce pan should have been completely covered.On 12/12/25 at 9:31 a.m., the Director of Nursing provided a copy of the Kitchen Operations: Food Storage policy, dated 1/1/23, and indicated it was the current policy in use by the facility. A review of the document indicated, .all foods shall be covered or wrapped tightly .may not exceed the manufacturer's use-by-date .On 12/10/25 at 2:55 p.m., a review of the retail Food Establishment Sanitation Requirements Title 410 IAC 7-26, effective April 16, 2025, indicated: .refrigerated, ready to eat, potentially hazardous food prepared .discarded .covered containers, or wrappings .wrap food tightly to prevent cross contamination . 3.1-21(i)(2)3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to provide special eating utensils for 1 of 2 residents reviewed for restorative services. (Resident 42) Finding included: On 12/10/25 at 1:39 p.m., the clinical record for Resident 42 was reviewed. The diagnoses included, but were not limited to, hemiplegia (loss of strength in the arm, leg, and sometimes face on one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing). The current Physician's orders, dated 11/9/25 indicated the following: - Regular diet, pureed texture, nectar/mildly thick consistency fluids. - An Occupational Therapy clarification Order, dated 11/17/25 with no end date, indicated Resident 42 was to use a Kennedy cup (a lightweight, easy to grip adapted drinking cup designed to prevent spills) and scoop plate (a scoop plate is a type of dish specifically designed to help individuals with limited motor skills or disabilities that makes eating challenging) during all meals. During a dining observation on 12/10/25 at 12:30 p.m., observed Resident 42 consuming lunch in the main dining room. Resident 42's plate was observed to be a regular plate and not the required scoop plate. The resident was using a regular cup for liquids. The Kennedy cup was not visible or accessible to the resident. During a dining observation on 12/11/15 at 12:45 p.m., observed the same. During a dining observation on 12/15/25 at 12:44 p.m., observed Resident 42 in his room consuming lunch. The required scoop plate was not observed. During an interview at that time a family member indicated the resident began using the Kennedy cup 3 days ago. An Occupational Therapy note, dated December 2025, indicated Goal: Resident 42 would safely perform self-feeding tasks with minimal assist with use of built-up utensils and a scoop dish with a plate guard and a Kennedy cup. During an interview on 12/11/25 at 11:25 a.m., Physical Therapist (PTA 4), indicated the facility was to provide the proper feeding utensils. During an interview on 12/12/25 at 10:20 a.m., the Director of Nursing indicated she was not aware of the order for the eating utensils. On 12/12/25 at 9:12 a.m., the Executive Director provided a policy titled, Meal Service and Distribution and indicated it was the current policy being used by the facility. A review of the policy indicated .2. All residents will be provided with the proper assistive devices when consuming meals and snacks. 3.1-21(h)

Based on observation, interview, and record review, the facility failed to implement infection control practices for 1 of 1 residents with urinary catheters observed. A urinary catheter drainage bag was touching the floor. (Resident 26)Finding includes: On 12/9/2025 from 12:10 p.m., until 12:30 p.m., observed Resident 26 sitting in the dining room. The resident's catheter drainage bag was observed to be hanging from the wheel chair and the drainage bag was touching the floor. During an interview on 12/9/25 at 12:33 p.m., Certified Nursing Assistant (CNA) 2, indicated the catheter drainage bag was not supposed to touch the floor. On 12/9/25 at 12:35 p.m., observed the Assistant Director Nursing adjust the catheter drainage bag so that it was not touching the floor. On 12/12/25 at 8:37 a.m., the Director of Nursing provided a policy titled Catheter Care, dated August, 2024, and indicated it was the current policy being used by the facility. A review of the policy indicated .11. Be sure the catheter tubing and drainage bag are kept off the floor. 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure foods were maintained and served in a sanitary and safe manner for 4 of 4 observations. Staff hair was not covered while in the kitchen food preparation and serving area. (Dietary Manager) Findings include: 1. The initial kitchen tour was conducted with the Dietary Manager (DM) on 12/10/24 from 9:00 a.m. to 9:20 a.m. The DM was observed walking through out the kitchen area and near the food preparation table where the noon meal was being prepared. The DM was observed to have multiple loose facial chin hairs approximately one-fourth inch to one-half inch in length. The chin hairs were observed to not be covered. 2. During a follow up kitchen observation on 12/10/24 from 11:25 a.m. to 11:45 a.m., the DM was observed at and near the steam table where the noon meal foods were being held. The DM was observed taking and recording the noon meal food temperatures. The DM was observed to have multiple loose facial chin hairs approximately one-fourth inch to one-half inch in length. The chin hairs were observed to not be covered. 3. Prior to the noon meal service on 12/10/24 from 12:15 p.m. to 12:45 p.m., the DM was observed at and near the steam table that was located in the main dining room area. The DM was taking and recording the starting food temperatures for the foods being held at the steam table. The DM was observed to have multiple loose facial chin hairs approximately one-fourth inch to one-half inch in length. The chin hairs were observed to not be covered. 4. During a follow up observation on 12/10/24 from 12:50 p.m. to 12:55 p.m., the DM was observed in the main dining room area where the steam table was located. The steam table held the noon meal foods. The DM was observed taking the ending food temperatures. The DM was observed to have multiple loose facial chin hairs approximately one-fourth inch to one-half inch in length. The chin hairs were observed to not be covered. During an interview on 12/10/24 at 1:00 p.m., the DM indicated staff hair was to be kept covered while in the kitchen and when working with resident foods. On 12/11/24 at 10:45 a.m., the Director of Nursing Services provided a copy of the Envive Healthcare Policies and Procedures Manual: Preventing Foodbourne Illness-Employee Hygiene and Sanitary Practices policy, dated August 2024, and indicated it was the current policy in use by the facility. A review of the policy indicated, .Hair Nets .beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens . On 12/10/24 at 3:00 p.m., a review of the Retail Food Establishment Sanitation Requirements Title 410 IAC 7-24, effective November 13, 2004, indicated, .food employees shall wear hair restraints such as .hair coverings or nets .that are designed and worn to .effectively keep their hair from contacting .exposed food . 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure a physician's ordered skin tear treatment was followed for 1 of 3 residents reviewed for skin integrity. Wound dressings were not dated and initialed and the dressing change was continued beyond the physician's orders.(Resident 6) Findings include: During an observation on 12/10/24 at 10:45 a.m., Resident 6 was observed sitting in her wheelchair in the hall near her room. Resident 6's left mid-shin area was observed. A dry and intact tan colored dressing, approximately two inches by three inches, was observed covering the mid-shin area. The dressing lacked any documentation that indicated when and who had applied the dressing to the resident's shin area. During an interview at that time, Resident 6 indicated she was unsure when or why the dressing had been applied to her leg. On 12/12/24 at 1:15 p.m., Resident 6 was observed in her room and was sitting in her recliner with both legs elevated. Resident 6's left mid-shin area was observed. A dry and intact tan colored dressing, approximately two inches by three inches, was observed covering the mid-shin area. The dressing lacked any documentation that indicated when and who had applied the dressing to the resident's shin area. During an interview at that time, Resident 6 indicated she was unsure when the staff had applied the dressing to her leg. During an observation with RN 3 on 12/12/24 at 1:35 p.m., Resident 6 was observed sitting in her recliner with both legs elevated. Resident 6's left mid-shin area was observed. A dry and intact tan colored dressing, approximately two inches by three inches, was observed covering the mid-shin area. The dressing lacked any documentation that indicated when and who had applied the dressing to the resident's shin area. During an interview at that time, RN 3 indicated the dressing should have indicated the date and who had applied the dressing to Resident 6's mid-shin area. RN 3 indicated the shin skin tear was considered healed several weeks ago and since that time, the dressings were still being applied to Resident 6's mid-shin area as a preventative measure as per Resident 6's family request. On 12/12/24 at 12:15 p.m., Resident 6's clinical record was reviewed. The diagnoses included, but were not limited to, anemia, generalized weakness, dementia, restless leg syndrome, tremors, and a potential for impaired skin integrity. The Quarterly Minimum Data Set (MDS) assessment, dated 11/17/24, indicated Resident 6 was severely cognitively impaired and indicated Resident 6 had a skin tear. Resident 6's care plan, revised on 1/12/23, indicated the resident had potential for impaired skin integrity. The care plan was reviewed and considered current through 2/16/25. The care plan indicated Resident 6's skin would be kept clean and intact. Physician orders included, but were not limited to, monitor skin tear to lower left leg daily and change bordered foam dressing daily and as needed until healed .start date: 10/7/24 . Resident 6's Skin Assessments included, but were not limited to, the following: - Skin assessment, dated 10/5/24, indicated Resident 6 had a new left lower leg skin tear, approximately five centimeters in length, physician was notified, treatment order was in place, and staff were to monitor the area. - Skin assessment, dated 11/23/24, indicated Resident 6 had no impairments with skin integrity. - Skin assessment, dated 11/27/24, indicated Resident 6 had no impairments with skin integrity. - Skin assessment, dated 11/30/24, indicated Resident 6 had no impairments with skin integrity. - Skin assessment, dated 12/7/24, indicated Resident 6 had no impairments with skin integrity. - Skin assessment, dated 12/11/24, indicated Resident 6 had no impairments with skin integrity. A review of the November 2024 Treatment Administration Record (TAR) record indicated that staff had monitored the left shin skin tear and had applied a new dressing to the left shin area on a daily basis from 11/1/24 through 11/30/24. A review of the December 2024 TAR record indicated that staff had monitored the left shin skin tear and had applied a new dressing to the left shin area on a daily basis from 12/1/24 through 12/12/24. The clinical record lacked documentation that indicated a physician's prescribed treatment order to discontinue the daily dressing changes for a healed skin tear was followed. The physician was not notified and a new treatment order received prior to the continued dressing treatments having been applied to a healed skin tear from 11/24/24 through 12/12/24. During an interview on 12/12/24 at 3:40 p.m., the Director of Nursing Services (DNS) indicated Resident 6's left mid-shin skin tear was identified on 10/5/24 and the physician prescribed dressing changes were applied. When the skin tear was considered healed on 11/23/24, staff should have contacted the physician to obtain a revised treatment plan. All treatment dressings were to include the date and who had applied the dressings. On 12/12/24 at 2:15 p.m., the DNS provided a copy of the Envive Healthcare Policies and Procedures Manual: Subject-Skin Tears policy, dated August 2024, and indicated it was the current policy in use by the facility. A review of the policy indicated, .apply the ordered dressing and secure .label with date and initials to top of dressing . On 12/16/24 at 9:05 a.m., the DNS provided a copy of the Envive Healthcare Policies and Procedures Manual: Change in Resident's Condition or Status policy, dated August 2024, and indicated it was the current policy in use by the facility. A review of the policy indicated, .Our facility promptly notifies the resident, his or her attending physician .of changes in the resident's medical/mental condition and/or status .nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . 3.1-37(a)

Based on interview and record review, the facility failed to document the drug dispositions for 1 of 2 residents reviewed for closed records. (Resident 47) Finding includes: On 12/13/24 at 12:36 p.m., Resident 47's clinical record was reviewed. The diagnoses included, but were not limited to, hypertension, cerebral infarction (stroke), and hyperlipidemia (high cholesterol). A physician's order summary report of medications, dated for active orders as of 9/17/24, included but were not limited to: - hydralazine HCL 25 milligrams (mg) for hypertension (high blood pressure) - atorvastatin calcium 80 mg for lowering cholesterol - carvedilol 3.125 mg for hypertension - hydrochlorothiazide 12.5 mg for hypertension The Envive Discharge Summary document, was initiated on 9/16/24 in anticipation for Resident 47's planned discharge. A review of the document indicated Resident 47's current medications were to be sent home with the resident on her scheduled discharge date of [DATE]. The record included Resident 47's current medications; however, it lacked the actual number of pills per medication that were to be provided to the resident upon her discharge. The clinical record lacked a completed drug disposition record for Resident 47 upon her discharge from the facility. During an interview on 12/13/24 at 1:15 p.m., RN 3 indicated Resident 47 was discharged home on 9/17/24 and the facility lacked a drug disposition record for Resident 47 medications. During an interview on 12/16/24 at 11:46 a.m., the Director of Nursing Services (DNS) indicated Resident 47's current medications were sent home with the resident. The DNS indicated she was unsure of the number of pills for each specific medication that were sent home with the resident or how many were returned to the pharmacy. The DNS indicated the facility lacked a drug disposition record for Resident 47's medications. On 12/16/24 at 9:05 p.m., the DNS provided an undated copy of the Discharge Medications policy and indicated it was the current policy in use by the facility. A review of the policy indicated, .discharge medications are counted or the volume of liquid estimated and the following information is entered on the discharge medication documentation form .date .name and strength of each medication .quantity or amount .facility will adhere to the rules and regulations of their specific State Health Department . 3.1-25(s)

Based on observation, interview, and record review, the facility failed to ensure a soiled utility room lock was repaired for 1 of 1 soiled utility rooms observed. Findings included: On 12/10/24 at 10:00 a.m., observed the door to the Soiled Utility Room between room [ROOM NUMBER] and room [ROOM NUMBER] to be unlocked. An observation of the lock to the door was missing numerical key pads and the door latch was taped to prevent the door from locking when the door closed. In the unlocked room, a barrel labeled trash, three barrels labeled soiled linen, and two barrels containing items in biohazard bags were observed. The door to the Soiled Utility Room had a sign which read, Restricted Area, Authorized Personnel Only. During an interview on 12/10/14 at 10:05 a.m., Qualified Medication Aide (QMA) 2 indicated the door should have been locked, but the lock was broken and there should have been a work order for it. During an interview on 12/10/24 at 10:22 a.m., the Director of Nursing (DON) indicated the door should have been locked. On 12/10/24 at 2:03 p.m., the DON provided, a copy of CDC Infection Control, Regulated Medical Waste, dated 1/8/24, and indicated it was the current policy in use by the facility. A review of the document indicated, .Any facility that generates regulated medical wastes should have a regulated medical waste management plan to ensure health and environmental safety as per federal, state, and local regulations . 3.1-19(f)

Based on interview and record review, the facility failed to ensure a Resident's Advanced Directive (code status) preference was implemented and recorded accurately in the clinical record for 1 of 16 residents reviewed for Advanced Directives. (Resident 46) Finding includes: On [DATE] at 2:45 p.m., Resident 46's clinical record was reviewed. Resident 46 was admitted to the facility on [DATE]. The new admission MDS (Minimum Data Set) assessment, dated [DATE], indicated Resident 46 was severely cognitively impaired. Resident 46's baseline care plan indicated .Focus: Kardex Care Guide, date initiated: [DATE] and current through [DATE] .Goal: The resident's care will be provided .Interventions: Code status/advanced directive [decision regarding health care intervention]: Full code [meaning a desire for all life sustaining measures were to be implemented] . Resident 46 had an appointed Health Care Power of Attorney (a legal document that grants a trusted person the authority to make healthcare decisions on your behalf). On [DATE] at 9:30 a.m., the Administrator provided a copy of Resident 46's Indiana Physician Orders for Scope of Treatment (POST) form. During an interview at that time, the Administrator indicated on [DATE] that the facility's Admission Director had assisted Resident 46's Healthcare Power of Attorney in the completion of the POST form on behalf of Resident 46. A review of the document indicated the Resident's code status preference was Do Not Attempt Resuscitation/DNR. Resident 46's Healthcare Power of Attorney signed the document on [DATE]. The POST form lacked the physician's signature to indicate to the best of my knowledge that these orders are consistent with the patient's current medical condition and preference . Therefore, the DNR code status was unable to be executed due to the missing physician's signature. On [DATE] at 2:20 p.m., the Director of Nursing Services provided an updated version of Resident 46's POST form. A review of this POST form indicated Resident 46's Healthcare Power of Attorney had chosen the DNR (Do Not Attempt Resuscitation) code status as indicated by his signature on [DATE]. This document was also signed by the physician on [DATE] which indicated to the best of my knowledge that these orders are consistent with the patient's current medical condition and preference Resident 46's Healthcare Power of Attorney's preferred DNR code status was then able to be executed on [DATE]. During an interview on [DATE] at 3:55 p.m., the Corporate Nurse Consultant indicated that Resident 46's code status preference was DNR. The POST form was initiated on [DATE] as indicated by the Health Care Power of Attorney's signature. The facility had misfiled the POST form and so the required physician's signature on the document was not obtained until [DATE]. Therefore, Resident 46's preferred code status was not honored until the POST form was completed and executed on [DATE]. On [DATE] at 2:26 p.m., the Corporate Nurse Consultant provided a copy of the Comprehensive Care Plan Guideline policy, dated [DATE], and indicated it was the current policy in use by the facility. A review of the document indicated, .to ensure appropriateness of services and communication that will meet the resident's needs .care plans need to remain accurate and current . On [DATE] at 9:13 a.m., the Corporate Nurse Consultant provided a copy of the Advanced Directives policy, dated [DATE], and indicated it was the current policy in use by the facility. A review of the document indicated, .if the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative .if the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives .the Attending Physician will provide information to the resident and legal representative regarding the Resident's health status, treatment options, and expected outcomes during the development of the initial comprehensive assessment and care plan .plan of care for each resident will be consistent with his or her documented treatment preference and/or advanced directive .the resident has the right to refuse treatment .a resident will not be treated against his or her own wishes .do not resuscitate-indicates that, in case of respiratory or cardiac failure, the resident .legal representative has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used .will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record . 3XXX,d+[DATE](f)(4)(A)(ii)

Based on record review and interview, the facility failed to initiate a baseline care plan for a newly admitted resident for 1 of 2 residents reviewed for baseline careplans. (Resident 27) Finding includes: On 12/12/23 at 1:38 p.m. the clinical record for Resident 27 was reviewed. The diagnoses included, but were not limited to, Diabetes Mellitus and fractured left patella. Resident 27 was admitted on [DATE]. The clinical record lacked a personalized baseline careplan. During an interview 12/14/23 at 2:12 p.m., RN 2 indicated Resident 27 should have had a baseline careplan initiated within 48 hours of admission. On 12/14/23 at 2:30 p.m., the Director of Nursing provided a policy titled Nursing Admission/Return Admission, dated August of 2022, and indicated it was the current policy being used by the facility. A review of the policy indicated .6. After completion of the admission nursing assessment a Baseline care plan will be initiated for all new admissions . 3.1-30(a)

Based on observation, interview, and record review, the facility failed to ensure the daily posted nursing hours reflected the actual hours worked by nursing staff for 14 of 14 days reviewed. Findings include: On 12/12/23 at 9:33 a.m., observed the posted nursing hours. The posted nursing hours did not specify the actual nursing hours worked. On 12/12/23 at 9:45 a.m., the Director of Nursing provided copies of the previous posted nursing hours. The posted nursing hours for November 28, 29, 30, December 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11, 2023, lacked the actual hours worked by nursing staff. On 12/12/23 at 10:00 a.m., during an interview the Director of Nursing was not aware the actual hours had to be posted and indicated the facility follows the Centers for Medicare and Medicaid Services nursing home requirements. On 12/12/24 at 10:05 a.m., the facility policy was requested from the Director of Nursing. On 12/20/23 at 10:00 a.m., a specific policy for posted nursing hours was not provided by the end of the survey.

Based on observation, interview, and record review, the facility failed to serve food in a sanitary manner during 4 of 4 observations where staff's hair was uncovered. (Kitchen Staff 1, Dietary Cook 2) Findings include: During the initial kitchen tour on 3/28/22 from 10:55 a.m. to 11:00 a.m., Kitchen Staff 1 was observed walking through out the kitchen where the noon meal was being prepared. Kitchen Staff 1's hair, at the neckline was 3 inches in length. The hair was observed to not be covered. On 3/28/22 from 11:50 a.m. to 12:00 p.m., observed Kitchen Staff 1 walking through out the kitchen where the noon meal was being prepared and near the steamtable area where the noon meal foods were being held. Kitchen Staff 1's hair at the neckline was 3 inches in length. The hair was observed to not be covered. On 3/28/22 from 12:00 p.m. to 12:10 p.m., Dietary Cook 2 was observed walking through out the kitchen area where the noon meal was being prepared and near the steamtable where the noon meal foods were being held. Dietary Cook 2's hair, in front of her ears, was 2 inches in length. The hair was observed to not be covered. On 3/28/22 from 12:55 p.m. to 1:00 p.m., Dietary Cook 2 was observed walking through out the kitchen area where the noon meal had been prepared and near the steamtable where the noon meal had been plated. Dietary Cook 2's hair, in front of her ears, was 2 inches in length. The hair was observed to not be covered. During an interview on 3/28/22 at 10:45 a.m., the Dietary Manager indicated all kitchen staff's hair was to be covered while in the kitchen. During an interview on 3/28/22 at 1:10 p.m., Dietary Cook 2 indicated all kitchen staff's hair was to be kept covered when in the kitchen. On 4/1/22 at 8:15 a.m., the Administrator provided a copy of the Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices policy, dated 2022, and indicated it was the current policy in use by the facility. A review of the document indicated, .hair nets .must be worn to keep hair from contacting exposed food, clean equipment, utensils . On 3/28/22 at 3:00 p.m., a review of the Retail Food Establishment Sanitation Requirements Title 410 IAC 7-24, effective November 13, 2004, indicated, .food employees shall wear hair restraints such as .hair coverings or nets .that are designed and worn to .effectively keep their hair from contacting .exposed food . 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure a cognitively impaired resident left the facility without supervision for 1 of 3 residents reviewed for elopement. (Resident B) Finding includes: On 3/28/22 at 2:17 P.M., Resident B's clinical record was reviewed. Resident B's diagnoses included, but were not limited to, Alzheimer's disease, unspecified dementia, and hypertension. The Admission MDS (Minimum Data Set) assessment, dated 3/22/22, indicated Resident B was severely cognitively impaired. On 3/30/22 at 10:45 A.M., Resident B's care plan was reviewed. The care plan indicated the resident was an elopement and wandering risk related to the Alzheimer's diagnoses and impaired safety awareness. The Progress Notes, included, but were not limited to: 3/16/22 at 7:20 P.M., Resident B did not remember where her room was but was leaving her room often just to find out what this is like over here. 3/17/22 at 6:20 A.M., Resident B was noted as pleasant and confused walking around in circles in her room and out in the hallway looking for the bathroom or the bed. 3/19/22 at 3:15 P.M., Resident B spent the day walking in the hallway and asked continually to go to the Monastery; she was noted to be difficult to redirect and was still pleasant and cooperative but determined to get to Monastery today. 3/21/22 at 5:08 P.M.(time stamped prior to the incident), The resident eloped from the facility for 22 minutes. She returned to the Monastery from the facility at 5:30 P.M. Staff was unaware that she left. The resident's POA (Power of Attorney) returned the resident to the facility at 5:52 P.M. During an interview on 3/30/22 at 2:30 P.M., the Administrator indicated that on the early evening of 3/21/22, Resident B left the dining room and approached an elevator that required a keypad code. A staff member coming up from the ground floor, the only other floor that elevator goes to, left the area before the elevator doors closed and Resident B got on the elevator. Resident B went down to the ground floor and out the back employee entrance. Resident B then walked to the Monastery across the grounds and rang the front doorbell where she was recognized and brought back to the facility. The Administrator indicated Resident B was a staff member for years in the dietary area located downstairs and lived at the nearby Monastery on the grounds of the facility until very recently. During an observation on 3/30/22 at 2:45 P.M., the Monastery was approximately a football field length away from the facility door Resident B exited from. The two buildings were connected by a low traffic facility service road. On 3/29/22 at 8:30 A.M., the Administrator provided an undated facility policy titled Policy and Procedure for Missing Resident and indicated it was the policy currently in use. The policy included safeguards to mitigate the risk of a missing resident. This Federal tag relates to Complaint IN00375987. 3.1-45(a)(2)