Every finding on record at Heritage House Rehabilitation & Health Care Center

Bases on interview and record review, the facility failed to honor resident's choice of schedules related to morning showers for 1 of 6 residents reviewed for Self Determination. (Resident 62)Findings include:The clinical record for Resident 62 was reviewed on 01/22/2026 on 10:10 AM. The resident's diagnoses included, but were not limited to, Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroyed memory, thinking skills, and eventually the ability to carry out simple tasks) and depression. A Quarterly Minimum Data Set Assessment, dated 11/18/2025, indicated Resident 62 was not cognitively intact and needed substantial to maximal assistance with personal hygiene. An activities of daily living care plan, date 11/01/2018 and reviewed on 1/22/2026, indicated for Resident 62 was to be offered showers twice per week with partial baths in between. A preference assessment, dated 11/19/2025, indicated it was very important for Resident 62 to have bathing preferences met. Resident 62 preferred to have a shower twice a week in the mornings. During an interview and observation, on 1/20/2026 at 1:36 PM, with Family Member 2 and Resident 62, the family member indicated he did not believe the resident received her showers in the mornings like she should have based on her preferences. Review of shower sheets, dated 11/22/2025 through 1/17/2026, indicated Resident 62 received 11 showers in the evening and 7 without a timeframe assigned to indicated what time of day. A policy entitled, Preferences for Daily Routine, was provided by the Executive Director on 1/23/2026 at 7:21 PM. The policy indicated, .The information from the worksheet will be shared with the interdisciplinary team so that each department can address the resident's preferences .3.1-3(u)(1)

Based on observation, interview, and record review, the facility failed to accurately assess a resident's oral status for 1 of 2 residents reviewed for dental status and services. (Resident 66)Findings include:The clinical record for Resident 66 was reviewed on 1/20/26 at 1:20 p.m. The resident's diagnosis included, but was not limited to, dysphagia (difficulty or discomfort in swallowing).The Annual MDS (Minimum Data Set) assessment, dated 1/6/26, indicated the resident was cognitively intact. The resident had no dental conditions, including no obvious or likely cavity or broken natural teeth. An interview was conducted with Resident 66 on 1/20/26 at 1:23 p.m. The resident indicated she needed to see the dentist, because she had a bunch of bad, broken teeth. An observation and interview were conducted with Resident 66 on 1/22/26 at 12:51 p.m. The resident pointed to an upper tooth in the front of her mouth and indicated it was broken. She indicated the tooth did not hurt, but it was uncomfortable when she ran her tongue across it. Her tooth had been broken a good while. The tooth had became loose and fell into her mouth while she was eating two to three weeks ago. Some of the staff knew she lost the tooth. An interview with the Minimum Data Set Coordinator (MDSC) was conducted on 1/22/26 at 12:56 p.m. The MDSC indicated she completed the dental section of the Annual MDS assessment. Her process for completing the dental section of the MDS assessment was to have Resident 66 show her her oral cavity. An observation of Resident 66's oral cavity was made with the MDSC on 1/22/26 at 12:56 p.m. Resident 66 opened her mouth and indicated one of her top teeth was broken. The MDSC indicated this was what her mouth looked like, when she assessed it for the Annual MDS assessment dated [DATE]. The MDSC indicated she could modify the assessment to capture the broken tooth.

Based on observation, interview, and record review, the facility failed to provide residents' assistance with bathing related to Activities of Daily Living for 2 of 4 residents reviewed for ADL for Dependent Residents. (Resident 4 and Resident 10)Findings include:1. During an observation and interview with Resident 4 on 1/21/26 at 10:30 a.m., the resident indicated they could not remember the last time they received a shower or when their hair was washed last. During an observation the resident's hair appear shinny and oily. The clinical record for Resident 4 was reviewed on 1/21/2026 2:35 p.m. The resident's diagnosis included, but was not limited to, muscle weakness. The Quarterly Minimum Data Set (MDS) assessment, dated 12/4/25, indicated Resident 4's cognition was intact. The resident had bilateral impairment to both lower extremities. The resident used a walker/wheelchair for ambulation. A Preferences for Customary Routine and Activities document, dated 11/25/25, indicated Resident 4 chose to bathe at least twice per week in the a.m. and was preferred a shower. A plan of care, dated 3/5/25, indicated Resident 4 required assistance with all Activities of Daily Living (ADLs) related to not being able to care for self at home. The interventions included, but were not limited to, assist with bathing as needed per resident preference, offer showers two times per week, and assist with grooming/hygiene as needed. The shower sheets for Resident 4 were reviewed on 1/23/26 at 10:45 a.m. The resident received a shower on 1/9/26, and 1/21/26. Review of the Electronic Health Record (EHR) indicated Resident 4 received only partial bed baths, no showers for the dates of 1/10/26, 1/11/26, 1/13/26, 1/15/26, 1/17/26, 1/18/26, and 1/19/26. The shower sheets and EHR both indicated Resident 4 did had not received a shower or complete bed bath from 1/10/26 through 1/20/26. No refusals were documented for showers on the shower sheets or EHR. 2. The clinical record for Resident 10 was reviewed on 1/21/2026 1:40 p.m. The resident's diagnoses included, but were not limited to, rhabdomyolysis (rapid breakdown of damaged skeletal muscle, releasing harmful proteins and electrolytes in the blood) and acute respiratory failure. The admission Minimum Data (MDS) assessment, dated 1/11/26, indicated Resident 10 was cognitively intact, had no behaviors exhibited of refusals of care, and required substantial/maximal staff assistance with shower/bathing. During an observation and interview with Resident 10 on 1/20/26 at 2:11 p.m., the resident indicated they went three days with the same t-shirt on over the weekend and had only been to the shower room for a shower one time since admission on [DATE]. Resident 10 indicated someone had come into his room the day before and indicated someone would be in today, 1/20/26, to help him get cleaned up. The resident indicated no one had been in yet to offer to help him clean up and shower. The resident indicated he preferred showers. Resident 10 was observed with greasy, disheveled hair. A progress note, dated 1/21/26, indicated the resident preferred to shower on 1/22/26. During an interview with Resident 10 on 1/21/26 at 1:57 p.m., the resident indicated staff had washed them briefly. The staff washed his genital area (privates/crotch area), but he was not provided a washcloth to wash his face and did not go to the shower room as he had preferred. The EHR for Resident 10 indicated the resident only received one shower on 1/10/26. A complete bed bath was given on 1/14/26. No showers were documented as offered or refused from 1/14/26 through 1/20/26. A Preferences for Customary Routine and Activities document, dated 1/7/26, indicated Resident 10 preferred to shower twice per week in the a.m. During an interview, on 1/23/2026 at 2:06 p.m., the Executive Director indicated that it was the expectation of the facility to offer two showers (or bathing as preference) unless a resident's preference stated otherwise. The Shower Policy was provided by the Executive Director on 1/22/26 at 12:10 p.m. It indicated .4. Transport resident to shower room.11. Help resident shampoo and rinse hair.12. Assist with washing and rinsing entire body.12. Document procedure. 3.1-38(a)(3)

Based on interview, observation, and record review, the facility failed to identify a skin alteration (Resident 24), and failed to check placement of a resident's ear protectors for comfort/prevent skin breakdown (Resident 6) for 2 of 2 residents reviewed for quality of care. Findings include: 1. The clinical record for Resident 24 was reviewed on 01/23/2026 on 11:57 AM. The resident's diagnosis included, but was not limited to, dementia (a decline in mental abilities). A Quarterly Minimum Data Set Assessment, dated 12/18/2025, indicated Resident 24 was cognitively intact and needed sub to max assistance for personal hygiene. Review of Resident 24's shower records indicated on the following dates the resident received partial bed baths on 1/18/2026, in the evening; on 1/19/2026 in the morning and evening; and on 1/20/2026 in the morning. During an interview and observation, on 1/20/2026 at 12:05 PM, Resident 24 indicated a week or so ago she had went out of the facility with a family member. While she was out, she had a cigarette and sustained a burn to her middle and index fingers. Resident 24 then showed two areas of redness with a thick scab in the middle on the inside of each finger. During an interview, on 1/20/2026 at 1:30 PM, Executive Director confirmed she was unaware of the area to Resident 24's left hand. A nursing progress note, dated 1/20/2026, indicated Noted scabs to left 1st and 2nd finger. Resident reports it is from cigarette burn while out with family member. The resident's clinical record lacked documentation related to the resident's left 1st and 2nd finger prior to 1/20/26. A policy entitled, Bed Bath, was provided by the Executive Director on 1/23/2026 at 7:31 PM. the policy indicated .Wash, rinse, and pat dry shoulder, underarm, arm, hand, and fingers . and to .Report any unusual findings to charge nurse . 2. The clinical record for Resident 6 was reviewed on 1/20/26 at 1:00 p.m. The resident's diagnoses included, but were not limited to, chronic respiratory failure and chronic obstructive pulmonary disease (a progressive lung condition characterized by long-term airflow obstruction, making it hard to breath). The current at risk for skin breakdown care plan, starting on 8/29/17 and last revised 1/22/26, indicated an approach was preventive treatment as ordered. The physician's order indicated staff were to administer oxygen at three liters per nasal cannula twice a day, starting 10/12/25, and ear protectors (cushioned ear protectors designed specifically for oxygen tubing to protect the skin during oxygen therapy) were to be placed on the oxygen tubing with special instructions to check placement every shift, starting 10/12/25. An observation and interview was conducted with Resident 6 on 1/20/26 at 1:12 p.m. The resident was receiving oxygen per nasal cannula, but the oxygen tubing lacked ear protectors. The resident indicated her ears felt better when she was wearing the ear protectors. An observation and interview were conducted with Resident 6 on 1/22/26 at 2:23 p.m. The resident was lying in bed receiving oxygen per nasal cannula, the oxygen tubing lacked ear protectors. Resident 6 indicated she wanted some ear protectors, because it was more comfortable for her to wear them. The January, 2026 treatment administration record (TAR) was reviewed on 1/22/26 at 2:23 p.m. The TAR indicated Registered Nurse (RN) 3 had already signed off on checking the placement of Resident 6's ear protectors on 1/22/26 for the first shift, 7:00 a.m. to 7:00 p.m. An interview was conducted with RN 3 on 1/22/26 at 2:24 p.m. She indicated Resident 6 fiddled with her oxygen tubing sometimes and the ear protectors would come off. She did not verify the placement of Resident 6's ear protectors when she signed off on the TAR today. An observation of Resident 6 was made on 1/22/26 at 2:28 p.m., after RN 3 retrieved the ear protectors from the medication supply room. RN 3 applied the ear protectors to Resident 6's oxygen tubing. Resident 6 was receptive to having them applied. The Skin Management Program policy was provided by the ED (Executive Director) on 1/22/26 at 12:10 p.m. It indicated, It is the policy of [name of facility] to ensure that each resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable.PROCEDURE FOR ALTERATIONS IN SKIN INTEGRITY – PRESSURE AND NON-PRESSURE 1. Alterations in skin integrity will be reported to the MD/NP [Nurse Practitioner,] the resident and/or resident representative as well as to the direct care staff. 2. Treatment order will be obtained from MD/NP.4. All newly identified areas after admission will be documented on the New Skin Event.6. A plan of care will be initiated to include resident specific risk factors and contributing factors with appropriate interventions implemented. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to timely address a resident's missing bottom denture, as care planned, for 1 of 2 residents reviewed for dental status and services. (Resident 6) Findings include: The clinical record for Resident 6 was reviewed on 1/20/26 at 1:00 p.m. The resident's diagnosis included, but was not limited to, edentulous (having no teeth). An observation and interview was conducted with Resident 6 on 1/20/26 at 1:10 p.m. The resident was wearing an upper denture, but no bottom denture was present. The resident indicated she did not have bottom dentures, but she would like some. She hadn't seen a dentist. The current care plan, dated 8/16/24 last reviewed 11/11/25, indicated the problem was that Resident 6 reported throwing away her bottom denture, because the denture did not fit. An approach was for staff to monitor her eating and to get her set up with dental care, starting 8/16/24. The resident's clinical record lacked a dental consultation scheduled after the care plan intervention on 8/16/24. An interview was conducted with the Social Services Director (SSD) on 1/22/26 at 2:40 p.m. The SSD indicated she was responsible for setting up dental appointments for the residents. She reviewed Resident 6's clinical record and indicated she was only enrolled in podiatry services. She did not see any dental notes or a dental consent on file for Resident 6. She was unsure of how things were handled prior to April, 2025, when she began working at the facility. The facility was unable to provide any verification dental care was provided related to addressing Resident 6's missing bottom dentures. The Dental Services/Missing Dentures policy was provided by the ED (Executive Director) on 1/23/26 at 9:05 a.m. It indicated, The facility will assist with providing services to replace lost or damaged dentures regardless of responsibility. The facility will assist in scheduling and transporting residents to dental appointments as needed. 3.1-24(a)(3)3.1-24(b)

Based on observation, interview, and record review, the facility failed to assist dependent residents with dressing, personal hygiene, eating, and applying heel guards for 3 of 6 residents reviewed for Activities of Daily Living (ADL) assistance (Resident K, Resident G and Resident Q). Findings include: 1. During an observation and interview with Resident K's family member on 1/22/25 at 12:13 p.m., they indicated the resident had several bras in the drawer and the family had asked the facility, multiple times, to put a bra on the resident. Resident K had always been particular about wearing a bra. Resident K's family member indicated the facility was not brushing the resident's hair either. The resident had a doctor's appointment earlier in the week and the family met her at the appointment. The resident's hair was not combed when at the appointment. The family member indicated they had talked to the Social Service Director (SSD) about the staff not combing her hair and not putting a bra on her and it had improved for a few days, and then they stopped doing it again. The family member indicated it was very important to the resident for these things to be done. An observation at the time of the interview indicated Resident K's hair was not combed and she did not have a bra on. During an observation on 1/23/25 at 11:00 a.m., Resident K was dressed, she did not have a bra on, and her hair was not brushed. During an observation on 1/24/25 at 11:23 a.m., Resident K was in therapy with two other residents. Resident K did not have a bra on, and her hair was not brushed. During an observation and interview with Resident K on 1/24/25 at 11:55 a.m., the resident pulled her shirt down and indicated she did not have a bra on. Resident K indicated she wanted to wear a bra, but they said they do not wear them here. They are the boss. During an interview with the SSD on 1/24/25 at 12:48 p.m., they indicated Resident K's family reported to her, in December 2024, that it was important to the resident to wear and bra and have her hair combed. The SSD indicated she did talk with the staff about the importance of putting a bra on the resident and combing her hair. It was the responsibility of the Certified Nurse Aides (CNA's) and nurses to ensure these were completed for the resident. During an observation and interview with the SSD on 1/24/25 at 12:54 p.m., they verified Resident K did not have a bra on and her hair was not brushed. The SSD requested approval from the resident to look in her drawer for a bra and the resident agreed. The resident had three bras in her drawer. The clinical record for Resident K was reviewed on 1/23/25 at 11:48 a.m. The diagnoses included, but were not limited to, left femur fracture, osteoporosis, dementia, major depressive disorder, and muscle weakness. The plan of care for Resident K, dated 12/4/24, indicated the resident required assistance with ADL care. The resident had functional changes and weakness. The interventions included, but were not limited to, assisting with dressing and grooming. The Significant Change Minimum Data Set (MDS) assessment for Resident K, dated 1/14/25, indicated the resident was moderately impaired for daily decision making. The resident did not exhibit behaviors that included rejection of care. It was somewhat important to choose what clothes to wear. The resident required partial to moderate assistance with upper body dressing and substantial to maximal assistance with personal hygiene, including combing hair. 30344 2. The clinical record for Resident G was reviewed on 1/22/25 at 11:00 a.m. Her diagnoses included, but were not limited to, dementia and chronic kidney disease. The 12/24/24 Quarterly MDS assessment indicated she was dependent on staff for putting on and taking off footwear. The physician's orders indicated heel guards to bilateral feet at all times, starting 5/11/24. The at risk for skin breakdown care plan indicated she had an inability to care for herself and was unaware of her needs. The goal was for her to be free from skin breakdown. An intervention was heel guards to bilateral lower extremities at all times, starting 6/24/24. An observation of Resident G was conducted on 1/22/25 at 11:09 a.m. She was sitting in her wheelchair in the dining room. She was not wearing heel guards. An observation of Resident G was conducted on 1/24/25 at 12:33 p.m. She was sitting in her wheelchair in the dining room. She was not wearing heel guards. An observation of Resident G was conducted, on 1/27/25 at 11:31 a.m., with Licensed Practical Nurse (LPN) 4. She was sitting in her wheelchair in the dining room. She was not wearing heel guards. An observation of Resident G's room was conducted with LPN 4 on 1/27/25 at 11:34 a.m. LPN 4 looked in Resident G's closet and drawers for heel guards but was unable to locate any. An observation of the clean linen room was conducted, and an interview was conducted with the Assistant Director of Nursing (ADON), on 1/27/25 at 11:39 a.m., to look for heel guards. The ADON located a plastic bag, containing heel guards, in the room. The ADON removed a pair and handed them to LPN 4 for her to apply to Resident G. The Skin Management Program policy was provided by the Director of Nursing (DON) on 1/27/25 at 12:45 p.m. It indicated, Interventions to prevent wounds from developing and/or promote healing will be initiated based upon the individual's risk factors to include but not limited to the following .Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.) . 45291 3. The clinical record for Resident Q was reviewed on 1/24/2025 at 1:45 p.m. The medical diagnoses included dementia and pain. An Annual Minimum Data Set assessment, dated 1/9/2025, indicated Resident Q was cognitively impaired and needed partial to moderate assistance with the daily activity of eating. A care plan, last revised 5/30/2024, indicated to assist Resident Q with eating as needed. During an observation on 1/24/2025 at 12:21 p.m., Resident Q was sitting at a table in the dining room with a plate of pureed food. Resident Q was using her fingers to feed herself without staff at the table with her. An interview conducted with CNA 2, on 1/24/2025 at 12:45 p.m., indicated Resident Q often needed assistance with eating and will sometimes eat with her fingers. An interview conducted with CNA 3, on 1/24/2025 at 1:30 p.m., indicated Resident Q needed assistance with eating and has been noted to eat with her fingers. An interview conducted with the Administrator, on 1/27/2025 at 1:00 p.m., indicated the facility did not have a policy for assisting residents with eating. The expectation of the facility was that staff would ensure residents' hands were clean, the diet was as ordered, set up the meal for the resident, and then assist the resident with the meal as needed. Once assistance was initiated, staff would stay at the table with residents through the meal. A policy entitled, AM [morning] Care, was provided by the Director of Nursing on 1/27/2025 at 10:45 a.m. The policy indicated for staff to assist with dressing, as well as combing and styling a resident's hair as preferred. This citation relates to Complaints IN00450713 and IN00451373. 3.1-38(a)(2)(A) 3.1-38(a)(2)(D) 3.1-38(a)(3)(A) 3.1-39(a)(3)(B)

Based on interview and record review, the facility failed to ensure effective pain management was provided for a newly admitted resident who experienced pain for 1 of 3 residents reviewed for pain medication administration. (Resident D) Findings include: A hospital discharge summary for Resident D, dated 12/31/24, provided by the Director of Nursing (DON) on 1/27/25 at 1:25 p.m., indicated Resident D was ordered Dilaudid 4 mg (milligram) tablet by mouth every four hours as needed for pain. An Epic Care Link provided by the DON, on 1/27/25 at 2:30 p.m., indicated Resident D was administered Dilaudid 4 mg by mouth, at 3:22 p.m., while at the hospital before arrival to the facility. The clinical record for Resident D was reviewed on 1/27/25 at 12:13 p.m. The diagnoses included, but were not limited to, amputation of right foot and toes, diabetes mellitus type 2, and diabetic neuropathy. Resident D was admitted to the facility, on 12/31/24 at 5:30 p.m., from the hospital. The admission physician order for Resident D, dated 12/31/24, indicated the resident was ordered Dilaudid 4 mg every four hours as needed. The admission assessment for Resident D, dated 12/31/24 at 8:17 p.m., indicated Resident D verbalized experiencing pain rated 10 out of 10 on the pain scale. Per the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.19.1 published by the Centers for Medicare and Medicaid Services, the numeric pain scale indicated 0 being no pain and 10 as the worst pain one could imagine. This indicated a 10 would be concurrent with very severe or horrible pain. Pain was recorded as almost constantly, sharp, shooting, and stabbing, and analgesic therapy made it better. Resident D was documented as being alert and oriented to person, place, time, and situation. There was no documentation in the EHR to indicate follow up after Resident D expressed being in pain rated 10 out of 10 on 12/31/24 at 8:17 p.m. A progress note in the Electronic Health Record (EHR), dated 12/31/24 at 11:19 p.m., indicated the following, .resident [Resident D] became very anxious, asking aide to get him out of bed because he felt too confined in room .was on the phone saying he didn't think he was able to stay here d/t [due to] this and being unable to sleep The Medication Administration Record (MAR), dated 1/1/25 at 1:10 a.m., indicated Resident D was experiencing pain and received Dilaudid 4 mg. This documentation indicated Resident D was experiencing pain from 8:17 p.m. on 12/31/24, until 1:10 a.m. on 1/1/25, (4 hours and 53 minutes). The MAR, progress notes, and assessments for Resident D, dated 12/31/24 until 1/1/25, did not indicate any documentation of implementation of any non-pharmacological pain interventions. A care plan for Resident D, dated 1/2/25, indicated they were at risk for pain related to recent surgical procedure, functional changes, and neuropathy. Resident would be free from adverse effects of pain, and administer medications as ordered. Also, to observe for non-physical signs of pain, i.e. vocalizations and mood/behavior changes. During an interview on 1/27/25 at 12:44 p.m., Resident D indicated he did not receive any pain medications for over six hours after arriving at the facility. He had a pain level of 10 out of 10. During an interview with the Regional Director of Clinical Support (RDCS) and DON on 1/27/25 at 2:00 p.m., they indicated Resident D had an admission assessment completed at 8:20 p.m. After he had voiced his pain level, he was offered Tylenol because the facility did not have Dilaudid 4 mg tablets in the Emergency Drug Kit (EDK). Resident D refused the Tylenol, so at 8:30 p.m., a STAT (without delay) order was placed to the pharmacy. The DON indicated it usually takes four hours for emergent deliveries. The DON indicated there was a problem getting the medications timely from the pharmacy. The DON indicated the facility did not have any documentation of when the pharmacy was contacted, nor that Tylenol was offered or refused by Resident D. Resident D's clinical record indicated there were no physician orders for Tylenol inputted until 1/7/25. A Pain Management Policy was provided by the Executive Director (ED) on 1/27/25 at 1:55 p.m. The policy indicated the following, . It is the policy of [name of corporation] to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, including pain management .Pain medications will be prescribed and given based upon the intensity of the pain This citation relates to Complaints IN00451373 and IN00450713. 3.1-37(a)

Based on interview, observation, and record review, the facility failed to assist a dependent resident (Resident 26) with nail care for 1 of 4 residents reviewed for activities of daily living. Findings include: The clinical record for Resident 26 was reviewed on 11/15/2023 at 1:25 p.m. The medical diagnoses included dementia and stroke. The Admission Minimum Data Set Assessment, dated for 9/20/2023, indicated that Resident 26 was cognitively impaired, did not exhibit behaviors or reject care, and needed substantial assistance with self-care activities of daily living. An observation on 11/13/2023 at 12:48 p.m. indicated Resident 26 had moderately long uneven fingernails with light brown debris under his nails. An observation on 11/15/2023 at 12:30 p.m. indicated that he had moderately long uneven fingernails with light brown debris under his nails. An interview with the DON on 11/16/2023 at 2:00 p.m. indicated that nursing staff are to keep nails trimmed and clean. Routinely nail care is to be provided to the residents with showers, during activities on Fridays, and as needed. A skills checkoff, provided by the DON on 11/17/2023 at 10:00 a.m., indicated .Clean under nails with orange stick. Clip fingernails straight across, then file in a curve . 3.1-38(a)(3)(E)

Based on observation, interview and record review, the facility failed to ensure a staff member's bare hands did not come into contact with a resident's medication during a medication administration observation for 1 of 3 medication administration observations and 1 of 3 staff administering medications. (LPN 3 and Resident 74) Findings include: On 11/15/23, at 9:14 a.m., LPN 3 was observed removing pills from a medication card, into her bare hands, and then placed them in a medication cup. She indicated the medications were for Resident 74 and he was receiving 8 pills but she would hold his lisinopril for blood pressure if his blood pressure was too low. On 11/17/23, at 9:40 a.m., the Director of Nursing indicated staff know not to do that; touch pills with their bare hands. On 11/17/23, at 12:21 p.m., the Administrator provided a Policy for Medication Pass Procedure. The policy indicated, but was not limited to, Procedure Steps .3. Medications are opened without contaminating 3.1-48(c)(2)

Based on observation, interview, and record review, the facility failed to ensure one dietary staff member's hair was appropriately covered, failed to ensure a range hood was clean, and failed to ensure an area of floor was clean. This had the potential to affect all 90 residents who resided in the facility. Findings include: A dietary observation, on 9/22/22 at 10:32 a.m., indicated, on the floor beside the wall, on the right of the walk in freezer door, a 6 inch by 3 inch area had a buildup of dark brown debris with white particles on top of it. The inside of the range hood, above the range and steam table, had rust colored areas on the galvanized steel. A sticker on the outside corner of the range hood indicated the range hood was last cleaned on 4/6/22. Culinary Aide 7, who was preparing beverages, had long hair in braids and did not have her hair covered. Cook 9 indicated she wasn't sure of the policy for wearing hair covering for synthetic hair. On 9/22/22 at 12:43 p.m., the Dietary Manager indicated he didn't know if the hood vent was rusty, and there was no debris falling from it. He said the area beside the freezer door was caused by a build up of moisture from the freezer being so cold because it was along the wall by the freezer and it would be deep cleaned. Culinary Aide 7 was working and did not have her hair covered. When queried about hair covering, Culinary Aide 7 said they told her to wear a hair net and she tried to wear it but it slides off. The Dietary Manager said he would find out from the Dietitian what the policy was for synthetic hair covering. On 9/22/22 at 1:18 p.m., the Maintenance Supervisor said when the range hood vent was cleaned in April, it had been steam cleaned and it is due to be cleaned in October. He said he rubbed the rust colored areas of the vent and nothing came off of it. A policy for Dietary Personal Hygiene was provided by the Administrator on 9/22/22 at 1:57 p.m. The policy included, but was not limited to: Policy: Employees will maintain good personal hygiene to prevent food contamination .3. Personal Cleanliness. a. Wear a clean hat and/or other hair restraint 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview and record review the facility failed to implement fall interventions for residents who were at high risk for falls for 2 of 5 residents reviewed for accidents (Resident 22 and Resident 33). Findings include: 1.) During an observation and interview 9/21/22 at 10:00 a.m., CNA 5 and CNA 6 lifted Resident 22 underneath her arms and transferred her from the bed to the wheelchair without utilizing a gait belt. Resident 22 was minimally able to assist with the transfer. When queried why a gait belt was not used, CNA 5 indicated there was usually a gait belt in each of the resident's room, but Resident 22 did not have one in her room. Review of the record of Resident 22 on 9/21/22 at 1:00 p.m., indicated the resident's diagnoses included, but were not limited to, [CONDITION(S)], dementia, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, chronic kidney disease, major depressive disorder, unsteadiness on feet, lack of coordination and muscle weakness. The Admission Minimum Data (MDS) for Resident 22, dated 4/13/22, indicated the resident required extensive assistance of two staff for transfers. The plan of care for Resident 22, dated 7/13/22, indicated the resident required assistance with ADL's including bed mobility, transfers, eating and toileting related to inability to care for self, [CONDITION(S)], inability to walk, dementia, [CONDITION(S)]. The interventions included, but were not limited to, assist with transfers x's 2 people. The fall risk assessment for Resident 22, dated 7/13/22, indicated the resident was at high risk for falls. 2. The clinical record for Resident 33 was reviewed on 9/19/2022 at 1:52 p.m. The medical diagnoses included, but were not limited to, muscle weakness and age-related [CONDITION(S)]. A Significant Change in Condition Assessment completed on 7/24/2022 indicated Resident 33 needed assistance of two staff members for transferring tasks, was only able to stabilize during transfers with staff assistance, and had no falls during the review period. A fall risk assessment completed on 7/21/2022 indicated Resident 33 was a high risk for falls. A fall care plan, reviewed on 8/3/2022, indicated for Resident 33 to be assisted to bed or recliner following meals. An observation on 9/19/2022 at 1:32 p.m. indicated Resident 33 sitting in her wheelchair to the side of her bed. An observation on 9/21/2022 at 1:05 p.m. indicated Resident 33 sitting in her wheelchair to the side of her bed. An observation on 9/21/22 at 10:20 a.m. indicated Resident 33 sitting in her wheelchair to the side of her bed. An interview with the Director of Nursing on 9/22/2022 at 11:12 a.m. indicated that the care plan indicated to assist Resident 33 back to bed or in the recliner needed to be updated. She indicated that Resident 33's preference was to be in her wheelchair, but right after admission it was the family's preference to have the resident lay down or back to the recliner after meals. A policy entitled, Fall Management Policy, was provided by the Director of Nursing on 9/22/2022 at 10:05 a.m. The policy indicated, .A care plan will be developed at the time of admission with specific care plan intervention to address each resident's fall risk factors. Care plan including interventions and fall risks will be reviewed at least quarterly . A policy entitled, TRANSFER TO WHEELCHAIR, was provided by the Director of Nursing on 9/22/2022 at 10:05 a.m. The policy indicated, .Place gait belt around resident's waist . 3.1-45(a)(2)

Based on observation and interview, the facility failed to ensure the area around the dumpsters was free of debris for one of one observation. This had the potential to affect all 90 residents who resided in the facility. Findings include: On 9/22/22 at 12:55 p.m., the fenced in dumpster area was observed with the Dietary Manager. He unlocked the gate and four covered dumpsters were observed. Around the dumpsters was debris that included, spoons, styrofoam cups, paper towel rolls, masks, gloves, cup lids, clear plastic bags, clear plastic cups, papers, an empty odor eliminator bottle, a wooden pallet, used depends, and broken glass. The Dietary Manager indicated housekeeping was responsible to keep the area clean. On 9/22/22 at 1:14 p.m., the Administrator said their trash service just picked up the trash today; when they come and do the trash, some of it falls out and they don't pick it up. 3.1-21(i)(5)

Based on observation, interview and record review the facility failed to complete proper hand washing and change of gloves during incontinent care for 1 of 3 observation of incontinent care (Resident 22). Finding include: During an observation and interview 9/21/22 at 10:00 a.m., CNA 5 and CNA 6 provided incontinent care for Resident 22. Resident 22 was incontinent of her bowels and bladder. CNA 5 was observed touching both curtains and top of cabinet with soiled gloves searching for a incontinent brief. CNA 5 picked up the soiled linen and soiled trash and left the resident's room touching the door knob with soiled gloves. When queried about not removing soiled gloves and performing handwashing prior to touching surfaces, CNA 5 indicated she normally would have all her supplies gathered prior to providing care so she would not leave the resident's bedside and avoid potentially contaminating surfaces with soiled gloves. Review of the record of Resident 22 on 9/21/22 at 1:00 p.m., indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data (MDS) for Resident 22, dated 4/13/22, indicated the resident is frequently incontinent of bowels and bladder. The incontinent care policy provided by the Director Of Nursing (DON) on 9/22/22 at 11:05 a.m., indicated after providing incontinent care to remove gloves and wash hands. Do not leave the resident room. 3.1-18(a)

Based on observation, interview and record review the facility failed to complete COVID-19 testing for three staff (CNA 1, CNA 3 and CNA 4) working the memory care unit, 11 of 11 residents reviewed for COVID-19 protocol on the memory care unit contracted COVID-19 (Resident Resident C, Resident D, Resident H, Resident I, Resident J, Resident K, Resident L, Resident M, Resident N, Resident N, Resident O and Resident P), this had the potential to affect 21 of 21 residents residing on the memory care unit. Finding include: During an infection control observation tour with the Infection Control Nurse on 11/29/21 at 12:00 p.m., the memory care unit had two double doors locked with a key pad, there was a sign indicating to see the nurse before entering. The Infection Control nurse indicated the memory care unit had 11 residents that were COVID-19 positive. During an interview with the Infection Control Nurse on 11/29/21 at 12:40 p.m., indicated CNA 1 tested positive for COVID-19 on 11/26/21 and had not been fully vaccinated for COVID-19. CNA 1 worked on the memory care unit. CNA 3 tested positive for COVID-19 on 11/28/21 and had not been vaccinated for COVID-19, CNA 3 worked on the memory care unit. CNA 4 tested positive for COVID-19 on 11/28/21 and had not been vaccinated for COVID-19, CNA 4 worked on the memory care unit. During an interview with the Infection Control on 11/29/21 at 3:10 p.m., the county that the facility resided in a county that had been in high (red) positivity rate/community transmission rate for the month November 2021. The facility required that when the positivity rate was high unvaccinated staff were required to have a COVID-19 test twice a week. The facility began outbreak testing for COVID-19 on 11/18/21 and fully vaccinated and unvaccinated facility staff were required to test twice a week. The Infection Control Nurse indicated she was responsible to obtain the facility staff's COVID-19 test and if she was not available there were test kits at the nursing station for the staff to complete their own test. The method that she alerts staff that they need to be tested was she placed a sign at the time clock and sent out a mass text message. The facility staff did not always comply with the mandated testing. The facility policy is that if staff do not comply with the COVID-19 testing they were not suppose to work, but the facility was not enforcing this due to low staffing. The Infection Control Nurse indicated she had reported the facility staff's noncompliance to the Administrator and the issue had not been addressed. During an interview with the Infection Control Nurse on 11/29/21 at 3:25 p.m., indicated CNA 1 tested negative for COVID-19 on 11/5/21 and 11/19/21 in the Month of November 2021. CNA 3 tested negative for COVID-19 on 11/3/21 and 11/11/21 in the Month of November 2021. CNA 4 tested negative for COVID-19 on 11/3/21, 11/17/21, 11/22/21 and 11/24/21 for the Month of November 2021. This indicated CNA 1, CNA 3 and CNA 4 did not complete COVID-19 testing twice week in November 2021 as mandated by the facility. Review of the record of Resident C on 11/29/21 at 12:50 p.m., indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident resided on the memory care unit. Review of the record of Resident D on 11/29/21 at 1:00 p.m., indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident resided on the memory care unit. Review of the record of Resident H on 11/30/21 at 11:48 a.m., indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident resided on the memory care unit. Review of the record of Resident I on 11/30/21 at 11:52 a.m., indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident resided on the memory care unit. Review of the record of Resident J on 11/30/21 at 11:55 a.m., indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident resided on the memory care unit. Review of the record of Resident K on 11/30/21 at 12:04 p.m., indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident resided on the memory care unit. Review of the record of Resident L on 11/30/21 at 12:10 p.m., indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident resided on the memory care unit. Review of the record of Resident M on 11/30/21 at 12:11 p.m., indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident resided on the memory care unit. Review of the record of Resident N on 11/30/21 at 12:14 p.m., indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident resided on the memory care unit. Review of the record of Resident P on 11/30/21 at 12:18 p.m., indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident resided on the memory care unit. Review of the record of Resident O on 11/30/21 at 12:19 p.m., indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident resided on the memory care unit. During an interview with the Infection Control Nurse on 11/30/21 at 2:05 p.m., indicated the facility staff had not been complying with the facilities mandated COVID-19 for a few and she had reported the issue to the former Administrator at the facility. The COVID-19 employee testing policy provided by the Administrator in training on 11/30/21 at 10:33 a.m., indicated All unvaccinated staff are required to test two times a week when the county positivity rate is above 10%. Any employee who refuses to test will be removed from work and will be given an opportunity to agree to testing. Failure to test will be considered a violation of company policy and failing to meet the terms of employment and considered a voluntary termination, without notice. Unvaccinated staff were to be tested twice a week when the county was in high community transmission. 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed during the COVID-19 pandemic related to the improper use of Personal Protective Equipment (PPE) and hand hygiene prior to exiting resident rooms on droplet precautions for 2 of 4 residents (C and B) and 3 of 6 staff (ADON, QMA 2, and Maintenance Supervisor) Findings include: 1. An observation was made of the 300 hall on 9/3/20 at 12:22 p.m. The Director of Nursing (DON), Assistant Director of Nursing (ADON) and Infection Preventionist (IP) were observed in the 300 hall obtaining specimens from the residents to test for COVID-19. a. The ADON donned on PPE and was observed entering Resident D's room. She then exited the room with her PPE on. She walked out of the resident's room and was swirling the collection swab around in the open collection tube. After concealing the specimen at the bedside table in the hallway, the ADON doffed her gloves and used hand hygiene. The ADON donned new gloves and entered Resident C's room. After collection of the specimen, the ADON exited the resident's room wearing all her PPE and returned back to the bedside table in the hallway. As she walked in the hallway to a bedside table, she was swirling the collection swab around in the open collection tube. At the bedside table she doffed her gloves and used hand hygiene. b. The ADON donned on new set of gloves and entered Resident B's room. She then exited the resident's room and walked down the hall towards the bedside table. As she walked down the hall she was swirling the swab in the open collection tube. She doffed her gloves and used hand hygiene at the bedside table. During an interview with the ADON, on 9/3/20 at 9:41 a.m., she indicated she was testing the whole 300 hall for COVID and placed the residents in droplet precautions due to potential exposure to COVID. She had obtained the COVID specimens in the resident's room. The swabs had to be swirled in the vial 10 times and then placed in a white container in an upward position that she placed in the hallway. She indicated a positive resident had resided on 300 hall and due to possible exposure the whole hall was being tested . 2. An observation, on 9/3/20 at 12:28 p.m., Qualified Nursing Aide (QMA) 2 was observed at the medication cart pulling resident E's medications. She then donned PPE and entered Resident E's room. The QMA 2 left the resident's room with her PPE still on and walked back to the medication cart. The QMA removed her PPE and discarded the PPE in a trash can that was attached to the side of the medication cart. During an interview with QMA 2, on 9/3/20 at 12:28 p.m., she indicated she was told to remove her PPE in the hallway and not in the residents' room. 3. An observation, on 9/3/20 at 12:29 p.m., the Maintenance Supervisor (MS) was observed donning on PPE beside the medication cart and walked down the 300 Hall and entered a resident's room. He then exited the resident's room and walked back down the hall to the medication cart. While he was standing at the medication cart the MS removed his PPE and placed the items in the trash can attached to the side of the medication cart. The residents' test results were provided by the Executive Director on 9/3/20 at 2:18 p.m. The testing log indicated 8 of 19 residents on the 300 hall were positive with COVID 19. There were no observations of staff removal of gloves and utilizing hand hygiene prior to exiting of the residents' rooms and walking down the hallway. The Standard and Transmission-Based Precautions (Isolation) policy reviewed dated 7/2020, indicated .Policy: The facility shall utilize the appropriate transmission-based precaution based on the means of transmission and the infectious agent or organism involved. The isolation precautions should be the least restrictive possible for the resident under the circumstances. Purpose: To implement appropriate transmission-based precautions to prevent the transmission of infection .Transmission-based precautions: refers to the actions (precautions) implemented, in addition to standard precautions, that are based upon the means of transmission (airborne, contact, and droplet) to prevent or control infections .Use of Personal Protective Equipment - Gown and Gloves: Applies to anyone entering the room who may touch the resident or objects in the room should wear PPE. Perform Hand Hygiene prior to entering the room and before leaving the room .PPE should be discarded prior to leaving the room and hand hygiene performed. Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room . Droplet Precautions: refers to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Use for resident(s) known or suspected to be infected with pathogens transmitted by respirator droplets that are produced when coughing, sneezing and/or talking. In addition to standard precautions the following should be included: 3.1-18(l)

Based on interview and record review the facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for preferences of activities and pain assessment for 1 of 22 residents reviewed for MDS accuracy (Resident 81). Finding include: During an interview with Resident 81 on 7/15/19 at 10:53 a.m., indicated she did not feel like the facility managed her pain well and did not offer activities of interest for her. During an interview with the MDS Coordinator 1 on 1/17/19 at 11:45 a.m., indicated an interview was not conducted for Resident 81's pain on her Significant Change MDS assessment completed on 4/11/19, because there had not been a pain assessment completed by the floor nurses during this look back period. The MDS Coordinator 1 indicated she was directed by her Resident Assessment Instrument (RIA) Specialist to complete this interview through looking at the Electronic Health Record (EHR) for a pain assessment completed by the floor nurse and not to verbally interview the resident about her pain. During an interview with the Activity Director on 7/17/19 at 2:48 p.m., indicated she did not complete an interview with Resident 81 regarding her preferences of activities on the Significant Change MDS completed on 4/11/19, because during that time the facility required her to perform other job duties besides activities and the assessment for activity preference was not completed. Review of the record of Resident 81 on 07/17/19 03:10 PM indicated the resident's [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) assessment for Resident 81, dated 4/11/19, indicated the resident was cognitively intact. The resident was reasonable and consistent with daily decision making. The activity preference assessment interview was not completed. The pain assessment portion indicated a pain assessment interview should be conducted, the pain assessment interview was blank. 3.1-31(b)

Based on record review and interview the facility failed to implement a care plan for an anticoagulant medication for 1 of 5 residents reviewed for medications, (Resident 23). Findings include: The record for Resident 23 was reviewed on 7/17/19 at 11:07 a.m. The [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Care plans reviewed and no care plan found for anti-coagulant. On 7/18/19 10:35 a.m., an interview with MDS 1 indicated, she could not find a care plan for the anti-coagulant. The IDT (interdisciplinary team) Comprehensive Care Plan Policy provided by the Director of Nursing on 7/19/19 at 9:47 a.m., indicated, Policy: It is the policy of this facility that each resident will have a comprehensive person-centered care plan developed based on comprehensive assessment. The care plan will include measurable goals and resident specific interventions based on resident needs and preferences to promote the residents highest level of functioning including medical, nursing, mental and psychosocial needs . 3.1-35(a) 3.1-35 (b)(1)

Based on observation, interview, and record review, the facility failed to keep a resident's fingernails clean for 1 of 1 resident reviewed for Activities of Daily Living (ADL's). (Resident 77) Findings include: Resident 77's record was reviewed on 7/18/19 at 11:15 a.m. His [DIAGNOSES REDACTED]. His Admission Minimum Data Set (MDS) assessment dated [DATE], indicated he required extensive assistance of 1 person for personal hygiene. A plan of care for Resident 77 initiated 5/2/19, indicated he required assistance with his ADL's. An approach indicated he would be assisted with dressing, grooming, and hygiene as needed. On 7/16/19 at 9:57 a.m., Resident 77 was observed lying in bed. He had a dark substance underneath all 10 fingernails and around his fingernail beds. An unidentified staff member stepped into his bedroom briefly and indicated she was going to give him a bed bath and would be back to complete that. He continued to be observed with a dark substance underneath all 10 fingernails and around his fingernail beds on 7/17/19 at 11:26 a.m., and 7/1819 at 9:49 a.m. During an interview with CNA 2 on 7/18/19 at 9:49 a.m., she indicated she had given Resident 77 a bed bath that morning. His fingernails needed cleaned and she would get an orange stick and supplies needed to clean his fingernails. A CNA Skills Validation procedure provided by the DON on 7/19/19 at 10:50 a.m., indicated the following: 7. Soak resident's hands and pat dry. 8. Put on gloves. 9. Clean under nails with orange stick 3.1-38(a)(3)(E)

Based on observation, interview and record review the facility failed to provide an ongoing activity program to meet the resident's interest for 1 of 2 residents reviewed for activities (Resident 81). Finding include: During an interview with Resident 81 on 7/15/19 at 10:44 a.m., indicated the facility did not offer an ongoing activity program that she was interested in. The resident indicated the facility did not offer enough activities for adults with sound minds at an adult level. The resident indicated activities were geared toward residents with dementia. The resident indicated she felt the activities were childish. Resident 81 indicated she was mentally and physically well and it was embarrassing for her to participate in most of the activities provided. The resident was observed to be watching TV in her room. During an interview with the Activity Director on 7/17/19 at 2:48 p.m., indicated she did not complete an interview with Resident 81 regarding her preferences of activities on the Significant Change Minimum Data Set (MDS) assessment completed on 4/11/19, because during that time the facility required her to perform other job duties besides activities and the assessment for activity preference was not completed. During an interview with the Activity Director on 7/17/19 at 3:03 p.m., indicated the activity assessment for residents was on the MDS assessment and there were no other assessments completed for residents activity preferences. Review of the record of Resident 81 on 07/17/19 03:10 PM indicated the resident's [DIAGNOSES REDACTED]. The plan of care for Resident 81, dated 1/18/19, indicated the resident enjoyed bingo, games, music and socials. The goal was the resident would participate in 8 activities per week. The interventions were as follows: give verbal reminders to activities of interest, provide assist to activities as needed, provide calendar for room and provided independent supplies for room as needed. The Significant Change Minimum Data Set (MDS) assessment for Resident 81, dated 4/11/19, indicated the resident was cognitively intact. The resident was reasonable and consistent with daily decision making. The activity preference assessment interview was not completed. Review of Resident 81's activities were as follows: (MONTH) 2019, the resident went to word games, birthday party, bingo four times, resident council and a movie, (MONTH) 2019, the resident went to crafts, glamour nails, wonders, pet fashion show, barn quilt presentation, jewelry party, word game, and bingo three times, (MONTH) 2019, the resident went to table talk, movie twice, birthday party, fathers day pie social, resident council, glamour nails, trivia, a lunch outing and bingo three times, (MONTH) 2019, the resident went to word puzzles, glamour nails twice, birthday party, the wanders, lunch outing and bingo twice. During an interview with Resident 81 on 7/18/19 at 9:45 a.m., indicated she would like the facility to provide more adult activities such as knitting, crocheting, euchre and 500 rummy. The resident indicated the facility had card games that were childish where you matched up cards by memory. The resident indicated the facility had not talked to her about her activity preferences. The resident indicated she had not thought about what activities she would like to do before because she did not know it was an option to have input in the activities offered. The resident indicated when she lived in a community prior to coming to the facility where she belonged to clubs that played cards and was very social. The resident was observed watching TV in her room at this time. The activity policy provided by the Director Of Nursing on 7/19/19 at 9:55 a.m., indicated the facility was to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident in accordance with the comprehensive assessment. 3.1-33(a)

Based on observation, interview, and record review, the facility failed to address significant weight loss and notify the physician for 2 of 3 residents reviewed for nutrition. (Resident 56 and 53)) Findings include: 1. Resident 56's record was reviewed on 7/17/19 at 9:55 a.m. Her [DIAGNOSES REDACTED]. Her Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated she required extensive assistance of 1 person for eating. A nutritional plan of care for Resident 56 initiated 6/12/18, indicated the physician and family would be notified of a significant weight change. Weight documentation indicated she weighed 135 pounds on 5/6/19, 120 pounds on 6/9/19, and 114 pounds on 7/5/19. These weights indicated a 11.11% weight difference from 5/6/19 to 6/9/19 and a 15.56% weight difference from 5/6/19 to 7/5/19. On 7/16/19 at 12:07 p.m., Resident 56 was observed being fed by staff in the assisted dining room. During an interview with the Dietary Manager on 7/17/19 at 11:08 a.m., she indicated she had just reviewed Resident 56's weights on 7/15/19. She had informed a nurse to notify the physician of Resident's significant weight loss on this date. 2. During an interview with Resident 53 on 7/15/19 at 1:30 p.m., indicated she had lost weight since being was admitted to the facility because she did not like the food they served her. During an observation on 7/16/19 at 12:17 p.m., Resident 53 was in the main dining room sitting by herself. The resident received the alternate meal of beef steak and mashed potatoes and gravy. The resident was feeding herself independently. The resident ate approximately 25 percent of her meal. During an interview with Resident 53 on 7/17/19 at 10:30 a.m., indicated the facility had not talked to her about her likes and dislikes of food. The resident indicated her favorite foods were fried chicken, macaroni cheese, cooked carrots, strawberry ice cream and butterscotch pudding. The resident indicated she did not like spinach or peas. The resident indicated her normal weight was 180 pounds. During an observation on 7/17/19 at 12:10 p.m., Resident 53 was sitting by herself in the main dining room. The resident was served a turkey and cheese sandwich and cucumber salad. The resident indicated she did not want the food and requested pudding. During an interview with the Dietary Manager on 7/17/19 at 11:12 a.m., indicated Resident 53 was not put on Nutrition at Risk (NAR) in (MONTH) 2019 when she had the 7.2 percent significant weight loss. The Dietary Manager indicated the resident had very low meal consumption and had declined since being admitted to the facility. The Dietary Manager indicated resident food preferences were documented on the residents tray cards. The Dietary Manager indicated the resident would be placed on NAR at this time. Review of the record of Resident 53 on 7/18/19 at 10:30 p.m., indicated the resident's [DIAGNOSES REDACTED]. The plan of care for Resident 53, dated 2/17/19, indicated the resident received a regular diet with thin liquids. Eats all meals in room per preference. Tolerates diet well with no chewing/swallowing issues. Prefers not to eat breakfast, only drinks fluids. 7/2019 165 lbs, overweight. Fluids were adequate. Had a poor appetite and will declined most times any supplements offered from staff. Showing a slow weight decline. Refused breakfast meal and only drinks fluids. The interventions were food/diet preference was coffee and orange juice, prefers not to eat breakfast, had many food dislikes, notify the physician of significant weight changes, offer substitute if 50% or less of any meal was consumed and regular diet with thin liquids. The plan of care documentation indicated no interventions were implemented since 2/17/19. The Significant Change Minimum Data Set (MDS) assessment for Resident 53, dated 5/29/19, indicated the resident was cognitively intact for daily decision making. The resident's decisions were reasonable and consistent. The resident required limited assistance of one person for eating. The (MONTH) 2019 Physician recapitulation (recap) for Resident 53, indicated the resident was ordered a regular diet. The resident was ordered ensure plus 120 milliliters (ml) four times a day on 6/5/19. The weights for Resident 53 were as follows: 2/18/19 - 182 pounds, 2/25/19- 180 pounds, 3/1/19- 180 pounds, 4/2/19-167 pounds, 5/6/19- 168 pounds, 5/24/19- 165 pounds, 6/9/19- 168 pounds and 7/7/19- 165 pounds. This indicated the resident had a 7.2 % weight loss in one month on 4/2/19 and an 8.3 % weight loss in three months on 5/24/19. The documentation indicated the resident was not weighed weekly. The meal ticket for Resident 53 provided by the Dietary Manager on 7/17/19 at 11:30 a.m., indicated the resident preferences were coffee, orange juice, milk and fruit punch low calorie. There were no food preferences listed. During an interview with the Dietary Manager on 7/18/19 at 10:00 a.m., indicated the physician was not notified of Resident 53's significant weight loss in (MONTH) 2019. The Dietary Manager indicated it was the responsibility of the Registered Dietician or the NAR team to notify the physician of significant weight loss. The Dietary Manager indicated Resident 53 should have been placed on NAR and monitored. There were no interventions implemented for the resident's significant weight loss or any other supplements attempted until 6/5/19 when the ensure supplement was added. The Interdisciplinary Team (IDT) were responsible to implement interventions for residents with significant weight loss. The resident weight monitoring policy provided by the Director Of Nursing (DON) on 7/17/19 at 11:30 a.m., indicated the interdisciplinary team (IDT) would review any resident who had weight or nutritional concerns. The IDT would complete weekly weights for residents who had experienced a significant weight loss of 5 % in 30 days, 7.5 % in 90 days or 10 % in 180 days. The physician would be notified of unplanned weight loss. 3.1-46

Based on interview and record review, the facility failed to ensure 1 of 3 residents reviewed for abuse was not mentally or verbally abused by a staff member who took away her doll, threw it onto the floor and told her it was dead, resulting in psychosocial distress to the resident. (Resident B) Findings include: Resident B's clinical record was reviewed on 12-27-16 at 10:59 a.m. It documented her [DIAGNOSES REDACTED]. Her most recent Minimum Data Set (MDS) assessment, dated 10-11-16, indicated she is significantly cognitively impaired. Resident B's care plans included, but was not limited to, a care plan, dated 8-17-16, and revised on 10-19-16, which reflected she has a baby doll that she will carry around the facility for which the staff are to provide to her when she is looking for it or when she is upset as it calms her. On 12-27-16 at 11:30 a.m., the Administrator provided copies of an Indiana State Department of Health (ISDH) Survey Report System document, also referred to as a State Reportable form, dated 8-20-16 and 8-25-16, in which Aide #1 took a doll from Resident B, drop it to the floor and tell the resident her baby doll was dead, resulting in Resident B being very upset and crying. This was preceded by Aide #1 announcing, Watch this. A written statement from CNA #2, dated 8-21-16, shared she had observed Resident B with her baby doll on 8-20-16 at 10:00 a.m. She reported, (Name of Aide #1) told myself and (names of Activity Staff #3 and CNA #5) to watch this, this is hilarious. She then took the doll from (name of Resident B) and then threw the doll on the floor and said look your baby is dead (sic). A written statement from Activity Staff #3, dated 8-21-16, relayed on 8-20-16 at 10:00 a.m., (Name of Aide #1) had walked up to (name of Resident B) in the dining room where (names of CNA #5 and CNA #2) and myself were standing. She proceed (sic) to ask (name of Resident B) for her doll, when (name of Resident B) handed it to her (name of Aide #1) looked at us and said, 'Watch this, it's hilarious.' She then dropped the baby (doll) on the ground and told (name of Resident B) it was dead .I grabbed the doll and gave it back to (name of Resident B), who was upset about it .I told (name of Aide #1) that what she did was not okay. (Name of Aide #1) continued to laugh about it. A written statement from CNA #5, dated 8-21-16, indicated on 8-20-16 at 10:00 a.m., that she, CNA #2 and Activity Staff #3 were in the dining room after breakfast. She shared, Aide #1 looked at us and asked if we wanted to see something hilarious. She then proceeded to laugh. She then asked (name of Resident B) for her baby doll and then dropped it on the ground and was laughing about it. (Name of Resident B) was very upset that she did that .(Name of Aide #1) continued to laugh about. A written statement from Aide #1, dated 8-22-16, explained on 8-20-16, with no time indicated, Resident B had dropped her baby doll when she had exited her room and had stated it was dead. She shared RN #6 explained to Resident B that her baby doll was not dead. She continued, In the dining room, (name of Resident B) had her baby and I dropped her baby to show the girls (other staff) that she thought it was (sic) because I didn't believe she thought it was dead. She thought it was dead and I picked it up and showed her that it wasn't dead. She wasn't upset. She just said she couldn't deal with the baby crying all the time. A nursing progress note, dated 8-20-16 at 7:47 a.m. documented, the RN on duty witnessed Resident B's baby doll fall from the resident's lap during a transfer in which the resident stated the baby doll was dead, resulting in the resident becoming upset and crying. Staff re-assured res (resident) that 'baby' OK, w/ (with) improved mood. In an interview with the Director of Nursing on 12-28-16 at 11:10 a.m., she indicated Aide #1 was initially hired as an Activity Assistant, then switched from an area vocational school's training program for CNA's to ours. She indicated she was then also hired as a Nurse's Aide, but did not complete the final written examination to become a CNA, due to the events related to Resident B. Aide #1's employee record indicated she was hired on 3-5-16 as an Activity Assistant and transitioned into a Nurse Aide position on 7-31-16. She was terminated, effective as of 8-22-16. On 12-27-16 at 9:52 a.m., the Executive Director provided a copy of a policy entitled, Abuse Prohibition, Reporting, And Investigation. This policy had a revision date of 11/16, and was indicated to be the current policy utilized by the facility. This policy stipulated, It is the policy of (name of the facility corporation) to protect residents from abuse, including physical abuse, sexual abuse, verbal abuse, mental abuse, neglect, involuntary seclusion, misappropriation of resident property and/or funds, and any physical/chemical restraint not required to treat the resident's medical symptoms .Definition of Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or pain, or mental anguish. This includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well being. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain, or mental anguish. Willful - the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm .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, such as telling a resident that he/she will never be able to see his/her family member again; or scolding and/or speaking to them in harsh voice tones .Mental Abuse - Verbal or nonverbal infliction or anguish, pain, or distress that results in psychological or emotional suffering. Examples: humiliation, harassment, threats of punishment or deprivation, bullying. (This applies for) Staff to resident- any episode (or) Resident to resident, if it appears to be willfully directed toward a specific resident . (Name of the facility corporation) will not permit residents to be subjected to abuse by anyone, including employees, other residents, consultants, volunteers, staff or personnel of other agencies serving the resident, family members, legal guardians, sponsors, friends, or other individuals . This Federal tag relates to Complaint IN 123. 3.1-27(a)(1) 3.1-27(b)