Every finding on record at Hickory Creek at Franklin

Based on observation, interview, and record review, the facility failed to ensure food was stored in a sanitary manner for 1 of 2 kitchen observations. Food was not labeled or dated. Finding includes:On 6/25/26 at 8:20 a.m., in the kitchen inside freezer two, observed an opened clear plastic bag that contained approximately 12 frozen unidentified meat patties. The bag was not labeled or dated.During an interview on 6/25/26 at 8:25 a.m., [NAME] 1 indicated unidentified meat patties were hamburger patties should have been labeled with the date the bag was opened. During an interview on 6/25/26 at 8:29 a.m., the Dietary Manager indicated the staff should have labeled and dated the opened bag of hamburger patties when the bag was opened. On 6/25/26 at 9:18 a.m., the Administrator provided a copy of a facility policy, titled Food Storage, dated 5/2025, and indicated this was the current policy used by the facility. A review of the policy indicated food was stored in an appropriate method to prevent contamination.This citation relates to Intake 2785952.410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(2)410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to notify the physician of a weight gain of more than 5 pounds in a week in accordance with the written plan of care for 1 of 16 residents reviewed for physician's orders. (Resident 36)Finding includes: On 2/10/26 at 12:15 p.m., Resident 36's clinical record was reviewed. The diagnoses included, but were not limited to, end stage renal disease and dependence on renal dialysis. A Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident 36 had moderate cognitive impairment. A Physician's Order, initiated 4/22/25, indicated to weigh Resident 36 every Monday, Wednesday, Friday if weight gain of more than 3 pounds in a day or 5 pounds in a week notify the physician. On 9/3/25 Resident 36's weight was 154.7 pounds and on 9/5/25 the weight was 161.6, which indicated a weight gain of 6.9 pounds. On 10/10/25 Resident 36's weight was 167.5 pounds and on 10/13/25 the weight was 201.2, which indicated a weight gain of 33.7 pounds. On 1/7/26 Resident 36's weight was 151.6 pounds and on 1/9/26 the weight was 159.2, which indicated a weight gain of 7.6 pounds. The facility lacked documentation for physician notification regarding the greater than five-pound weight gain for Resident 36 on 9/5/25, 10/12/25, and 1/9/26. During an interview on 2/11/26 at 8:04 a.m., the Director of Nursing Services indicated there should have been physician notifications as per physician orders. On 2/11/26 at 8:27 a.m., the Executive Director indicated that the facility did not have a policy on following physician orders. The facility was to follow Federal guidelines. On 2/10/26 at 9:00 a.m., the Executive Director provided a policy titled Dialysis Care with a revision date of 11/2017. A review of the policy indicated Procedure, .1. Physician orders will be received at time of admission specific to the residents; Weight monitoring if indicated. 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident received the correct diet as ordered by the physician for 1 of 1 residents reviewed for diet order. (Resident 228) Finding includes: During an interview on 4/2/24 at 9:00 a.m., Resident 228 indicated she did not like the food at the facility. It's terrible. On 4/2/24 at 12:30 p.m., Resident 228 was observed in the main dining room. Resident 228's meal consisted of, but was not limited to, pureed cornbread and pureed salad. On 4/4/24 at 8:30 a.m., observed Resident 228 in her room. Resident 228's bedside table was sitting next to her bed. The breakfast tray was sitting on top and included scrambled eggs and ham in pureed consistency. On 4/4/24 at 12:57 p.m., observed a bedside table in Resident 228's room. The table had her lunch tray sitting on top. The tray consisted of, but was not limited to, meatballs in pureed consistency and green beans in pureed consistency. On 4/2/24 at 1:15 p.m., the clinical record of Resident 228 was reviewed. The diagnosis included, but was not limited to, dysphasia. An Admission MDS (Minimum Data Set) assessment, dated 4/4/24, indicated Resident 228 had moderate cognitive impairment. A care plan dated 4/4/24 and current through 7/4/24, indicated Resident requires mechanically altered diet related to dysphasia. Goal: Resident will tolerate current diet consistency without signs/symptoms of difficulty chewing/swallowing. Approach: .Honor known food preferences and provide diet per MD order. A physicians order, dated 3/29/24 with no end date, indicated Resident 228 was to receive a Regular, Soft Bite-Sized diet. During an interview on 4/4/24 at 9:59 a.m., the Dietary Manager indicated the facility followed the physicians orders and a diet guide sheet. The diet guide sheet specified if the resident was to receive pureed or bite sized consistency for each food item. On 4/4/24 at 11:30 a.m., the Dietary Manager provided a diet Guide Sheet, dated 2023. The guide sheet indicated the following food items should be served in the following consistency for a soft and bite sized diet: - Sweet and sour meatballs should be soft and bite sized. - green beans should be soft and bite sized. - corn bread should be soft and bite sized. During an interview on 4/4/24 at 1:11 p.m., the Regional Nurse consultant indicated the green beans and meatballs should have been soft and bite sized as ordered by the physician. On 4/4/24 at 12:30 p.m., the Administrator provided a policy titled General Food Preparation and Handling, dated June 2023, and indicated it was the current policy being used by the facility. A review of the policy indicated .14. Recipes will be followed as written. 15. Food will be altered to the appropriate consistency to meet individual needs of the residents. 3.1-21(a)(3)

Based on observation, interview, and record review, the facility failed to ensure infection control procedures were completed for 1 of 5 residents reviewed for resident care. Glove changes and hand hygiene was not performed. (LPN 2, Resident 11) Findings include: On 4/3/24 at 12:55 p.m., Resident 11's clinical record was reviewed. The diagnoses included, but were not limited to, obstructive and reflux uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow; back-up of urine into the kidneys) and chronic kidney disease. The Physician Orders included, but were not limited to, the following: - catheter order: foley catheter (device that helps drain urine from the bladder) care, every shift, start date of 3/9/24 with no end date indicated. -bilateral buttocks treatment: MASD [moisture associated skin damage, inflammation of the skin] .cleanse area with Medline Hydrating Spray Cleaner, pat dry, MIX 1:1 Calmoseptine and House antifungal cream and apply to bilateral buttocks every shift, start date 4/2/24 with no end date indicated. The Admission Minimum Data Set (MDS) assessment, dated 3/15/24, indicated Resident 11 was mildly cognitively impaired, had an indwelling urinary catheter, and had MASD to the bilateral buttocks. Resident 11's care plans included, but were not limited to the following: Problem: Resident has impaired skin integrity: Dermatitis rash to bilateral buttocks [related to] fecal incontinence .Start date - 3/26/24 and current through 6/26/24 .Approach: treatment as ordered . Problem: Resident requires an indwelling urinary catheter [related to] obstructive uropathy .Start date - 3/13/24 and current through 6/20/24 .Approach: provide assistance for catheter care . On 4/2/24 at 10:34 a.m., Resident 11 was observed resting in bed. A covered urinary catheter bag and catheter tubing were observed hanging on the bed rail. During an interview at that time, Resident 11 indicated he has had a urinary catheter for a while and had a sore on his back. On 4/4/24 at 2:15 p.m., Licensed Practical Nurse (LPN) 2 was observed providing catheter care and bilateral buttocks care to Resident 11. The following was observed: - Resident 11 was resting in bed on his back. The urinary catheter bag and catheter tubing were observed hanging on the bed rail. - LPN 2 donned the plastic PPE (personal protective equipment - gown and two sets of plastic gloves) and placed the urinary catheter care and bilateral buttocks care supplies on the over-bed table located next to Resident 11's bed. - LPN 2 performed urinary catheter care. LPN 2 was not observed to change the gloves or conduct hand hygiene prior to transitioning from a contaminated (dirty) area to a non-contaminated (clean) area. - LPN 2 then assisted Resident 11 to turn onto his left side to begin the bilateral buttocks care. Upon turning the resident, LPN 2 observed Resident 11 had been incontinent of bowel. A red-colored rash was observed on Resident 11's buttock area. - LPN 2 walked to Resident 11's closet, approximately 10 feet from the bed, to retrieve a clean incontinent brief and handy wipes. LPN 2 then performed incontinent care to Resident 11. The soiled incontinent brief and wipes were placed on top of the bed linens at the foot end of the bed. LPN 2 was not observed to change the gloves or conduct hand hygiene prior to transitioning from the contaminated area to a clean area. - LPN 2 then performed the bilateral buttocks treatment care by cleansing the area with Medline Hydrating Spray Cleaner and patted dry the exposed area. LPN 2 was not observed to change the gloves or conduct hand hygiene prior to transitioning from the contaminated area to a clean area. - Using the left hand, LPN 2 picked up the previously prepared medicine cup of Calmoseptine and House antifungal cream and placed her right index finger into the medicine cup. LPN 2 turned toward the resident. Just prior to LPN 2 having reached Resident 11 with the medicine cup in hand, LPN 2 indicated during an interview at that time, she had spaced having to change the gloves and perform hand hygiene when going from a contaminated [dirty] area to a clean area. LPN 2 then asked if she should change the gloves before continuing the treatment. - LPN 2 then walked to the PPE supply storage unit, located on the floor at the foot end of Resident 11's bed. LPN 2 removed the original gloves, applied hand sanitizer, and donned new gloves. - LPN 2 picked up the original medicine cup that contained the Calmoseptine and House antifungal cream. LPN 2 indicated at that time, she was using the left side of the cup since she had previously put her finger in the right side of the cup. LPN 2 then applied the Calmoseptine and House antifungal cream. During an interview on 4/5/24 at 8:55 a.m., the Corporate Nurse Consultant indicated staff were to conduct hand hygiene and change gloves during personal care when going from a contaminated area to a clean area. During an interview on 4/5/24 at 9:57 a.m., the Director of Nursing Services (DNS) indicated staff were to wash hands and change gloves during personal care when going between contaminated and clean areas. On 4/5/24 at 8:55 a.m., the Corporate Nurse Consultant provided a copy of the Standard and Transmission-Based Precautions (isolation) policy, dated September 2023, and indicated it was the current policy in use by the facility. A review of the document indicated, .prevent the spread of infection from resident to resident .hand hygiene: hand washing .hand rub .perform hand hygiene: before having direct contact with a resident; before performing clean/aseptic procedure; after contact with the resident; after contact with .body fluids .contaminated surfaces; after touching resident surroundings .Gloves: wear gloves when it can be anticipated that contact with .body fluids .change gloves during care and perform hand hygiene if hands will move from a contaminated site to a clean site . 3.1-18(b)(1)

Based on interview and record review, the facility failed to complete a thorough investigation for an allegation of physical abuse for 1 of 3 residents reviewed for abuse. (Resident B) Finding includes: During an interview on 12/13/23 at 10:44 a.m., LPN 1 (Licensed Practical Nurse) indicated on 12/7/23 at approximately 2:00 p.m., Resident B indicated they were going to get her that night. When LPN 1 asked who Resident B was talking about, Resident B indicated a tall male night nurse and a female night nurse. During an interview on 12/13/23 at 10:30 a.m., Family Member 1 indicated on 12/8/23, Resident B called Family Member 1 and indicated a large black female nurse and a tall, skinny, white male nurse beat her and raped her on night shift. Family Member 1 was not sure what night Resident B was talking about. Family Member 1 notified the Administrator on 12/8/23. During an interview on 12/13/23 at 10:57 a.m., the Administrator indicated on 12/7/23, Resident B reported that the night shift nurses beat her up. First Resident B's described the staff as 2 females and a male, all of them German. Then Resident B indicated it was a tall male and one female. On 12/8/23, Resident B's daughter called the Administrator and indicated Resident B called and indicated Resident B was beaten and raped on night shift. The description Resident B gave her daughter of the night nurses was a large black female nurse and a tall, skinny, white male nurse. The physical description Resident B gave to the Administrator matched the description of CNA 1 and LPN 2. CNA 1 and LPN 2 worked night shift on 12/6/23. Resident B made the allegation about the night shift nurses on 12/7/23 at approximately 2:00 p.m. Both CNA 1 and LPN 2 were allowed to return to work for night shift on 12/7/23, because Resident B indicated the alleged perpetrators were German. At that time, the facility did not have any nurses that were German that worked in the facility. The description Resident B gave didn't match the nurses that were working at that time so the facility closed the investigation. During an interview on 12/13/23 at 11:05 a.m., the DON (Director of Nursing) indicated she did not complete a thorough interview with CNA 1 nor LPN 2 regarding the allegation of physical abuse made by Resident B on 12/7/23. The DON reviewed the facility's abuse questionnaire with CNA 1 and LPN 2. During an interview on 12/13/23 at 11:56 a.m., the ADON (Assistant Director of Nursing) indicated she had not witnessed nor heard about any abuse in the facility, but on 12/7/23 the ADON completed interviews with CNA 1 and LPN 2 regarding the allegation Resident B made, on 12/7/23. The ADON reviewed the abuse questionnaire with CNA 1 and LPN 2. The clinical record for Resident B was reviewed on 12/13/23 at 8:27 a.m. The diagnoses included, but were not limited to, mood disorder, anxiety disorder, and cognitive communication deficit. The Annual MDS (Minimum Data Set) assessment, dated 10/10/23, indicated Resident B was cognitively intact. A witness statement, dated 12/7/23, indicated Resident B indicated to LPN 1 they were really going to get her that night. LPN 1 asked what they looked like and Resident B indicated there were 2 women and one man. The man was tall and laughed a lot. He laughed when he hurt Resident B. The man and women were German. A witness statement, dated 12/7/23 at 2:05 p.m., indicated Resident B indicated to LPN 1 that the two night shift nurses from last night were trying to kill her and that was why Resident B was so sore. The two night shift nurses beat her up really bad. Resident B told LPN 1 to be careful who LPN 1 told. On 12/13/23 at 1:22 p.m., the DON provided a copy of a document, titled Staff Abuse Questionnaire, dated 12/7/23, and indicated this was the abuse questionnaire that was reviewed with CNA 1. A review of the abuse questionnaire indicated CNA 1 did not witness any employee, resident, nor visitor abuse or mistreat another resident. CNA 1 was not suspicious of any employee mistreating residents. CNA 1 did not witness any employee acting frustrated, stressed, short, fatigued, irritable, isolated, nor showing other signs of burnout. CNA 1 did not witness any employee treat residents unkindly, laugh at residents, rush or perform care roughly, use unsafe practices, nor treat resident in an inappropriate manner. CNA 1 had not seen any unusual bruises, markings, nor witnessed a resident act guarded nor fearful. The signature line for CNA 1 indicated over the phone. The Staff Abuse Questionnaire was reviewed with CNA 1 by the ADON. The document lacked a completed thorough interview with CNA 1 regarding the physical abuse allegation involving CNA 1, that Resident B reported on 12/7/23. On 12/13/23 at 1:22 p.m., the DON provided a copy of a document, titled Staff Abuse Questionnaire, dated 12/7/23, and indicated this was the abuse questionnaire that was reviewed with LPN 2. A review of the abuse questionnaire indicated LPN 2 did not witness any employee, resident, nor visitor abuse or mistreat another resident. LPN 2 was not suspicious of any employee mistreating residents. LPN 2 did not witness any employee acting frustrated, stressed, short, fatigued, irritable, isolated, nor showing other signs of burnout. LPN 2 did not witness any employee treat residents unkindly, laugh at residents, rush or perform care roughly, use unsafe practices, nor treat resident in an inappropriate manner. LPN 2 had not seen any unusual bruises, markings, nor witnessed a resident act guarded nor fearful. The signature line for LPN 2 indicated over the phone. The Staff Abuse Questionnaire was reviewed with LPN 2 by the ADON. The document lacked a completed thorough interview with LPN 2 regarding the physical abuse allegation that involved LPN 2, Resident B reported, on 12/7/23. A daily staffing report, dated 12/6/23, indicated LPN 2 and CNA 1 were the only nursing staff that worked night shift. A daily staffing report, dated 12/7/23, indicated LPN 2 and CNA 1 were the only nursing staff that worked night shift. During an interview on 12/13/23 at 10:20 a.m. CNA 1 (Certified Nursing Aide) indicated CNA 1 worked night shift on 12/6/23 from approximately 10:00 p.m. until 12/7/23 at approximately 6:00 a.m. CNA 1 worked night shift again on 12/7/23 from approximately 10:00 p.m. until 12/8/23 at approximately 6:00 a.m. The first time CNA 1 was interviewed regarding an abuse allegation that involved CNA 1 and LPN 2 was after his shift ended on 12/8/23. The clinical record lacked documentation of a completed thorough investigation that included interviews with LPN 2 and CNA 1 that included facts and observations regarding the physical abuse allegation made by Resident B on 12/7/23 before CNA 1 and LPN 2 returned to work for night shift on 12/7/23. On 12/13/23 at 9:02 a.m., the Administrator provided a copy of a facility policy, titled Abuse Prohibition, Reporting, and Investigation, dated 2/2010, and indicated this was the current policy used by the facility. A review of the policy indicated any staff member implicated in the alleged abuse will be removed from the facility at once and will remain suspended until an investigation is completed. The investigation will include facts and observations by involved employees. All residents will be protected from physical harm during an investigation by implementing staffing changes, if necessary, to protect the residents from the alleged perpetrator. This citation relates to Complaint IN00423709. 3.1-28(d)

Based on observation, interview, and record review, the facility failed to ensure infection control practices implemented to mitigate the spread of COVID-19 for 2 of 3 residents reviewed for infection control. A staff member entered a resident's room with droplet precautions without eye protection and 2 staff members where observed not wearing a facemask inside the facility as indicated on the sign posted at each entrance to the facility. (Resident B, CNA 1, CNA 2, Maintenance Director) Finding includes: 1. On 9/27/23 at 9:00 a.m., observed the Maintenance Director walk through a hallway approximately 4 feet from multiple residents sitting in the hallway without a facemask on. On 9/27/23 at 1:12 p.m., observed CNA 2 in a resident room with both residents in the room. CNA 2 was kneeling between the 2 beds approximately five feet from each resident. CNA 2 was not wearing a facemask. CNA 2 picked up a clear garbage bag that contained a soiled brief then walked out of the room. At that time, CNA 2 indicated she should have re-applied the facemask after the resident pulled it off of her face. CNA 2 pulled an intact, folded, face mask out of her pocket and put the mask on her face. During an interview on 9/27/23 at 1:17 p.m., the Maintenance Director indicated a facemask was required while in the facility. 2. During an interview on 9/27/23 at 9:45 a.m., CNA 1 (Certified Nursing Aide) indicated Resident B was in isolation precautions for testing positive for COVID-19. At that time, the door to Resident B's room was closed. There was a red sign on Resident B's door that indicated droplet/contact precautions and a gown, gloves, N95 mask, and eye protection were required to enter Resident B's room. Observed CNA 1 knock on Resident B's door and open the door. CNA 1 walked into the room and walked toward Resident B's roommate but within 4 feet of Resident B. Resident B was not wearing a face mask and the privacy curtain was not fully pulled to separate the room. Then CNA 1 exited the room. At that time, CNA 1 indicated eye protection was required to enter the room and she should have worn a face shield into the room. The clinical record for Resident B was reviewed on 9/27/23 at 11:37 a.m. The diagnoses included, but were not limited to, COVID-19, diabetes, and morbid obesity. An Admission MDS (Minimum Data Set) assessment, dated 9/12/23, indicated Resident B was cognitively intact. A progress note, dated 9/25/23 at 12:08 p.m., indicated exposure testing took place. Resident B tested positive with a point of care antigen test. Resident B was noted to have a cough, congestion, fatigue, and shortness of breath. Resident B was placed in droplet/contact isolation for 10 days. A physicians order initiated on 9/25/23, indicated Resident B droplet/contact isolation due to a highly transmissible pathogen, related to COVID-19. On 9/27/23 at 9:27 a.m., the Administrator provided a copy of a facility policy, titled COVID-19 Policy, dated 7/2023, and indicated this was the current policy used by the facility. A review of the policy indicated this community will implement infection control practices to reduce the risk of transmission of COVID-19. Residents and staff that reside or work on a unit or area of the facility experiencing a COVID-19 outbreak when the source of COVID-19 cannot be determined through contact tracing. This Federal tag relates to Complaint IN00416222. 3.1-18(b)(1)

Based on observation, interview, and record, the facility failed to provide supervision to prevent elopement 1 of 1 residents reviewed. A resident was able to exit the facility with a delivery person. The resident was found by a family member on a in the turn lane of a heavily traveled highway. (Resident 20) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on, 5/15/23 at approximately 10:30 a.m., when the facility failed to provide supervision to prevent elopement. The resident was found walking in the turn lane of a highly traveled highway. The Administrator and the Director of Nursing were notified of the Immediate Jeopardy on 5/16/23 at 4:30 p.m. The Immediate Jeopardy was removed on 5/17/23 at 2:15 p.m., but noncompliance remained at the lower scope and severity level of isolated, no actual harm but potential for more than minimal harm that is not Immediate Jeopardy. Finding includes: During an interview on 5/16/23 at 10:40 a.m., the Administrator indicated Resident 20 had eloped from the facility yesterday (5/15/23). She indicated they suspected a flower delivery person that was in the facility at approximately 10:30 a.m., left the facility and Resident 20 exited the building at that time. Resident 20's parents take him to their house every evening for dinner. Resident 20 will stand by the door waiting for his parents to pick him up. The facility was unaware Resident 20 had exited the facility until his parents called the facility and reported they saw him walking outside at 10:40 a.m. On 5/16/23 at 10:50 a.m., the Administrator provided a written interview with RN 3, who had indicated she had last seen Resident 20 at 10:21 a.m. on 5/15/23. During an interview on 5/16/23 at 11:04 a.m., the DON indicated Resident 20 usually stood at the door. That was where his parents picked him up. The staff was unaware Resident 20 had went out the facility door until his parents called and reported it. During an interview on 5/16/23 at 11:39 a.m., CNA 2 indicated Resident 20 liked to stand by the door and wait for his parents to come and get him for dinner. During an interview on 5/16/23 at 1:20 p.m., the Administrator indicated the code to open the doors was posted above the key pad. On 5/16/23 at 1:30 p.m., the key pad at the front door and the side doors were observed. The key pads had a visible taped on paper on the top of the key pad. The paper indicated *(next mm [month]current yy[year]) was posted on the paper on top of the key pad. During an interview on 5/16/23 at 3:09 p.m., Resident 20's mother indicated Resident 20's father was on driving on State Road 31 on the morning of 5/15/23. His father observed Resident 20 walking south in the median, on the heavily traveled high way, approximately 0.25 - 0.5 miles away from the facility. At that time, Resident 20 was attempting to walk back across the northbound lanes of State Road 31 and was in the turn lane on the southbound side. A semi truck was driving close to the area Resident 20 was standing in. Resident 20 was observed in the turn lane with during a heavy traffic time. Resident 20's father pulled over and redirected Resident 20 into his car. On 5/16/23 at 3:30 p.m., Resident 20's clinical record was reviewed. The diagnosis included, but was not limited to, diffuse traumatic brain injury. A Quarterly Minimum Data Set (MDS) assessment, dated 3/17/23, indicated Resident 20's cognitive status was severely impaired. A care plan, dated 4/7/23 and current through 7/7/23, indicated Resident 20 was at risk for elopement per the Elopement Risk Assessment due to impaired cognition, ability to ambulate independently, and a history of intrusive wandering and waiting by exit doors. The interventions included, but was not limited to, all facility exits secured. A Interdisciplinary Progress Note, dated 5/16/23 at 8:59 a.m., indicated Resident 20 exited the building. During an observation on 5/17/23 at 8:10 a.m., the outside of the facility was observed. The facility was observed to be on the east side of State Road 31, approximately one half block from the highway, on the northbound side. During an interview on 5/17/23 at 10:30 a.m., Resident 20's father indicated on 5/15/23 he was driving south bound on State Road 31. He observed his son walking south bound in the turn lane of State Road 31. Resident 20's father was afraid his son was going to cross back over the north bound lane into heavy traffic. Resident 20's father pulled over and told his son to stay where he was. Resident 20's father approached his son and redirected him to his car. He drove Resident 20 to his mothers house. Resident 20's mother immediately called and informed the facility of the incident. On 5/16/23 at 3:00 p.m., the Administrator provided a policy titled Elopement Prevention and Response Program, dated October 2013, and indicated it was the current policy being used by the facility. A review of the policy indicated .c. Resident will be identified as an 'Elopement Risk', 'Wanderguard', 'electric monitoring device', 'security bracelet' etc on direct care staff communication method (ie Matrix Profile, resident care sheets, etc). The Immediate Jeopardy that began on 5/15/23 was removed on 5/17/23 when the facility inserviced staff, family, and visitors not to let residents out of the facility, but the noncompliance remained at the lower scope and severity level of no harm but potential for more than minimal harm that is not Immediate Jeopardy because a systemic plan of correction had not been implemented to prevent recurrence. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure foods were served in a sanitary and safe manner for 3 of 3 kitchen observations. Staff hair was not covered while in the kitchen food preparation area. (Cook 2 and Dietary Manager) Findings include: 1. During the initial kitchen tour on 5/15/23 from 10:15 a.m. to 10:30 a.m., Cook 2 was observed organizing the lunch meal tickets at the kitchen's center preparation table while the DM (Dietary Manager) was preparing the noon meal at the stove and preparation table area. Cook 2 was observed to have multiple loose hairs, approximately 3 inches in length, in front of the ears and at the neck line that were not covered. 2. During a follow-up kitchen observation on 5/15/23 from 11:45 a.m. to 11:55 a.m., Cook 2 was observed filling the noon meal drink glasses at the kitchen's center preparation table while the DM was recording the starting food temperatures for the noon meal at the stove and preparation table area. Cook 2 was observed to have multiple loose hairs, approximately 3 inches in length, in front of the ears and at the neck line that were not covered. 3. During a follow-up kitchen observation on 5/15/23 from 12:30 p.m. to 12:40 p.m., the following was observed: - Cook 2 was walking through-out the kitchen area where the noon meal had been prepared and served to the residents. Cook 2 was observed to have multiple loose hairs, approximately 3 inches in length, in front of the ears and at the neck line that were not covered. - The DM was observed recording the ending noon meal temperatures. The DM was observed to have multiple loose hairs, approximately 3 inches in length, at the neckline that were not covered. During an interview on 5/15/23 at 12:45 p.m., the DM indicated staff's hair was to be covered while in the kitchen. On 5/15/23 at 1:25 p.m., the Administrator provided a copy of the American Senior Communities Culinary Personal Hygiene policy, dated November 2022, and indicated it was the current policy in use by the facility. A review of the policy indicated, .Employees will maintain good personal hygiene to prevent food contamination .all employees working in the culinary department must wear a clean hair restraint which effectively covers all hair . On 5/15/23 at 3:05 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 hats, hair coverings or nets .that are designed and worn to wear effectively keep their hair from contacting .exposed food . 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure an AIMS (Abnormal Involuntary Movement Scale) was completed for 1 of 5 residents reviewed for unnecessary medications. (Resident 134) Finding includes: On 5/18/23 at 9:21 a.m., Resident 134's clinical record was reviewed. The diagnoses included, but were not limited to, schizoaffective disorder and bipolar disorder. The Physician Orders included, but were not limited to: Zyprexa (an antipsychotic medication), 5 mg (milligrams), one tablet at bedtime for schizoaffective disorder and bipolar disorder, initiated 4/7/23. The Pharmacy Consultation Report, dated 4/15/23, indicated .[Resident 134] receives an antipsychotic, olanzapine 5mg. [at bedtime] .recommendation: please include the following guidance for olanzapine in the interdisciplinary care .ensure the following are monitored and documented in the medical record .perform an assessment for involuntary movements (AIMS) at baseline and then at least every 6 months . The document was signed by the ADNS (Assistant Director of Nursing) on 4/18/23. Resident 134's care plan indicated, Resident is at risk for adverse side effects relate to use of psychotropic medication. The interventions included, but were not limited to, AIMS assessment two times a year. During an interview on 5/19/23 at 9:10 a.m., the facility Corporate Nurse indicated Resident 134's AIMS assessment was not completed until 5/18/23. During an interview on 5/19/23 at 9:20 a.m., the Interim DNS (Director of Nursing Services) indicated Resident 134's baseline AIMS assessment should have been completed when Zyprexa was started in April. On 5/19/23 at 11:15 a.m., the Interim DNS provided a copy of the Psychotropic Management policy, dated July 2022, and indicated it was the current policy in use by the facility. A review of the policy indicated, .it is the policy of American Senior Communities to ensure that a resident's psychotropic medication regime helps promote the resident's highest practicable mental, physical, and psychosocial well-being with person centered intervention and assessment. These medications are managed in collaboration with professional services and facility staff to include non-pharmacological interventions, assessment, and reduction as applicable. Definition: a psychotropic drug is any drug that affects brain activities associated with mental processes and behavior: anti-psychotic; anti-depressant .Potential adverse side effects to psychotropic medications will be observed each shift by a license nurse. An AIMS assessment will be completed for residents who are taking antipsychotic medication as a tool to monitor for adverse side effects. The assessment should be completed within 72 hours of a new order . 3.1-48(a)(3)

Based on observation, interview, and record review, the facility failed to ensure the dumpster side panel door was kept closed when not in use for 1 of 2 dumpster observations. Findings include: During the initial facility tour with the DM (Dietary Manager) on 5/15/23 from 10:33 a.m. to 10:37 a.m., the facility dumpster area, located adjacent to the facility, was observed. The dumpster container had two side sliding panel doors. The left side panel area lacked a door. Inside the dumpster multiple filled trash bags were observed. No staff were observed in the area. During an interview at that time, the DM indicated the left sliding door had been missing for quite some time. The dumpster container was supposed to be kept closed when not in use. During an interview on 5/16/23 at 8:55 a.m., the Corporate Director indicated a make shift sliding door was installed on the dumpster yesterday [5/15/23] and he had observed a [NAME] of birds flying near the dumpster container. The Corporate Director indicated the facility did not have a dumpster policy regarding the doors and lids being kept closed. During an interview on 5/19/23 at 9:06 a.m., the DM who indicated she was unsure how long the dumpster sliding door had been missing from the dumpster; however, the previous Maintenance Director who left in mid April was aware. During an interview on 5/19/23 at 10:24 a.m., the Maintenance Supervisor indicated the dumpster's side sliding panel door had been missing for at least a month. On 5/15/23 at 2:00 p.m., a review of the Retail Food Establishment Sanitation Requirements - Title 410 IAC 7-24, effective November 13, 2004, indicated, .receptacles and waste handling units for refuse, recyclables and returnables shall be kept covered with tight-fitting lids or doors if kept outside .accumulation of debris .are minimized .effective cleaning is facilitated around .the unit . 3.1-21(i)(5)

Based on observation, interview, and record review, the facility failed to ensure food was stored in a sanitary manner for 1 of 2 observations. Milk provided to residents was past the manufacturer's use by date and resident's snack refrigerator food items were not labeled to indicate who the items belonged to and the date it was placed into the refrigerator. Findings include: 1. During the initial kitchen tour on 6/27/22 at 7:15 a.m., observed the DM (Dietary Manager) reach into the kitchen refrigerator to retrieve a gallon jug of 2% Country Fresh milk. The jug was observed to be 1/2 full of milk. The DM then poured milk into a medium sized plastic glass; covered the glass with plastic wrap; and then placed the glass of milk onto the breakfast food tray to be delivered to a resident. The jug of milk was then placed back into the kitchen refrigerator. On 6/27/22 at 7:50 a.m., observed the contents within the kitchen refrigerator. One gallon jug of 2% Country Fresh milk was observed. The jug was 1/2 full of milk. Near the upper portion of the milk jug and close to the milk jug's lid, the manufacturer's pre-printed label best by - 6/15/22 was visible. The pre-printed lettering and date was approximately 3/4 inches high and 2 inches long. No other jugs of milk were observed inside the kitchen refrigerator. During an interview at that time, the DM indicated she was unaware the milk was past the use by date and the milk should have been discarded. On 6/27/22 at 7:55 a.m., observed the contents within the facility's milk cooler, located near the food pantry and kitchen area. Inside the milk cooler, the following was observed: -1 unopened gallon of 2% Country Fresh milk. Near the upper portion of the milk jug close to the lid, the manufacturer's pre-printed label best by - 6/15/22 was visible. The pre-printed lettering and date was approximately 3/4 inches high and 2 inches long. -1 unopened gallon of 2% Country Fresh milk. Near the upper portion of the milk jug close to the lid, the manufacturer's pre-printed label best by - 6/21/22 was visible. The pre-printed lettering and date was approximately 3/4 inches high and 2 inches long. -3 unopened gallons of 2% Country Fresh milk. Near the upper portion of the milk jug close to the lid, the manufacturer's pre-printed label best by - 6/26/22 was visible. The pre-printed lettering and date was approximately 3/4 inches high and 2 inches long. During an interview at that time, the DM indicated she was unaware the milk was past the use by date and the milk should have been discarded. 2. On 6/27/22 at 8:00 a.m., during the initial tour of the facility with the DM, observed the resident snack refrigerator, located in the resident pantry room. Inside the small refrigerator, the following items were observed: -One opened 32 ounce bottle prune juice. The bottle was 1/2 full, dated 1/24/22, and lacked a resident's name on it to identify to whom it belonged. -Four plastic wrapped sausage biscuits which lacked a date when the food items were placed into the refrigerator. -One plastic container that contained a small slice of lemon meringue pie that had a nickel sized dark black substance observed in the middle of the pie. The container lacked a date when the food item was placed into the refrigerator. -One plastic container that held a slice of meat-loaf, 2 deviled eggs, and potato salad. The container lacked a label to identify when the food items were placed into the refrigerator and to whom the item belonged. -One unopened 11.5 ounce bottle of FairLife protein shake. At the upper portion of the bottle near the lid, the manufacturer's pre-printed best if used by - 2/15/22 was visible. The bottle lacked a label to indicate to whom the bottle belonged. -Two unopened small sugar free pudding cups. The containers lacked a label to identify when the food items were placed into the refrigerator and to whom the items belonged. -One unopened 8 ounce bottle of Ensure High Protein supplement which lacked a label to identify to whom the item belonged. During an interview at that time, the DM indicated all items in the resident snack refrigerator were to be labeled to indicate to whom the item belonged to and the date they were placed into the refrigerator. The DM indicated the resident snack refrigerator should have been monitored to ensure all items were labeled, dated, and outdated items were discarded. During an interview on 6/28/22 at 3:35 p.m. the Interim DNS (Director of Nursing Services) indicated 16 of the 30 residents residing in the facility received milk from the kitchen. All 30 residents residing in the facility received food from the kitchen and had access to storing snack foods items in the resident snack refrigerator. On 6/28/22 at 12:05 p.m., the Corporate Nurse provided a copy of the Date Marking policy, dated 1/1/16, and indicated it was the current policy in use by the facility. A review of the policy indicated, .all prepared foods that are stored will be properly dated to ensure food safety .when to discard: .the expiration date with which the manufacturer guarantee the food will no longer meet quality standards .expiration dates: the date with which the manufacturer guarantees the food will meet its quality standards. Date marking for discard ensures the safety of the food . On 6/29/22 at 9:45 a.m., the Interim DNS provided a copy of the Distribution of Snacks/Nourishments/Therapeutic Supplements between Meals policy, dated 1/1/16, and indicated it was the current policy in use by the facility. A review of the policy indicated, .snacks/nourishments .will be stored and handled in accordance with applicable federal, state and local sanitary codes . On 6/29/22 at 11:30 a.m., the Interim DNS provided a copy of the Refrigerated Storage policy, dated 1/1/16, and indicated it was the current policy in use by the facility. A review of the policy indicated, .all foods will be properly wrapped and/or stored in sealed containers and dated and labeled .food will be discarded within appropriate shelf life . On 6/28/22 at 2:00 p.m., a review of the retail Food Establishment Sanitation Requirements Title 10 IAC 7-24, effective November 13, 2004, indicated .may not exceed a manufacturer's use by date . On 6/28/22 at 3:00 p.m., a review of the retail Food Establishment Sanitation Requirements Title 10 IAC 7-24, effective November 13, 2004, indicated .refrigerated, ready to eat, potentially hazardous food prepared and held in a retail food establishment for more than twenty-four (24) hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises .discarded . 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure the area surrounding the dumpster container was free of rubbish for 2 of 3 observations. Findings include: On 6/27/22 at 8:15 a.m., during the initial facility tour with the DM (Dietary Manager), observed the dumpster area, located near the north-west corner of the facility and near the west entrance door into the facility. On the ground surrounding two sides of the dumpster container, observed multiple used plastic gloves; paper cups; paper bags; plastic bags; plastic bottles; tree debris; and leaves. Along one side of the dumpster, the debris was approximately 5 inches deep. No staff were visible in the area at that time. During an interview at that time, the DM indicated the area surrounding the dumpster was be kept free of trash and debris. On 06/28/22 at 3:50 p.m., observed the dumpster area, located near the north-west corner of the facility and near the west entrance door into the facility. On the ground surrounding two sides of the dumpster container, observed multiple used plastic gloves; paper cups; paper bags; plastic bags; plastic bottles; tree debris; and leaves. Along one side of the dumpster, the debris was approximately 5 inches deep. No staff were visible in the area at that time. During an interview on 6/28/22 at 3:25 p.m., the Interim Director of Nursing Services indicated the facility lacked a policy that addressed the dumpster container and the surrounding area being kept free from debris. The current facility census was 30 residents. On 6/28/22 at 10:00 a.m., a review of the Retail Food Establishment Sanitation Requirements - Title 410 IAC 7-24, effective November 13, 2004, indicated, .receptacles and waste handling units for refuse, recyclables and returnables shall be kept covered with tight-fitting lids or doors if kept outside .accumulation of debris .are minimized .effective cleaning is facilitated around .the unit . 3.1-21(i)(5)

Based on observation, interview, and record review, the facility failed to ensure that person- centered care plans were developed for residents with specific medications and treatments related to their diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (Residents 182, 7, 9 and 181) Findings include: 1. The clinical record of Resident 182 was reviewed on 9/21/21 at 1:00 P.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment, dated 6/29/21, indicated Resident 182 was cognitively intact and was diagnosed with diabetes mellitus. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, on 9/23/21 at 10:25 A.M., the Director of Nursing indicated, there should have been a person-centered care plan in place for Resident 182 for diabetes mellitus. The clinical record for Resident 182 lacked a person-centered care plan for diabetes mellitus. 2. The clinical record of Resident 7 was reviewed on 9/22/21 at 11:08 A.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment, dated 6/25/21, indicated, Resident 7 was cognitively intact and was diagnosed with malignant neoplasm of sigmoid colon, malignant neoplasm of appendix and chronic pain. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/20/21 at 11:23 A.M., Resident 7 was sitting up in a chair. Observed Resident 7 had a smile on her face and was crocheting. During an interview on 9/20/21 11:23 A.M., Resident 7 indicated, she does have chronic pain, her pain level was 4/10, and the nursing staff address her pain immediately whenever she reports pain and that helps reduce the pain level. During an interview, on 9/23/21 10:25 A.M., the Director of Nursing (DON) indicated, there should have been a person-centered care plan in place for Resident 7 for pain. The clinical record for Resident 7 lacked a person-centered care plan for pain. 3. The clinical record for Resident 9 was reviewed on 9/22/21 at 10:43 a.m. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The discharge Minimum Data Set assessment which was completed on 8/22/21. The assessment indicated Resident 9 required total dependence for bed mobility, transfers, locomotion, dressing, eating, toileting, hygiene, bathing, and locomotion. Ambulation activities were unable to be assessed. Resident had not had a fall since prior to admission. Resident 9's admission assessment, completed on 9/1/21, indicated the resident had a [CONDITION(S)]. Resident 9's clinical record lacked a plan of care for the [CONDITION(S)] and care of the [CONDITION(S)]. The Director of Nursing (DON) was unable to provide a care plan identifying a [CONDITION(S)] for Resident 9 prior to facility exit. 4. The clinical record for Resident 181 was reviewed on 9/23/21 at 10:45 a.m. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment, completed on 7/13/21, indicated Resident 181 was moderately cognitively impaired. Resident was assessed as needing required assistance with transfers and ambulation. Resident did fall within one-month prior to admittance. Facility was unable to provide fall risk assessments. Interview with DON, on 9/23/21 at 10:50 a.m., indicated resident was a high risk fall and required assistance with transfers and ambulation. Facility was unable to provide a high-risk fall care plan for Resident 181 prior to exit. On 9/23/21 at 9:10 a.m., the DON provided a copy of the care plan policy, dated 7/2018, titled, Care Planning- Comprehensive, and indicated it was the current policy being used by the facility. Review of the policy indicated, Policy: The facility will develop ad implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframe's to meet a resident's medical, nursing, mental and psychosocial well-being, Purpose: To describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing. 3.1-35(b)(1)

Based on observation, record review, and interview, the facility failed to ensure a call light was in reach for a resident who required maximum assist for bed mobility and a resident with dementia and high fall risk. (Resident 9 and Resident 181) Findings include: 1. Observation, on 9/20/21 at 9:30 a.m. until 9:47 a.m., Resident 9 was lying in bed on his back with multiple pillows surrounding him, his eyes were closed. Resident 9's call light could not be found near the resident or on the bed with the resident. During an interview, at that time, Certified Nursing Assistant (CNA) 3 indicated all residents should have a call light. CNA 3 indicated Resident 9 was unable to move about in bed without the assistance of two staff. Observed CNA 3 retrieve the call light from the floor at the foot of the bed and place it next to the Resident 9's left hand. CNA 3 indicated Resident was able to use the call light only with the left hand. During observation, on 9/21/21 at 8:35 a.m. through 8:50 a.m., observed Resident 9 lying on his back in bed. The call light was coiled up on the far end of the bed. During an interview with the Business Office Manager 4, on 9/21/21 at 8:52 a.m., indicated Resident 9 was unable to retrieve the call light from the end of the bed. During an interview with CNA 3, at that time, he indicated Resident 9 was unable to move about in bed and retrieve his call light. Observed CNA 3 retrieve the call light from the floor, where it had fallen between the wall and bed and place it by the resident's left hand. CNA 3 indicated he would provide clips for the call lights so they could be secured next to the resident. 2. During an observation, on 9/21/21 at 9:09 a.m. through 9:23 a.m., Resident 181 was lying in bed on her back. The resident's call light could not be located. Interview with Resident 181, at that time, indicated she was unable to locate her call light. She indicated she was unsteady on her feet and unable to search for the call light in her room. During an interview, on 9/21/21 at 9:25 a.m., CNA 3 indicated the resident was unable to get up out of the bed, without the extensive assistance of two staff members, to obtain her call light. CNA 3 located the call light on the floor between the wall and the bed. Observed CNA 3 place the call light on the bed next to the resident. He indicated he was going to obtain a clip for the call light so it could be securely placed next to the resident. On 9/21/21 at 10:35 a.m., the clinical record for Resident 181 was reviewed. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS, completed on 7/13/21, indicated Resident 181 was moderately cognitively impaired. Resident was assessed as independent with supervision for ambulation. Resident required assistance with transfers and ambulation due to unsteadiness. Facility was unable to provide fall risk assessments. On 9/21/21 at 11:30 a.m., the DON provided a copy of the call light policy, dated 6/2004, titled, Call Light policy, and indicated it was the current policy being used by the facility. Review of the policy indicated, When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. 3.1-3(v)

Based on observation, interview, and record review, the facility failed to ensure staff supervision was provided to prevent falls for a resident who is at high risk for falls for 1 of 3 residents reviewed for falls. (Resident 6) Finding includes: Resident 6's clinical record was reviewed on 9/21/21 at 1:47 p.m. Diagnosis included, but were not limited to, abnormal gait, muscle weakness, and altered mental status. A Physicians order, with a start date of June 14, 2021, indicated [MEDICATION(S)] 10 mg (milligrams) by mouth twice daily for hypertension. A Physicians order, with a start date of June 14, 2021, indicated [MEDICATION(S)] 75 mg, one tab daily. A quarterly Minimum Data Set (MDS) assessment, dated 9/21/21, indicated Resident 6 had a history of falls. The resident had two or more falls with no injury, since the residents admitted . Resident 6's cognitive status was severely impaired. A fall assessment, dated 6/15/21, indicated Resident 6 was at high risk for falls. Ambulatory Aids: crutches/cane/walker. A Progress Note, dated 7/10/21 at 12:39 a.m., indicted Resident 6 was found sitting on the floor, in front of his wheel chair, the resident was unable to explain what happened. No injuries were noted. An Interdisciplinary Note, dated 7/13/21 at 3:38 p.m., indicated date and time of fall, 7/20/21 at 12:31 a.m., intervention put in place: frequent checks while in bed. A Progress Note, dated 8/10/21 at 1:39 p.m., indicated Resident 6 had an unwitnessed fall at 12:45 p.m., The resident was found lying on his left side and unable to tell staff what he was doing. The resident has poor safety awareness and was hard to redirect. He is frequently standing up out of wc (wheel chair) without assistance. An interdisciplinary team (IDT) note, dated 8/31/2021 at 10:30 a.m., indicated date/time of fall: 8/30/21 at 9:00 a.m. Description of incident: Resident was in dining room noted to get up without assistance and fell to the floor. No injuries noted. Determined root cause of fall: Resident 6 gets up without help and has decreased safety awareness and is not redirectable with his safety. Intervention put in place: Resident to stay in hallway in sight of staff when up in chair. A Progress Note, dated 8/31/2021 at 8:50 p.m., indicated Resident (Resident 6) was found on the floor in front of his room. No apparent injuries noted; Moves all extremities (MAE) with out any complaints of pain or difficulty noted. A care plan, with a start date of 6/15/21 and current through 12/31/21, indicated I (Resident 6) am at risk for falls due to: history of falls, and various medications. Goal: My (Resident 6) fall risk factors will be reduced in an attempt to avoid significant fall related injury. A care plan with a start date of 08/31/2021 and current through 12/1/21, indicated Falls: PROBLEM: Resident 6 is at risk for falls due to: Poor safety awareness and impulsivity. GOAL: Resident 6 will be free of falls. Interventions included, but were not limited to: When up in wheelchair Resident 6 will be within visual site of staff members. During an observation, on 9/22/21 at 1:33 p.m. a dark purple bruise approximately 5 cm round was noted on Resident 6's left hip. During an interview, at that time, Registered Nurse 1, indicated she was not sure why the bruise was there. The clinical record lacked documentation of the bruise observed on the Residents left hip. During an observation, on 9/22/21 from 9:45 until 10:00 a.m., observed Resident 6's door to be closed. During an observation on 9/22/21 at 10:00 am, observed staff enter Resident 6's room. The resident was observed to be sitting in his wheel chair with no staff present. During an observation, at that time, Resident 6 was observed standing in his room with no staff supervision. The residents wheelchair was approximately 2 feet behind him. He was standing at his sink in his room. During an interview at that time, Nurse 1 indicated he should not be in his room without staff supervision. Observed staff enter the residents room and assist him back to his wheelchair. During an observation, on 9/24/21 at 11:17 until 11:30 a.m., observed Resident 6's door to be opened. Resident 6 was observed to be sitting in his wheelchair behind his opened door and out of the view of the facility staff. The resident was sitting in his wheel chair in his room on the other side of his door. During an observation, on 9/24/21 at 11:30 a.m., observed staff enter Residents 6's room to provide care. During an interview, on 9/23/21 at 9:23 a.m., Registered Nurse 1 indicated Resident 6's room door should always be open, so that he can be supervised due to his lack of safely awareness. On 9/22/21 at 10:12 a.m., the Director of Nursing provided a policy titled, Fall Management Program, dated November 2017, indicated .5. Residents who are categorized as moderate to high risk should have fall interventions implemented based on residents specific risk factors. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to monitor urinary output for a resident with a nephrostomy tube (a tube which drains urine directly from the kidney to a bag, outside the body, attached to the tube) for 1 of 1 resident reviewed for quality of nephrostomy care. (Resident 7) Finding includes: The clinical record of Resident 7 was reviewed on 9/22/21 at 11:08 A.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment, dated 6/25/21, indicated, Resident 7 was cognitively intact and had a nephrostomy tube. A care plan, dated 9/22/21, and current through 12/31/21, indicated, Resident 7 had a nephrostomy tube with interventions that included, but were not limited to, monitor urinary output and staff to record urinary output in ml (milliliter). On 9/23/21 at 11:10 A.M., the Director of Nursing provided a copy of a report, titled POC History Report, date range 9/20/21 to 9/23/21, and indicated this report was the point of care documentation for urinary output from Resident 7's nephrostomy. A review of the report indicated, Resident 7 had 400ml of urinary output on 9/23/21 at 8:31 A.M. During an interview, on 9/23/21 at 11:10 A.M., the Director of Nursing indicated, she was not sure why there was only one urinary output documented from 9/20/21 to 9/23/21 and she would provide Resident 7's urinary output documentation from 9/1/21 to 9/23/21. On 9/23/21 at 12:15 P.M., the Director of Nursing provided a copy of a report, titled POC History Report, date range 8/24/21 to 9/23/21, and indicated this report was the point of care documentation for urinary output from Resident 7's nephrostomy. A review of the report indicated, Resident 7's urinary output included, but were not limited to, 400ml on 8/25/21 at 11:40 A.M., 400ml on 8/27/21 at 11:41 A.M., 350ml on 8/28/21 at 11:42 A.M., 400ml on 8/29/21 at 11:42 A.M., 600ml on 8/29/21 at 11:51 A.M., 600ml on 8/30/21 at 11:43 A.M., 600ml on 8/31/21 at 11:43 A.M., 400ml on 9/1/21 at 11:43 A.M., 600ml on 9/2/21 at 9:43 A.M., 400ml on 9/3/21 at 10:43 A.M., 600ml on 9/4/21 at 11:44 A.M., 500ml on 9/5/21 at 11:44 A.M., 600ml on 9/6/21 at 1:44 P.M., 400ml on 9/7/21 at 11:45 A.M., 600ml on 9/8/21 at 11:45 A.M., 600ml on 9/9/21 at 11:45 A.M., 700ml on 9/9/21 at 11:45 A.M., 650ml on 9/10/21 at 11:46 A.M., 600ml on 9/11/21 at 11:51 A.M., 450ml on 9/12/21 at 11:46 A.M., 550ml on 9/13/21 at 11:46 A.M., 500ml on 9/14/21 at 11:46 A.M., 400ml on 9/15/21 at 11:46 A.M., 600ml on 9/16/21 at 11:47 A.M., 550ml on 9/16/21 at 11:47 A.M., 350ml on 9/17/21 at 11:47 A.M., 600ml on 9/18/21 at 11:47 A.M., 575ml on 9/19/21 at 11:47 A.M., 450ml on 9/20/21 at 11:48 A.M., 600ml on 9/21/21 at 11:48 A.M. and 500ml on 9/22/21 at 11:48 A.M. All these urinary outputs were documented by the Consultant Nurse as indicated by the report. During an interview, on 9/23/21 at 12:25 P.M., the Consultant Nurse indicated, she had not emptied the nephrostomy to get the urinary outputs herself. She got the urinary outputs from a piece of paper and entered them into the point of care computer system. She would locate the paper the outputs were written on and provide that. On 9/23/21 at 12:48 P.M., the Director of Nursing provided a copy of a document, titled Hickory Creek Output, dated September 2021, and indicated this document was used by the floor nurses to document Resident 7's urinary outputs. A review of the document indicated, the urinary outputs documented included, but were not limited to, 400ml on 9/3/21, 800ml on 9/4/21, 900ml on 9/5/21, 650ml on 9/10/21, 600ml on 9/11/21, 400ml on 9/15/21, 1150ml on 9/16/21, 350ml on 9/17/21, 600ml on 9/18/21. All these urinary outputs were documented by RN2. During an interview, on 9/24/21 at 8:40 A.M., RN 2 indicated, she had never emptied Resident 7's nephrostomy bag because Resident 7 is a retired nurse and wanted to do that herself. Also indicated, she had not documented the urinary outputs on the Hickory Creek Output document, nor documented her initials on the document. During an interview, on 9/24/21 at 9:15 A.M., the Director of Nursing indicated, she had not initiated the documentation of urinary outputs until 9/22/21. Resident 7's urinary outputs should have been documented from the time of her admission. The Consultant Nurse documented the outputs on the Hickory Creek Output document, then the Consultant Nurse looked at the Treatment Administration Record (TAR) to see which nurse worked that day and documented that nurse's initials on the document. During an interview, on 9/24/21 at 10:00 A.M., Resident 7 indicated, she emptied her own nephrostomy appliance, and she had not made staff aware of her urinary outputs, but if she needed to start telling the staff what her outputs were she would start doing that. During an observation, on 9/24/21 at 10:00 A.M., Resident 7 was in her room. Observed the nephrostomy site to the right lower back, not visible to Resident 7, with a treatment in place around the nephrostomy site, dated 9/21/21. The clinical record lacked documentation of urinary outputs from the nephrostomy. On 9/24/21 at 11:00 A.M., the Administrator provided a copy of a facility policy, titled Nephrostomy Tubes (Percutaneous), Care of, dated March 2013, and indicated this was the current policy used by the facility. A review of the policy indicated, The Physician should be notified if any of the following occur of are observed .decreased urinary output and presence of any bleeding, clots, stones, sediment and odor. 3.1-47(a)(3)

Based on interview and record review, the facility failed to ensure monitoring of side effects of a [CONDITION(S)] medication for 1 of 6 residents reviewed for unnecessary medication administration. (Resident 26) Finding includes: The clinical record for Resident 26 was reviewed on 9/21/21 09:28 A.M. Diagnoses included, but were not limited to, depressive disorder, generalized anxiety disorder, unspecified [CONDITION(S)] not due to a substance or known physiological condition, and dementia without behavioral disturbance. The Admission Minimum Data Set (MDS) assessment, dated 8/27/21, indicated, Resident 26 was cognitively intact and had symptoms of mild depression. The September 2021 Physician's orders indicated, Resident 26 was prescribed lorazepam (prescription medication used to treat anxiety) tablet 0.5mg orally three times daily (start date 8/20/21), lorazepam tablet 0.5mg orally at bedtime (start date 8/20/21), [MEDICATION(S)] tablet (a prescription anti-psychotic medication) 0.5mg at bedtime (start date 8/19/21), [MEDICATION(S)] capsule (a prescription anti-depressant medication) 30mg orally at bedtime for depression take with 60mg capsule for a total dose of 90mg (start date 8/19/21), [MEDICATION(S)] 60mg orally at bedtime for depression take with 30mg capsule for total dose of 90mg (start date 8/19/21). The September 2021 Medication Administration Record (MAR) indicated, Resident 26 has received the lorazepam 0.5mg tablets, [MEDICATION(S)] 0.5mg and [MEDICATION(S)] 30mg and [MEDICATION(S)] 60mg as ordered by the Physician. A care plan, dated 8/20/21, and current through 11/20/21, indicated, Resident 26 takes an anti-depressant medication. Intervention included, but were not limited to, I need monitored for s/s of adverse effects every shift, I need my anti-depressant reviewed regularly for therapeutic effects, review routinely through [CONDITION(S)] medication/behavior committee and I need the Physician notified if I have any adverse side effects. A care plan, dated 8/20/21, and current through 11/20/21, indicated, Resident 26 takes an anti-psychotic medication. Interventions included, but were not limited to, monitor for s/s of adverse side effects every shift, notify Physician if adverse side effects are noted, review routinely through [CONDITION(S)] medication/behavior committee. A care plan, dated 8/20/21, and current through 11/20/21, indicated, Resident 26 takes an anti-anxiety medication. Interventions included, but were not limited to, I need monitored for signs and symptoms of adverse side effects every shift, I need my Physician notified if I have any adverse side effects, I need my medications reviewed regularly for therapeutic effects, review routinely through [CONDITION(S)] medication/behavior committee. On 9/22/21 at 8:50 A.M., the Director of Nursing indicated, Resident 26 should have been monitored for side effects of lorazepam, [MEDICATION(S)] and [MEDICATION(S)]. A side effect monitoring tool was added to Resident 26's MAR yesterday (9/21/21). The clinical record for Resident 26 lacked documentation of side effect monitoring for an anti-depressant, an anti-anxiety and anti-psychotic medication. On 9/23/21 at 10:20 A.M., the Administrator provided a copy of a facility policy, titled [CONDITION(S)] Medication Monitoring Program, dated 10/2007, and indicated this was the current policy used by the facility. A review of the policy indicated, The IDT (Interdisciplinary Team) will meet monthly to review all resident who are receiving [CONDITION(S)] medication. The IDT will answer the following questions, based on a review of the resident's chart . d. is the resident free of negative side effects? 3.1-48(a)(3)

Based on record review and interview, the facility failed to ensure a discharge Minimum Data Set (MDS) assessment was coded to reflect a resident's discharge status for 1 of 3 residents reviewed for accuracy of MDS discharge assessments. (Resident 30) Findings include: The closed clinical record of Resident 30 was reviewed on 10/30/19 at 1:28 p.m. [DIAGNOSES REDACTED]. A discharge Minimum Data Set assessment, dated 10/11/19, indicated, Section A2100 03, Discharge Status .03. Acute hospital. A nursing progress note, dated 10/11/19 at 11:02 a.m., indicated, Resident discharged home, with meds (medications), with her son . Interview, on 10/30/19 at 3:05 p.m., the Director of Nursing indicated Resident 30 was discharged from the facility to her home. 3.1-31(d)

Based on interview and record review, the facility failed to ensure a resident was referred to the State-designated authority for a required yearly Level II Pre-Admission Screening Resident Review (PASRR) evaluation for 1 of 2 residents reviewed for PASRR. (Resident 10) Findings include: The clinical record of Resident 10 was reviewed on 10/30/19 at 2:23 p.m. [DIAGNOSES REDACTED]. Resident 10 was admitted to the facility on [DATE]. A Notice of PASRR Level 1 Screen Outcome, dated 4/18/18, indicated, This screen shows you need a face-to-face Level II evaluation. A Level II PASRR Assessment was done on 4/18/18, which indicated the resident was not in need of specialized mental health services and nursing facility placement was appropriate. The assessment indicated a yearly review was required. Resident 10's clinical record lacked documentation a yearly review had been done. Interview, on 11/1/19 at 9:20 a.m., the Social Service indicated a yearly review should have been completed for Resident 10. On 11/1/19 at 11:35 a.m., the Director of Nursing provided a policy, dated 5/2015, and indicated it was the policy currently used by the facility. Review of the policy indicated, .Once a resident requires a Level 2 that resident will always require a Level 2 . 3.1-16(d)(1)(B)

Based on observation, interview, and record review, the facility failed to provide activity services designed to meet the needs and interests for 3 of 5 cognitively impaired residents, reviewed for activities. (Resident 3, 13, and 11) Findings include: 1. The clinical record of Resident 3 was reviewed on 10/31/19 at 10:10 a.m., [DIAGNOSES REDACTED]. A Brief Interview for Mental Status, dated 10/28/19, indicated Resident 3's cognitive status was moderately impaired. A careplan, dated 7/25/19 and current through 1/27/2020, indicated I prefer 1:1 activities 2-3 times a week, but invite me to small group activities as well. An (MONTH) 2019 activity calendar, indicated: 1:1 activities were to be provided 31 times. The (MONTH) attendance calendar indicated Resident 3 had not received 1:1 activities for the month of (MONTH) 2019. Observation: On 10/29/19 at 10:30 a.m., 11:30 a.m. (during a work game activity), and 2:36 p.m., and during all other observations through out the day the resident was observed in bed with both eyes closed. Observation: On 10/30/19 at 8:33 a.m., 9:22 a.m., 10:05 a.m., 11:22 a.m., 2:00 p.m., and during all other observations through out the day, observed the resident in bed with both eyes closed. Observation: On 10/31/19 at 8:30 a.m., 10:45 a.m. (during a Finishing Halloween treats activity), and 1:30 p.m.(during a music program), observed resident in bed with both eyes closed. 2. The clinical record for Resident 13 was reviewed on 10/29/19 at 11:00 a.m., the record indicated [DIAGNOSES REDACTED]. A Brief Interview For Mental Status, dated 9/3/19, indicated severe impairment of cognitive status. A careplan, dated 9/3/19 and current through 2/24/20, indicated, I have certain preferences for activities that I wouldn't mind going to and observe, bible studies, movies and music. Interventions included, I would like for you to take me down to those activities I would like to go to. The (MONTH) 2019 calendar indicated: activities included, but were not limited to, 9 music events, and 5 movies. An (MONTH) 2019, attendance calendar indicated Resident 13 only received 1:1 activities and did not attend any of the other posted activities. Observation: On 10/29/19 at 10:30 a.m., 11:30 a.m. (during a work game activity), and 2:36 p.m., and during all other observations through out the day the resident was observed awake in bed. Observation: On 10/30/19 at 8:33 a.m., 9:22 a.m., 10:05 a.m., 11:22 a.m., 2:00 p.m., and during all other observations through out the day, observed the resident awake in bed. Observation: On 10/31/19 at 8:55 a.m., 9:45 a.m., 10:45 a.m. (during a finishing Halloween treats activity), at 1:30 p.m. (during a music program), and during all observations through out the day, observed the resident awake in bed. 3. The clinical record of Resident 11 was reviewed on 10/31/19 at 9:22 a.m. [DIAGNOSES REDACTED]. An annual Minimum Data Set assessment, dated 12/14/18, indicated Resident 11 was severely cognitively impaired and enjoyed listening to music, being around pets, doing things with groups of people and spending time outdoors. A careplan, dated 9/11/15 and current through 2/10/20, indicated, I need assisted to and from activities and also during activities. I am in small group activities and will participate when I am feeling up to it. I don't like being alone. I will sit in on activities I have a hobby/activity box of things that interest me . Interventions included, I will be assisted to activities sitting next to next A/D (Activity Director) or volunteer, I will be assisted to and from activities of interest. I am now in a wheel chair and unable to propel myself. I will go to outdoor activities with supervision .I will sit with A/C (Activity Coordinator) or volunteer during bingo so they may assist me. A careplan, dated 1/26/16 and current through 2/10/20, indicated, I have impaired thought processes (related to) dementia. At times I become anxious wondering what to do next. I like to have people around me to reassure me. I like to come to activities with groups of people even though I may not participate in what they are going. Interventions included simple structured activities and, 'holding my baby doll.' An Activities-Quarterly/Annual participation review, dated 8/27/19, indicated the resident attended small group activities and 1:1 (1 staff per resident) 3 times per week. She, enjoys the bible studies, music and movies, in a small group with sensory activities. An (MONTH) 2019 Activity calendar for Resident 11 indicated Resident 11 did not attend or refuse eighteen 1:1 visits, 5 music events, 5 bingo games, 7 movie events, and 1 daily devotional, which were scheduled at the facility. A (MONTH) 2019 Activity calendar for Resident 11 indicated she did not attend or refuse 12 music events, twenty one 1:1 visits, 4 bingo games and 5 bible studies and 3 movies, which were scheduled at the facility. Observation, 10/30/19 at 9:22 a.m., Resident 11 was sitting in her wheelchair in her room, facing the hallway, with her eyes open. Observation, 10/31/19 at 10:54 a.m., Resident 11 was sitting in her room in her wheelchair facing the open door to the hallway. She did not have her hobby box or baby doll near her. When she looked up, she smiled and starting talking unintelligible words. A group of residents were in the dining area putting together treats for Halloween. Observation, on 11/1/19 at 8:57 a.m., Resident 11 was sitting in her wheelchair in her room, facing the door to the hallway. Her eyes were open. The TV was not on. She did not have her hobby box or baby doll near her. She smiled and gestured to not want her to leave. Unable to have conversation due to resident having used unintelligible words. Observation, on 11/1/19 at 9:45 a.m., Resident 11 was sitting in her wheelchair facing the door to hallway, her eyes were open and the TV was not on. She did not have her hobby box or baby doll near her. Observation, on 11/1/19 at 10:23 a.m., Resident 11 was sitting in her wheelchair facing door to hallway, her eyes were open and the TV was not on. She did not have her hobby box or baby doll near her. Observation, on 11/1/19 at 11:07 a.m., Resident 11 was sitting in her wheelchair in the assist dining room facing the wall with a TV. Her back was to the room and there were no other residents in the room. She did not appear to be engaged in the program showing on the TV. Observation, on 11/1/19 at 2:05 p.m., Resident 11 was lying in her bed. Her eyes were open, her head was raised off the pillow and she waved to surveyor. A music group was performing in the dining area, which was not visible from the resident's room. On 11/1/19 at 12:50 p.m., the Administrator provided a policy, dated (MONTH) 2004, titled, Activity Services, and indicated it was the policy currently used by the facility. Review of the policy indicated, This facility will provide an ongoing program of activities designed to meet the needs and interests of each resident . 3.1-33(a)

Based on record review and interview, the facility failed to ensure resident specific interventions were implemented upon a resident's admission to prevent the development of a necrotic pressure ulcer (Resident 34) and failed to ensure a resident admitted with a Stage 1 pressure ulcer had resident specific interventions implemented to prevent the increase in severity and occurrence of three stage 2 pressure ulcers (Resident 4) for 2 of 2 residents reviewed for pressure ulcers. Findings include: 1. The closed clinical record of Resident 34 was reviewed on 10/25/17 at 9:24 a.m. [DIAGNOSES REDACTED]. Resident 34 was admitted to the facility on [DATE]. An admission nursing assessment, dated 7/21/17, indicated the resident did not have a pressure ulcer. A nurse's note, dated 7/26/17 at 9:19 a.m., indicated the resident had a red area on his right buttock, no open area noted appears as friction/shearing area from decreased mobility. A care plan, initiated 7/26/17, indicated a focus of, Area to (right) buttock which is red. I have impaired mobility due to recent hip (fracture) . Interventions included an over the bed trapeze to assist with bed mobility and reduction of friction. No other pressure relieving interventions were documented in the care plan. An admission Minimum Data Set assessment, dated 7/28/17, indicated Resident 34 needed limited assistance of 2+ staff for bed mobility and had a stage 1 pressure ulcer (intact skin with non-blanchable redness of a localized area). A skin assessment, dated 7/29/17, indicated the resident had an unstageable pressure ulcer on the right buttock., Area is closed with no drainage/odor or (signs or symptoms of) infection noted. In order to see the area you have to pull buttocks cheeks apart . Resident is on a 2 hour turn and reposition . A nurse's note, dated 8/1/17 at 7:19 a.m. indicated the resident had an open, necrotic (dead tissue) area on the coccyx. A nurse's note, dated 8/2/17 at 12:09 p.m., indicated an appointment was made for the resident at (name of local hospital) Wound Center. A care plan initiated 8/3/17, 13 days after the resident was admitted to the facility, indicated a problem of an unstageable pressure ulcer, with interventions of pressure relieving cushions for wheelchair and a low air loss mattress for the bed. A Wound Assessment, dated 8/4/17, from the Wound Center, indicated Resident 34 had an unstageable pressure ulcer on the right coccyx. Resident 34 was discharged from the facility to home on 8/15/17. Interview on 10/26/17 at 4:05 p.m., the resident's case manager at the Wound Center indicated the resident continued to come to the center for wound treatment several times after his discharge from the facility, on 8/15/17, until his pressure ulcer was healed. On 10/26/17 at 9:34 a.m., the Director of Nursing indicated she was unable to find where any pressure relieving interventions, except for the overhead trapeze, were put in place for Resident 34, between his admission on 7/21/17 and 8/4/17 (14 days after admission, 9 days after the reddened area was first noted on his right buttock). 2. The clinical record of Resident 4 was reviewed on 10/25/17 at 11:53 a.m. [DIAGNOSES REDACTED]. Resident 4 was admitted to the facility on [DATE]. A Nursing Admission Assessment, dated 5/19/17, indicated the resident had a Stage 1 pressure ulcer (intact skin with non-blanchable redness of a localized area) on right entire buttock. A nurse's note, dated 5/19/17 at 11:32 a.m., indicated, Skin issues include: .entire buttocks and coccyx area with stage 1 ulcer . A care plan, initiated 5/19/17, indicated a focus of, I am at risk for skin breakdown/pressure ulcers related to my spending a lot of time in my bed or chair, poor intake and I have episodes of incontinence. I am resistive to turning on my side . The care plan did not indicate any pressure reducing interventions were put in place, on 5/19/17, when the resident was admitted to the facility and the Stage 1 pressure on the right buttock was first observed. An admission Minimum Data Set assessment, dated 5/26/17, indicated Resident 4 need extensive assistance of 2+ staff for bed mobility and was severely impaired in the ability to make decisions. A skin assessment for Resident 4, dated 5/23/17, indicated, New area noted resident has been not wanting to get up out of bed . and ability to change position very limited. The skin assessment indicated the resident now had three Stage 2 pressure ulcers; on her left and right buttocks and her coccyx. A nurse's note, dated 5/23/17 at 1:07 p.m. indicated, Reassessment of skin to buttock area. Resident with redness noted as upon admittance with open areas on (left) buttock x 2 .and one on coccyx .Resident to be turned (every) 2 hours . On 5/23/17, new interventions were added to Resident 4's pressure ulcer care plan, initiated on 5/19/17. The new interventions included, but were not limited to, pressure relieving cushion in wheel chair and on the bed. Turning/repositioning for pressure relief was not found on the care plan. Interview on 10/27/17 at 10:10 a.m., the Director of Nursing indicated Resident 4 was very resistant to turning and indicated other repositioning approaches had not been attempted. The pressure relieving cushions for the wheel chair and bed were not in place 4 days after the resident was admitted . On 10/27/17 at 11:32 a.m., the Administrator provided a policy dated June, 2004, titled, Skin Prevention - General Principles, and indicated it was the policy currently used by the facility. The policy indicated, Any reddened area that remains longer than 15 minutes after pressure is relieved is a high-risk area for a pressure ulcer .6. Turn dependent residents every 2 hours and position with pillows or pads, protecting bony prominences .9. If redness does not readily disappear, the turning schedule should be shortened to 1 hour .10. Use pressure-reducing mattresses. 11. Use pressure-reducing pads in chairs to protect bony prominences . 3.1-40(a)(1) 3.1-40(a)(2)