Every finding on record at Homeview Center of Franklin

Based on record review and interview, the facility failed to ensure services were provided by qualified persons in accordance with the plan of care for 1 of 23 residents reviewed. A medication was not held for a resident with vital sign parameters. (Resident 5)Findings include: On 3/26/26 at 1:00 p.m., Resident 5's clinical record was reviewed. The diagnoses included, but were not limited to, atrial fibrillation (an irregular and often very rapid heart rhythm), hypertension, and hypotension. The Physician Orders included, but were not limited to:- Metoprolol succinate (medication used to treat high blood pressure and high heart rate) ER (extended release) 25 mg (milligrams), give one tablet by mouth one time day, initiated 3/14/26. Hold for blood pressure less than 100/50 mm/Hg (millimeters of Mercury) and/or pulse less than 60 beats per minute. A Medication Administration Record dated March 2026 indicated the following: - On 3/17/26 Resident 5's recorded blood pressure was 96/48 mm/Hg and her pulse was documented as 54 beats per minute. The documentation indicated metoprolol succinate ER was given at that time. - On 3/19/26 Resident 5's recorded pulse was 56 beats per minute. The documentation indicated metoprolol succinate ER was given at that time. During an interview on 3/27/26 at 9:45 a.m., the Director of Nursing (DON) indicated the metoprolol succinate ER 25 mg should not have been administered on 3/17/26 and 3/19/26 as ordered by the physician due to low pulse rate and/or low blood pressure. On 3/27/26 at 1:22 p.m., the DON provided a policy titled Following Physician orders/Parameters, dated April 2024, and indicated it was the current policy being used by the facility. A review of the policy indicated Purpose: To administer resident care in a safe and effective manner and following physician orders and ordered parameters. 410 IAC (Indiana Administrative Code) 16.2-3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to ensure 1 of 3 treatment carts that contained medicated treatments was locked and secured for 2 of 2 observations. This had the potential to affect 1 of 23 cognitively impaired self-mobile residents that resided on the 300 hall in the facility.Finding includes: 1. During a random observation on 3/30/26 from 9:44 a.m. to 9:47 a.m., an unlocked treatment cart, located on the 300 Hall, approximately 35 feet from the nurse's station, was observed to be unlocked and unsupervised. During that time, no staff were observed near the cart. Multiple residents were observed in the Activity Room that was located across the hall from the nurse's station and near where the unlocked treatment cart was located. 2. During a follow-up observation on 3/30/26 from 9:50 a.m. to 9:52 a.m., an unlocked treatment cart, located on the 300 Hall, approximately 35 feet from the nurse's station, was observed to be unlocked and unsupervised. During that time, no staff were observed near the cart. Multiple residents were observed in the Activity Room that was located across the hall from the nurse's station and near where the unlocked treatment cart was located. On 3/30/26 at 9:52 a.m., Qualified Medication Aide (QMA) 3 approached the unlocked treatment cart, located on the 300 Hall approximately 35 feet from the nurse's station. The prescribed medications contained within the cart were observed and included, but were not limited to, the following: - Bio-Freeze Cream 10% tube (temporarily relieves minor aches and pain of muscles and joints);- Hydrocortisone Cream 1% Aloe tube (used to temporarily relieve itching, redness, swelling, and irritation caused by various skin conditions);- Triamcinolon Cream 0.1% 80 grams tube (used for eczema);- Zinc oxide ointment 20% (used as a skin protection, shields skin from moisture):- Equos Wound Cleanser (spray designed for fast, gentle, and thorough cleaning of various wound stages, suitable for removing protein and wound debris);- Dakin's Solution half strength (used to clean infected skin and wounds);- Vashe Wound Solution (used to clean, irrigate and moisten acute and chronic wounds); - Hy[DATE]-0.25% (topical antimicrobial, antiseptic wound cleaner, designed to cleanse and treat infections);- Hy[DATE]-0.50% (topical antimicrobial, antiseptic wound cleaner, designed to cleanse and treat infections); and- Multiple bandages and treatment dressings. During an interview at that time, QMA 3 indicated the treatment cart was to be kept locked when unattended. On 3/30/26 at 10:10 a.m. the Director of Nursing (DON) provided a document that indicated the cognitive status of the residents who resided on the 300 Hall. A review of the document indicated 1 of 23 residents who resided on the 300 hall were cognitively impaired and self-mobile. On 3/30/26 at 10:00 a.m. the DON provided a copy of the Medication Storage policy, dated 4/16/24, and indicated it was the current policy in use by the facility. A review of the document indicated, .All drugs and biologicals will be stored in locked compartments . 410 IAC (Indiana Administrative Code) 16.2-3.1-25(m)

Based on observation, record review, and interview, the facility failed to develop a care plan for a resident with broken and missing teeth for 1 of 1 residents reviewed for dental care. (Resident 82) Finding includes: On 3/11/24 at 10:22 a.m., observed Resident 82 sitting in her wheelchair in her room. Observed Resident 82's top front teeth to be missing and front bottom teeth observed to be broken. During an interview at that time, Resident 82 indicated her teeth are falling out. On 3/12/24 at 9:30 a.m., the clinical record of Resident 82 was reviewed. The diagnosis included, but was not limited to, malnutrition. An Admission Minimum Data Set (MDS) assessment, dated 1/9/24, indicated Resident 82 had .d. Obvious or likely cavity or broken natural teeth. The clinical record lacked a person centered care plan with dental services to be provided for Resident 82. A Physicians order with a start date of 12/27/23 with no end date, indicated .Dental .to evaluate and treat as indicated. During an interview on 3/13/24 at 8:33 a.m., the Director of Nursing indicated Resident 82's clinical record lacked a person centered care plan for dental services. A dental care plan should have been developed after the Admission MDS assessment. On 3/13/24 at 10:25 a.m., the Director of Nursing provided a policy titled Dental Services, dated 11/1/23, and indicated it was the current policy being used by the facility. A review of the policy indicated Policy explanation and compliance guidelines: 1. The dental needs of each resident are identified through the physical assessment and MDS assessment process, and are addressed in each resident's plan of care. 2. Residents and/or resident representatives, during the admission process, are notified of dental services available under the State plan . 3.1-35(a)

Based on interview and record review, the facility failed to ensure student Nurse Aides (Nursing Assistant in training) were certified within the 120 day guideline of nurse aide training for 3 of 5 nurse aide records reviewed. (NA 2, NA 3, NA 4) Findings include: 1. On 3/14/24 at 11:33 a.m., the education and training record for Nurse Aide (NA) 2 was reviewed. NA 2's date of hire was 6/5/23. NA 2 began Certified Nursing Assistant (CNA) training on 6/5/23. NA 2 completed the class on 6/23/23. NA 2's student record lacked a Certification from the Indiana Department of Health, verifying Certified Nursing Assistant status. On 3/15/23 at 9:45 a.m., the Nurse Educator provided a documentation indicating NA 2's first day to work on the floor after completion of the program was 6/27/23. On 3/11/24 at 9:33 a.m., the Director of Nursing (DON) provided a current as worked schedule. The schedule indicated NA 2 continued to work for the facility as an NA. 2. On 3/14/24 at 10:00 a.m., the education and training record for Nurse Aide 3 was reviewed. NA 3 had a start date of 6/5/23. NA 3 began Certified Nursing Assistant (CNA) training on 10/9/23. NA 3 completed the class on 10/27/23. NA 3's student record lacked a Certification from the Indiana Department of Health verifying Certified Nursing Assistant status. On 3/15/23 at 9:45 a.m., the Nurse Educator provided documentation indicating NA 3's first day to work on the floor, after completion of the program, was 6/27/23. NA 3 continued to work the floor providing care to the residents. On 3/11/24 at 9:33 a.m., the DON provided a current as worked schedule. The schedule indicated NA 3 continued to work as an NA. 3. On 3/14/24 at 10:00 am., the education and training record for Nurse Aide (NA) 4 was reviewed. NA 4 had a start date of 9/5/22. NA 4 began Certified Nursing Assistant training on 10/9/23. NA 4 competed the class on 10/27/23. NA 4's student record lacked a Certification from the Indiana Department of Health, verifying Certified Nursing Assistant status. On 3/15/23 at 9:45 a.m., the Nurse Educator provided documentation indicating NA 4's first day to work on the floor, after completion of the program, was 10/30/23. NA 4 continued to work the floor providing care to the residents. On 3/11/24 at 9:33 a.m., the DON provided a current as worked schedule. The schedule indicated NA 4 continued to work as an NA on 3/12/24. During an interview on 3/11/24 at 10:00 a.m., the Education Coordinator indicated the NAs were working with a Certified Nursing Assistant on the floor in the Certified Nursing Assistant (CNA) capacity. During an interview on 3/15/24 at 8:35 a.m., the Education Coordinator indicated the test provider sent the students a link to schedule the test to be certified as a CNA. It was up to the students to respond to the link and were to set up a time to test. The Education Coordinator indicated the students had put it off and had to be reminded several times. The NA's should be certified within 120 days of completing the class. On 3/15/24 at 8:49 a.m., the Director of Nursing provided a job description for Nursing Assistant in training, dated May 2009, and indicated it was the current job description. The job description indicated The primary purpose of this position is providing indirect daily care, safety and comfort of the residents while enrolled in a training program or obtaining nursing certification.Graduating CNA students, not yet certified, may also work 120 days while awaiting their Indiana certification. On 3/15/24 at 8:49 a.m., the Director of Nursing provided a policy titled Certified Nursing Assistant, dated May 2009, and indicated it was the current policy being used by the facility. A review of the policy indicated Must possess specific educational and experience such as: .Graduating CNA students, not yet certified may also work for 120 days while awaiting their Indiana certification. 3.1-14(b)(2)(A)

Based on interview and record review, the facility failed to complete a gradual dose reduction (GDR) for a psychotropic (a medication relating to or denoting drugs that affect a person's mental state) medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 63) Finding includes: On 3/11/24 at 11:00 a.m., Resident 63's clinical record was reviewed. The diagnosis included, but was not limited to, unspecified schizophrenia (a severe, lifelong brain disorder that causes people to interpret reality abnormally). The Quarterly MDS (Minimum Data Set) assessment, dated 12/14/23, indicated Resident 63 had moderate cognitive impairment. The Care Plan included, but was not limited to: Resident 63 has a risk for side effects related to the use of antipsychotic/antianxiety medications, initiated on 1/22/21 and current through 3/17/24. The Physician's Orders included, but were not limited to: Olanzapine (an antipsychotic medication) 5 mg (milligrams) give a half tablet at bedtime for schizophrenia, initiated on 2/19/24 with no end date noted. A Pharmacy Recommendation Report, dated 1/11/24, included, but was not limited to: Gradual dose reduction due at this time for relevant medication olanzapine 5 mg HS (at hour of sleep or at bedtime) for schizophrenia. Recommend reduction to olanzapine 2.5 mg HS and monitor for increase in symptoms related to schizophrenia. The physician marked agree in response and stated, Agree to GDR [gradual dose reduction] Zyprexa [olanzapine] to 2.5 mg, PO [by mouth], QHS [every night at hour of sleep] for schizophrenia. It was signed and dated by the physician on 1/18/24. A Pharmacy Recommendation Report, dated 2/15/24, included, but was not limited to: Gradual dose reduction due at this time for relevant medication olanzapine 5 mg HS for schizophrenia. Per previous recommendation signed and dated 1/18/24, provider agreed to decrease olanzapine. No new order entered in PCC [Point Click Care, a software program used for the tracking and administration of medications, care, and treatment for residents in the facility]. Recommend decrease olanzapine per provider order. The physician marked other in response and stated, Already at current dose of 2.5 mg. It was signed and dated by the physician on 2/19/24. The EMAR (electronic medication administration record) included, but was not limited to: Resident 63's olanzapine order indicated daily administration for the dates of January 18th through the 31st of 2024, resident received olanzapine 5 mg daily at bedtime for each of the 14 days. Resident 63's olanzapine order indicated daily administration for the dates of February 1st through the 18th of 2024, resident received olanzapine 5 mg daily at bedtime for each of the 18 days. During an interview on 3/13/24 at 9:45 a.m., the DON (Director of Nursing) indicated Resident 63's olanzapine order should have been reduced from the 5 mg to the 2.5 mg dose on 1/18/24 when it was signed by the physician. On 3/13/24 at 11:30 a.m., the DON provided a policy titled Following Medication-Physician Orders/Parameters, dated March of 2022, and indicated it was the current policy in use by the facility. A review of the policy indicated instructions on administering medications in a safe and effective manner following physician orders and the review of the 6 rights of medications which includes the right dosage of medications. 3.1-48(a)(1) 3.1-48(a)(2) 3.1-48(b)(2)

Based on observation, interview, and record review, the facility failed to ensure a staff member working as the Director of Dining and Nutrition Services (Dietary Manager) had a valid and active CDM (Certified Dietary Manager) certification. This had the potential to affect 110 of 110 residents residing in the facility who received food from the kitchen. Finding includes: On 1/27/23 at 8:30 a.m., the personnel file for the Director of Dining and Nutrition Services (Dietary Manager) was reviewed. The following documents were reviewed: -The Director of Dining and Nutrition Services job description indicated, .has the authority and responsibility for assuring that established policies are carried out .regulatory compliant .the Department shall be directed on a full time basis by an individual who, by education or specialized training and experience .assuring that State/Federal regulations, specific to dining and nutrition, are met .managing food production and service, using safe, sanitary and efficient principles .managing and directing all employees of the Dining and Nutrition Services department, including hiring, training, and evaluation .must meet .criteria as defined by federal regulation .a certified dietary manager or certified food service manager . The document was signed by the staff member on 9/5/21. -The Job Description Performance Management System (JDPMS) Signature Sheet indicated, Director of Dining and Nutrition Services .I have read and received a copy of the Job Description and Performance Management System for the position . The document was signed by the staff member on 9/5/21. The record lacked supporting documentation that the Director of Dining and Nutrition Services had successfully completed and received the required Certified Dietary Manager certification. The record also lacked supporting documentation that at least two years of working experience as a Dietary Manager had been fulfilled. During an interview on 1/27/23 at 8:42 a.m., the Administrator (ADM) indicated the Director of Dining and Nutrition Services was hired in 2016 as a cook. In September of 2021, the staff member was promoted to the Director of Dining and Nutrition Services position. On 1/27/23, the staff member enrolled and had not yet begun the Become a Certified Dietary Manager online course. The ADM indicated the Registered Dietician visited the facility weekly on Mondays. During an interview on 1/27/23 at 1:48 p.m., the Director of Dining and Nutrition Services indicated he was hired at the facility in 2016 as a cook and was promoted on 9/5/21 to the Director of Dining and Nutrition Services position. He enrolled into the Certified Dietary Manager online course today (1/27/23). He indicated, previously the staff member just hadn't had time to enroll in the course. The Director of Dining and Nutrition Service job responsibilities included all aspects of the kitchen, food service, and staff supervision to ensure all regulations were met. During an interview on 1/27/23 at 1:52 p.m., the ADM indicated the facility lacked a policy regarding the Director of Dining and Nutrition Services job specific education or certification requirements. The lack of a Certified Dietary Manager resulted in a lack of direct dietary staff supervision. Cross reference F812. On 1/25/23 at 3:30 p.m., a review of the Retail Food Establishment Sanitation Requirements Title 410 IAC 7-24, effective November 13, 2004, indicated, .the person-in-charge shall demonstrate this knowledge .having a certified food employee who has shown proficiency of required information through passing a test that is of an accredited program .food employees shall wear hair restraints such as .hair coverings or nets .that are designed and worn to wear effectively keep their hair from contacting .exposed food . 3.1-20(c)

Based on observation, interview, and record review, the facility failed to serve food in a sanitary manner during 4 of 4 observations where staff's hair was uncovered potentially affecting 110 of 110 residents residing in the facility who received food from the kitchen. (Cook 2, Cook 6) Findings includes: 1. During the initial kitchen tour, on 1/23/23 from 9:00 a.m. to 9:25 a.m., observed Cook 2 walking through out the kitchen area where the noon meal was being prepared. Cook 2 was observed labeling food containers for the noon meal. Cook 2 had multiple loose hairs, approximately 4 inches in length, hanging below the neckline that were observed to not be covered. 2. During a follow-up kitchen tour, on 1/23/23 from 11:10 a.m. to 11:30 a.m., observed Cook 2 walking through out the kitchen area where the noon meal was being prepared and observed walking near the steamtable where the noon meal foods were being held. Cook 2 was observed making a lettuce and tomato sandwich for a resident. Cook 2 had multiple loose hairs, approximately 4 inches in length, hanging below the neckline that were observed to not be covered. 3. During a follow-up kitchen tour, on 1/23/23 from 12:35 p.m. to 12:49 p.m., observed Cook 2 standing at the steamtable plating the resident's noon meal. Cook 2 had multiple loose hairs, approximately 4 inches in length, hanging below the neckline that were observed to not be covered. 4. During a follow-up kitchen tour, on 1/27/23 from 1:30 p.m. to 1:40 p.m., observed Cook 6 at the food preparation table preparing stuffing for the evening meal. Cook 6 was wearing a white hair net that covered the hair located above the ears to the top of her head. The hair located from the ears to the neckline was observed to not be covered. Cook 6 had multiple loose hairs, approximately 4 inches in length, that hung below the neckline that were observed to not be covered. During an interview on 1/23/23 at 9:15 a.m., the Administrator indicated the current facility census was 110. During an interview on 1/23/23 at 12:55 p.m., the Assistant Dietary Manager indicated all staff hair was to be covered while in the kitchen. All residents residing in the facility received food from the kitchen. On 1/26/23 at 8:55 a.m., the Administrator provided a copy of the Personal Hygiene and Jewelry policy, dated June 2021, and indicated it was the current policy in use by the facility. A review of the policy indicated, .employees of the Dining and Nutrition Services Department will be expected to maintain proper personal hygiene, in compliance with the state sanitation code and follow the facility uniform policy when on duty .all employees .must wear hair restraints (hairnet, hat .) when they are in the department to prevent hair from contacting exposed food . On 1/25/23 at 3:30 p.m., a review of the Retail Food Establishment Sanitation Requirements Title 410 IAC 7-24, effective November 13, 2004, indicated, .food employees shall wear hair restraints such as .hair coverings or nets .that are designed and worn to wear effectively keep their hair from contacting .exposed food . 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure a call light was in the reach of a resident for 1 of 32 residents reviewed. (Resident 165) Finding includes: On 1/24/23 at 9:05 a.m., Resident 165 was observed in her room. Resident 165 was in her wheel chair watching television. The wheel chair was in between the bed and the wall. Resident 165's call light was observed attached to the bed and behind the resident and out of the residents view. During an interview at that time, Resident 165 indicated she was not sure where her call light was. Resident 165 was observed to look for the call light. The call light was observed to be out of the residents reach. During an interview on 1/24/23 at 9:11 a.m., Nurses Aide (NA) 3 indicated Resident 165 should have had her call light in reach. Observed NA 3 provide the call light to the resident. NA 3 placed the call light on the bed on the right side of the wheel chair. No interaction by the NA to the resident was observed. NA 3 was not observed to communicate to the resident where the call light was placed. During an interview, on 1/24/23 at 9:20 a.m., Resident 165 indicated she did not know where NA 3 had placed the call light. At that time, Resident 165 was observed looking for the call light on the left side of the wheel chair. The clinical record for Resident 165 was reviewed on 1/24/23 at 10:00 a.m. The diagnoses included, but were not limited to, unsteadiness on feet and cognitive communication deficit. An Admission Minimum Data Set (MDS) assessment, dated 1/20/23, indicated Resident 165 was cognitively intact. A Plan of Care History, dated January 2023, indicated Resident 165 required one person physical assist for all Activities of Daily Living. During an interview, on 1/27/23 at 8:45 a.m., the Director of Nursing (DON) indicated the call light should have been in reach for Resident 165. The DON also indicated NA 3 should have communicated the placement of the call light. On 1/27/23 at 9:17 a.m., the DON provided a policy titled Resident Call System, dated October 2022, and indicated it was the current policy being used by the facility. A review of the policy indicated, All residents will be instructed in the use of the call light system .The call light should be within reach of the resident. 3.1-3(v)(1)

Based on observation, record review, and interview, the facility failed implement infection control practices to prevent the spread of infections for 2 of 4 observations of resident care. Handwashing was not complete. (LPN 5, CNA 4) Findings include: 1. During an observation of wound care on 1/24/23 at 10:00 a.m., Licensed Practical Nurse (LPN) 5 was observed to perform hand hygiene for 10 seconds before completing a treatment order for Resident 165's pressure ulcer. Licensed Practical Nurse (LPN) 5 was observed to perform hand hygiene for 10 seconds after completing the treatment. During an interview on 1/26/23 at 9:55 a.m., the Infection Preventionist (IP) indicated LPN 5 should have washed her hands for at least 20 seconds before and after wound care. 2. During a catheter care observation, on 1/25/23 at 11:20 a.m., observed Certified Nursing Assistant (CNA) 4 perform hand hygiene for 10 seconds prior to providing catheter care for Resident 107. Observed CNA 4 perform hand hygiene for 10 seconds after the providing catheter care for Resident 107. During an interview on 1/26/23 at 9:55 a.m., the IP indicated CNA 4 should have washed her hands for a at least 20 seconds before and after catheter care. The IP provided a document, titled Hand Hygiene: and indicated it was the current procedure used by the facility. The procedure indicated, Why, How and When, dated June 2021, indicated Duration of the entire procedure: 20-30 seconds. On 1/26/23 at 12:15 p.m., the IP provided a policy titled, Catheter Use and Care, dated July, 2018, and indicated it was the current policy being used by the facility. A review of the policy indicated Procedure: Perform hand hygiene and put on clean gloves. On 1/26/23 at 12:15 p.m., the IP provided a policy titled, Hand Washing, revised 6/2021, and indicated it was the current policy being used by the facility. A review of the policy indicated Policy: to ensure proper hand washing before and after procedures and/or resident care to prevent the spread of infection. Procedure: Refer to who Hand Hygiene: why, how and when of the patient safety packet. 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed ensure residents were treated with dignity for 1 of 32 residents reviewed. Staff failed to acknowledge a resident while providing care and failed to inform the resident of the placement of the call light. (Resident 165) Finding includes: On 1/24/23 at 9:05 a.m., Resident 165 was observed in her room. Resident 165 was sitting in her wheel chair that was in between the bed and the wall. Resident 165's call light was observed attached to the bed and behind the resident and out of the residents view. During an interview at that time, Resident 165 indicated she was not sure where her call light was. Resident 165 was observed to look for the call light. The call light was observed to be out of the residents reach. During an interview on 1/24/23 at 9:11 a.m., Nurses Aide (NA) 3 indicated Resident 165 should have had her call light in reach. Observed NA 3 provide the call light to the resident. NA 3 placed the call light on the bed on the right side of the wheel chair. No interaction by NA 3 to the resident was observed. NA 3 was not observed to communicate to the resident where the call light was placed. During an interview on 1/24/23, at 9:20 a.m., Resident 165 indicated she did not know where NA 3 had placed the call light. Resident 165 was observed looking for the call light on the left side of the wheel chair. The clinical record for Resident 165 was reviewed on 1/24/23 at 10:00 a.m. The diagnoses included, but were not limited to, unsteadiness on feet and cognitive communication deficit. An Admission Minimum Data Set (MDS) assessment, dated 1/20/23, indicated Resident 165 was cognitively intact. A Plan of Care History, dated January 2023, indicated Resident 165 required one person physical assist for all Activities of Daily Living. During an interview on 1/27/23 at 8:45 a.m., the Director of Nursing (DON) indicated the call light should have been in reach. The DON also indicated NA 3 should have addressed the resident by name and communicated the placement of the call light. On 1/27/23 at 9:17 a.m., the DON provided a policy titled Resident Rights, undated, and indicated it was the current policy being used by the facility. A review of the policy indicated, Basic rights: You have the right to be treated with respect and dignity in recognition of your individuality and preferences. 3.1-3(a)

Based on interview and record review, the facility failed to provide supervision and assistance to prevent falls for 1 of 3 residents reviewed for falls. (Resident B) Finding includes: On 8/26/22 at 1:15 p.m., Resident's B clinical record was reviewed. The diagnoses included, but not limited to, [CONDITION(S)] with behaviors and diabetes with diabetic [CONDITION(S)]. The Quarterly MDS (Minimum Data Set) assessment, dated 7/22/22 , indicated Resident B had severe cognitive impaired. Resident B's care plan, dated 6/14/22, indicated Resident B was a risk for falls and required the limited assistance of one person for locomotion on the unit. A Progress Note, dated 8/20/22 at 4:30 p.m., indicated Resident B was receiving her shower. After the shower, CNA 1 stepped away from the shower chair to get Resident B's clothes, when Resident B attempted to sit down the shower chair moved slightly, causing Resident B to slip to the floor. Resident B did not cry out in any pain. Assessment done by the nurse, Resident B did not indicate any concerns during assessment and was dressed and taken to her room. Upon Resident B being assisted to her bed she started to complain of pain near her tailbone. Resident B's hospital records, dated 8/21/22 at 1:36 p.m., indicated a CT (computed tomorgraphy scan) included but was not limited to, acute nondisplaced fracture cannot be excluded. During an interview with the Administrator and Unit Manager on 8/26/22 at 12:54 p.m., indicated Resident B always transfered herself and when in the shower she required the assistance of one. They indicated the locks for all chairs should be locked prior to transferring residents. During an interview with RN 1 on 8/26/22 at 2:20 p.m., indicated she working on 8/20/22 when Residnet B had her fall. RN 1 indicated Resident B was receiving therapy to help return her strength. During an interview with Administrator on 8/26/22 at 2:22 p.m., he indicated after the investigation of the incident, it was found that CNA 1 failed to lock the shower chair breaks. At that time, the Administrator provided the CNA Job Specific Orientation Checklist, undated, which indicated CNA 1 was orientated on 4/24/22. On 8/26/22 at 2:22 p.m., the Administrator provided a copy of the facility policy Resident Procedure #32: Shower/Shampoo, revised 3/2017, and indicated it was the current policy used by the facility. A review of the policy indicated under # 4 Assist Resident into shower via wheelchair. Lock wheels of shower chair and transfer resident to shower chair . This Federal tag relates to Complaint IN 432. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to serve food in a sanitary manner during 4 of 4 observations where staff's hair was uncovered. (Dietary Cook 2, Dietary Manager, Dietary Aide 3, Dietary Aide 4 Findings include: 1. During the initial kitchen tour on 3/2/22 from 11:10 a.m. to 11:25 a.m., the following was observed: a. Dietary Cook 2 was observed wearing a baseball cap and a surgical face mask while walking through out the kitchen where the noon meal was being prepared. Dietary Cook 2 was observed preparing the pureed vegetables for the noon meal. Below the baseball cap, Dietary Cook 2's hair, 1/2 inch in length, was visible and was observed to not be covered. Between Dietary Cook 2's ears and the surgical face mask area facial hair, 1/2 inch in length, was visible and was observed to not be covered. b. The Dietary Manager (DM) was observed wearing a baseball cap and surgical face mask while walking through out the kitchen where the noon meal was being prepared. Below the baseball cap, the DM's hair, 1/2 inch in length, was visible and observed to not be covered. Between the DM's ears and the surgical face mask area and below the chin area, facial hair, 1/2 inch in length, was visible and was observed to not be covered. c. Dietary Aide 3 was observed walking through out the kitchen where the noon meal was being prepared. Dietary Aide 3 was observed preparing the resident food trays. Dietary Aide 3's hair, at the neckline, was 4 inches in length, was visible and was observed to not be covered. d. Dietary Aide 4 was observed wearing a cap and a surgical face mask while walking through out the kitchen where the noon meal was being prepared. Dietary Aide 4 was observed preparing the resident food trays. Below the cap, Dietary Aide 4's ponytail hair, 8 inches in length, was visible and observed to not be covered. Between Dietary Aide 4's ears and surgical face mask area and below the chin area, facial hair, 1/2 inch in length, was visible and observed to not be covered. 2. During a follow up kitchen tour on 3/2/22 from 11:35 a.m. to 11:45 a.m., the following was observed: a. The DM was observed wearing a baseball cap and surgical face mask while walking through out the kitchen where the noon meal was being prepared. While at the steamtable, the DM was observed taking and recording the initial food temperatures for the noon meal. Below the baseball cap, the DM's hair, 1/2 inch in length, was visible and observed to not be covered. Between the DM's ears and the surgical face mask area and below the chin area, facial hair, 1/2 inch in length, was visible and was observed to not be covered. b. Dietary Aide 3 was observed preparing the resident food trays for the noon meal at the steamtable. Dietary Aide 3's hair, at the neckline, was 4 inches in length, was visible and was observed to not be covered. c. Dietary Aide 4 was observed wearing a cap and a surgical face mask while walking through out the kitchen where the noon meal was being prepared. Dietary Aide 4 was observed plating the noon meal at the steamtable area. Below the cap, Dietary Aide 4's hair, at the neck line was 4 inches in length, was visible and observed to not be covered. Between Dietary Aide 4's ears and surgical face mask area and below the chin area, facial hair, 1/2 inch in length, was visible and observed to not be covered. 3. During a follow up kitchen tour on 3/2/22 from 12:40 p.m. to 12:45 p.m., the following was observed: a. The DM was observed wearing a baseball cap and surgical face mask while walking through out the kitchen where the noon meal had been prepared. While at the steamtable, the DM was observed taking and recording the ending food temperatures for the noon meal. Below the baseball cap, the DM's hair, 1/2 inch in length, was visible and observed to not be covered. Between the DM's ears and the surgical face mask area and below the chin area, facial hair, 1/2 inch in length, was visible and was observed to not be covered. b. Dietary Aide 3 was observed completing the resident food trays for the noon meal at the steamtable. Dietary Aide 3's hair, at the neckline, was 4 inches in length, was visible and was observed to not be covered. c. Dietary Aide 4 was observed wearing a cap and a surgical face mask while plating the noon meal at the steamtable. Below the cap, Dietary Aide 4's hair, at the neckline was 4 inches in length, was visible and observed to not be covered. Between Dietary Aide 4's ears and surgical face mask area and below the chin area, facial hair, 1/2 inch in length, was visible and observed to not be covered. 4. During a follow up kitchen tour on 3/7/22 from 10:05 a.m. to 10:10 a.m., the following was observed: a. Dietary Aide 4 was observed wearing a surgical face mask while stacking the clean plates at the steamtable and walking through out the kitchen where the noon meal was being prepared. Between Dietary Aide 4's ears and surgical face mask area and below the chin area, facial hair, 1/2 inch in length, was visible and observed to not be covered. b. The DM was observed wearing a baseball cap and surgical face mask while walking through out the kitchen where the noon meal was being prepared. Below the baseball cap, the DM's hair, 1/2 inch in length, was visible and observed to not be covered. Between the DM's ears and the surgical face mask area and below the chin area, facial hair, 1/2 inch in length, was visible and was observed to not be covered. During an interview on 3/7/22 at 10:15 a.m., the DM indicated all staff hair, including facial hair, was to be covered while in kitchen. On 3/7/22 at 10:45 a.m., DM provided a copy of the Dining and Nutrition Services - Personal Hygiene and Jewelry policy, dated June 2021, and indicated it was the current policy in use by the facility. A review of the policy indicated, .all employees in the Dining and Nutrition Services Department must wear hair restraints (hair net, hat, and/or beard restraint) when they are in the department to prevent hair from contacting exposed foods .employees who have visible facial hair will wear a beard guard or other facial covering at all times while working in any food service area . On 3/2/22 at 4:00 p.m., a review of the Retail Food Establishment Sanitation Requirements Title 410 IAC 7-24, effective November 13, 2004, indicated, .food employees shall wear hair restraints such as .hair coverings or nets, beard restraints .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 observation, interview, and record review, the facility failed to ensure dietary staff's hair was restrained while in the kitchen food preparation and steam table areas during the meal service. This had the potential to affect 62 of 97 residents residing in the facility who received food items from the kitchen's steam table. Findings include: On 12/4/19 from 12:35 p.m. to 12:45 p.m., observed Dietary staff 2 and Dietary staff 3 plating foods, from the kitchen's steam stable, for the noon meal. Observed Dietary staff 2 and Dietary staff 3 to have hair, on both sides of the face and at the neck's hair line, outside of the hairnet. The hairs ranged in length from 1 inch to 4 inches in length. The hair was observed to not be covered. On 12/5/19 from 11:15 a.m. to 11:25 a.m., observed Dietary staff 2, Dietary staff 3 and Dietary staff 4 in the kitchen food prep area while the noon meal was being prepared and placed into the kitchen's steam table. Dietary staff 2, Dietary staff 3, and Dietary staff 4 were observed to have hair, on both side of the face and at the neck's hair line, outside of the hairnet. The hairs ranged in length from 1 inch to 4 inches in length. The hair was observed to not be covered. Interview, on 12/5/19 at 11:25 a.m., the Dietary Manager indicated kitchen staff's hair was to be restrained. Sixty-two residents residing in the facility received food from the kitchen's steam table unit. On 12/5/19 at 1:40 p.m., the Dietary Manager provided a copy of the Personal Hygiene and Jewelry policy, dated 3/6/17, and indicated it was the current policy in use by the facility. A review of the policy indicated, .all employees in the Dining and Nutrition Services department must wear hair restraints (hairnet, hat, and/or beard restraint) when they are in the department to prevent hair from contacting exposed food . On 12/5/19 at 2:55 p.m., a review of the Retail Food Establishment Sanitation Requirements Title 410 IAC 7-24, effective (MONTH) 13, 2004, indicated, .food employees shall wear hair restraints, such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, 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 observation, interview, and record review, the facility failed to ensure a resident with contractures wore palm protectors at all times, as indicated by his plan of care, for 1 of 9 residents reviewed for contractures. (Resident 40) Findings include: On 12/4/19 at 10:03 a.m., the clinical record of Resident 40 was reviewed, [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 10/15/19, indicated Resident 40's cognitive status was moderately impaired. A care plan, dated 2/11/15 and current through 1/21/20, indicated: I need Passive Range of Motion exercises to maintain my range of motion; I am at risk for decline related to [MEDICAL CONDITION]. Interventions included but were not limited to, I will wear palm protectors at all times, you may remove for hygiene and passive range of motion. A current Certified Nursing Assistant plan of care, dated 11/15/19, indicated Resident 40 was to have palm protectors on. On 12/4/19 at 1:45 p.m., the Physical Therapy Manager provided a copy of a Therapy/Staff Communication form, dated 5/13/18. The form indicated Problems/Needs: Resident 40 is at risk for skin breakdown and further hand contractures if resident is not wearing palm guards/protectors. On 12/3/19 from 12:00 p.m. until 1:00 p.m., Resident 40 was observed in the dining room with no palm protectors. On 12/3/19 from 2:00 p.m., until 2:15 p.m., Resident 40 was observed in his room sleeping with no palm protectors. On 12/4/19 from 12:05., until 12:30., Resident 40 was observed in the dining room with no palm protectors. On 12/4/19 from 12:55 until 1:03 p.m., Resident 40 was observed in is room, alert, with no palm protectors. Interview, on 12/4/19 at 1:03 p.m., Certified Nursing Assistant (CNA) 1 indicated, We know if a resident requires palm protectors by reviewing the CNA plan of care. We normally put them on Resident 40 every morning. I'm not sure what happened today. CNA 1 was observed to then put palm protectors on the resident without difficulty. On 12/5/19 at 12:54 p.m., the Director of Nursing provided a policy titled Contractures, dated (MONTH) 2005, and indicated it was the current policy being used by the facility. A review of the policy indicated, General Considerations: .3. Use splints, palm rolls, palm cones, finger separators. A rolled washcloth in the palm of the hand can help keep the non-bony tissues stretched and to keep skin on skin contact. 3.1-42(a)(2)

Based on interview and record review, the facility failed to ensure a baseline care plan was developed for a resident who received an antipsychotic medication for 1 of 9 residents reviewed for having baseline careplans. (Resident 86) Findings include: The clinical record of Resident 86 was reviewed on 12/5/19 at 10:39 a.m. [DIAGNOSES REDACTED]. Resident 86 was admitted to the facility on [DATE]. A recapitulated physician's orders [REDACTED]. [MEDICATION NAME] is an antipsychotic medication used to [MEDICAL CONDITION] disorder. A recapitulated physician's orders [REDACTED]. A baseline careplan, for monitoring Resident 86 for side effects from this medication, was not found in the resident's clinical record. Interview, on 12/5/19 at 12:40 p.m., the Director of Nursing (DON) indicated a baseline careplan for monitoring Resident 86 for side effects of [MEDICATION NAME] had not been developed. On 12/5/19 at 3:49 p.m., the DON provided a policy, dated 6/2019, titled, Care Planning, and indicated it was the policy currently used by the facility. Review of the policy indicated, Baseline Plan of Care .will include at a minimum and will be completed within 48 hours of admission: a. Physician orders [REDACTED].

Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately coded to reflect a resident was receiving an antianxiety medication for 1 of 12 residents reviewed for accuracy of the MDS assessments. (Resident 78) Findings include: The clinical record of Resident 78 was reviewed on 12/4/19 at 3:10 p.m. [DIAGNOSES REDACTED]. A recapitulated physician's orders [REDACTED]. [MEDICATION NAME] is a controlled medication used to treat anxiety. Medication Administration Records for October, 2019, and November, 2019, indicated the resident received [MEDICATION NAME] 0.25 mg twice every day. A quarterly Minimum Data Set assessment, dated 11/12/19, did not indicate Resident received an antianxiety medication. Interview, on 12/4/19 at 11:30 a.m., the Director of Nursing indicated the quarterly MDS assessment, dated 11/12/19, should have indicated Resident 78 was receiving an antianxiety medication. 3.1-31(d)

Based on record review and interview, the facility failed to ensure a discharge Minimum Data Set (MDS) assessment was documented accurately for 1 of 3 residents reviewed for MDS discharge status. (Resident 106) Findings include: The closed clinical record of Resident 106 was reviewed on 12/5/18 at 2:23 p.m. [DIAGNOSES REDACTED]. A discharge MDS assessment, dated 10/7/18, indicated Resident 106 was discharged to an acute care hospital. A nurse's note, dated 10/7/18 at 11:23 a.m., indicated, Family into facility to pick up resident for discharge . A social service progress note, dated 10/7/18 at 12:00 p.m., indicated Resident 106 was discharged to home with his wife. During an interview on 12/5/18 at 2:36 p.m., MDS Staff 1 indicated Resident 106 was discharged to home. His discharge MDS was coded incorrectly and should have been coded as discharged to home. 3.1-31(d)

Based on observation, interview, and record review, the facility failed to ensure the facility dumpster container side door panel and lid were closed when not in use and the facility failed to ensure trash was disposed of inside the dumpster. This had the potential to affect 105 of 105 residents residing in the facility. Findings include: 1. On 12/3/18 at 10:50 a.m., the facility's outside dumpster container side panel door was observed to not be closed and no staff members were disposing of garbage at that time. The dumpster container was located on the east side of the facility next to the facility parking lot. On 12/4/18 at 4:17 p.m., the facility's outside dumpster container lid was observed to not be closed and no staff members were disposing of garbage at that time. The dumpster container was located on the east side of the facility next to the facility parking lot. During an interview, on 12/3/18 at 10:50 a.m., the DM (Dietary Manager) indicated the dumpster was to be kept closed. 2. On 12/3/18 at 10:47 a.m., the facility's outside dumpster area was observed to have an uncovered white cart next to the dumpster, located on the east side of the facility next to the facility parking lot, and no staff members were disposing of garbage at that time. The uncovered white cart contained bags of trash. On 12/3/18 at 10:50 a.m., the facility's outside dumpster area was observed to have an uncovered large round garbage can next to the dumpster, located on the east side of the facility next to the facility parking lot, and no staff members were observed disposing of garbage at that time. The uncovered garbage can contained bags of trash. During an interview, on 12/3/18 at 10:50 a.m., DM (Dietary Manager) indicated all trash was to be put inside the dumpster and all trash cans were to be kept closed. On 12/5/18 at 1:20 p.m., the DM provided a copy of the Use of Outside Waste Disposal Dumpster policy, dated 12/9/17, and indicated it was the current policy in use by the facility. A review of the policy indicated, .items to be discarded, including food waste garbage, trash and delivery packaging, will be disposed of .such items will be held for pick up in covered dumpsters in good repair .prior to disposal, all waste shall be kept in leak-proof, non-absorbent containers that are kept covered when not in use .trash will be deposited into a sealed container .the area around the dumpster will be kept clean . On 12/6/18 at 2:00 p.m., a review of the Title IAC 7-24-392(a)(2), of the Retail Food Establishment Sanitation Requirements, indicated Receptacles and waste handling units for refuse, recyclables and returnable shall be kept covered with tight-fitting lids or doors if kept outside . 3.1-21(i)(5)

Based on record review, observation, and interview, the facility failed to ensure sanitary practices were followed according to the facility policy for 101 residents served in a census of 104 (Cook #1 and Dietary Aide #2). Findings include: 1. During the kitchen tour with the Dietary Manager (D. Mgr) on 10/3/16 at 10:45 a.m., she indicated the dishwashing machine was a hot water machine. Observation of the dishwashing cycle water temperatures indicated the wash temperature was 144 degrees and the rinse cycle was 191 degrees. During an interview with the Dietary Manager at that time, she indicated the wash cycle should be 150 degrees. 2. During the kitchen tour for the lunch meal on 10/4/16 at 11:00 a.m., Cook #1 pulled down the sleeves of her sweatshirt to cover her hands. She then placed her sweatshirt covered hands on the edges of the spaghetti sauce pan and removed it from the steam table for reheating. No handwashing was observed and at that time. The D. Mgr. indicated the Cook should have used oven mitts instead of the shirt sleeves to remove the pan from the steam table. 3. During the same kitchen tour on 10/4/16 at 11:00 a.m. Dietary Aide #2 (DA) was observed to be prepping the tray line for the noon meal. She dipped food onto the first plate, placing her thumb on the edge of the plate. No handwashing was observed. The DA continued to plate food until she ran out of prepared salads. She left the tray line, placed her hand on the cooler door handle and retrieved more salad bowls, placed them in ice and continued dipping food for the meal. No handwashing was observed after returning to the tray line. On 10/4/16 at 12:15 p.m., the D. Mgr. provided the untitled and undated guidelines for the dishwashing machine temperatures currently being used by the facility. . Sanitizing Mode-Hot Water Wash Temperature, Minimum Wash 150 degrees, Recommended Wash 150 degrees, Rinse Temperature-Minimum Rinse 180 degrees, Recommended Rinse 180 degrees. On 10/4/16 at 12:25 p.m., the D. Mgr. provided the Handwashing policy and procedure, Dated 7/8 and currently being used by the facility. . Purpose of Policy & Procedure: To prevent the spread of germs and microbes found on dietary employee hands. . Process/Procedure: 1) When to wash hands: a Before starting to work . b. after handling soiled articles . 3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure a care plan, to help a resident attain his highest level of mental and psychosocial well-being, was developed for a resident receiving an anti-anxiety medication, for 1 of 5 residents who met the criteria for review of unnecessary medications. (Resident #136) Findings include: The clinical record of Resident #136 was reviewed on 10/5/16 at 2:41 p.m. [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#36 was to receive [MEDICATION NAME], 1 milligram (mg) every 12 hours for anxiety or agitation, and he could receive an additional 1 mg every 4 hours as needed. [MEDICATION NAME] is a psychoactive medication used to treat anxiety. Medication Administration Records for July, August, September, and October, 2016, indicated Resident #36 was receiving the [MEDICATION NAME] as ordered daily. A care plan for anxiety was not found in Resident #136's record. On 10/6/16 at 12:03 p.m., Social Service staff #5 indicated a care plan for anxiety had not been created for this resident. On 10/7/16 at 10:18 a.m. the Nurse Consultant provided a policy titled Psychoactive Medications/Gradual Dose Reduction Policy, dated 6/2013, and indicated it was the policy currently used by the facility. The policy indicated, .2. Residents receiving psychoactive medications will have a care plan initiated that contains interventions regarding the target behaviors . 3.1-35(a)

Based on record review and interview, the facility failed to ensure a laboratory blood test was drawn according to physician's orders, resulting in a critical lab level and emergency admission to an acute care hospital. (Resident #136) Findings include: 1. The clinical record of Resident #136 was reviewed on [DATE] at 1:19 p.m. [DIAGNOSES REDACTED]. [MEDICAL CONDITION] is a condition where the level of sodium in the blood is abnormally low. Sodium is an electrolyte which helps nerves and muscles work, and helps maintain the fluid balance in the body. Resident #136 was admitted to the facility on [DATE]. Discharge orders from the hospital, dated [DATE], indicated the resident should have a Basic Metabolic Panel (BMP) laboratory blood test drawn 2 - 3 days after her hospital discharge ([DATE]). A BMP blood test measures the electrolyte and fluid balance in the body. Review of a lab result dated [DATE] (a Friday), indicated Resident #136's sodium level was 128. The lab result indicated the normal range for sodium is ,[DATE]. A physician's order dated [DATE], indicated Resident #136 should have a BMP drawn weekly on Monday for 4 consecutive weeks. Another lab result, dated [DATE] (a Monday), ordered by the physician on [DATE], indicated the resident's sodium level was down to 122, below the normal range of ,[DATE]. No lab results were found in the resident's record for Monday, [DATE]. On [DATE] at 3:00 p.m. the Unit Manager on the 100 Hall indicated she was not aware until Thursday, [DATE], that the BMP ordered for Resident #136 to be drawn on [DATE], had not been drawn as ordered by the physician. A Stat (to be done immediately) BMP was ordered by the physician on [DATE]. The results indicated the resident's sodium level was down to 112. After the physician reviewed the sodium level at 112, the physician ordered the resident to be sent to the emergency room STAT for evaluation and treatment. A facility Change in Condition Evaluation, dated [DATE], indicated the resident had abnormal vital signs, her oxygen saturation level was decreasing, and, Labs are critical values. The nurse who filled out the evaluation indicated, RN: I think the problem may be: [MEDICAL CONDITION]. A nurse's note, dated [DATE], at 7:36 p.m., indicated, Updated on residents condition, resident admitted to (name of hospital) with [DIAGNOSES REDACTED]. A hospital Discharge Diagnosis, dated [DATE], indicated, septic shock-source [MEDICAL CONDITION]: Resolving. Acute (onset) chronic [MEDICAL CONDITION]: Resolving. Acute [MEDICAL CONDITION] secondary to pneumonia/volume overload. Volume overload means too much fluid in the blood. The hospital discharge indicated Resident #136 died on [DATE]. 3XXX,[DATE](a)