Every finding on record at Orchard Pointe Health Campus

Based on interview and record review, the facility failed to ensure a therapeutic diet, ordered by the physician to treat heart failure, was provided to 1 of 3 residents reviewed for nutritional needs (Resident D). Findings include:On 4/14/26 at 1:15 P.M., Resident D's record was reviewed. Diagnoses included hypertensive (high blood pressure) heart and chronic kidney disease with heart failure. An admission Minimum Data Set (MDS) assessment, dated 3/11/26, indicated Resident D had no cognitive impairment and no rejection of care. The MDS indicated she had not been prescribed a therapeutic diet (example: low salt) prior to or since admission to the facility. A care plan, dated 3/6/26, indicated Resident D was at risk for malnutrition due to her diagnoses, inadequate nutrient/energy intakes, and metabolic demands. The goal included the resident being able to tolerate her physician ordered Low Salt diet. Interventions included to provide her diet as ordered. A hospital Care and Services Coordination form, dated 3/4/26, indicated while hospitalized , Resident D's heart failure was treated with multiple interventions including a physician ordered therapeutic 3-gram sodium restricted regular diet. Hospital discharge orders, dated 3/5/26, were for Resident D to have a regular diet with 3-gram sodium restriction and mechanically soft foods with thin liquids. A physician's order, dated 3/5/26, was for a regular diet with thin liquids. A Dietary Tech review, dated 3/16/26 at 3:34 P.M., indicated Resident D received a regular diet. Staff were monitoring the resident's weight for changes related to fluid shifts with edema (swelling), providing diuretics (water pill) as ordered, and monitoring labs. Recommendation was to discontinue the resident's diet and change to regular diet with no added salt (NAS) to reduce some sodium at meals. A nurse note, dated 3/17/26 at 11:37 a.m., indicated Diet Tech recommendations had been noted and orders were received to change Resident D's diet to regular with NAS. A Registered Dietician note, dated 3/17/26 at 2:05 p.m., indicated Resident D's chart was reviewed. She was prescribed diuretics, had some abnormal labs, and daily weights due to 4+ pitting edema and weight gain. Resident D was anticipated to have fluid shifts due to edema, diuretics, abnormal labs, and heart failure. Her diet was to remain NAS, regular texture with thin liquids. A diet order, dated 3/17/26, was for a regular diet with ground meat. The resident may have regular bacon. Extra gravy/sauce with all ground meat. The order hadn't indicated no added salt. The dietary recommendations were not followed. On 4/14/26 at 2:40 P.M., the Director of Health Services (DHS) was interviewed. She indicated the facility received diet orders from the hospital prior to, per pre-admission hospital paperwork, and at the time of admission to the facility. Residents were to be provided with therapeutic diets as ordered by the physician. A current facility policy, titled Diet Order Formulary and Translation Guide was provided by the DHS on 4/14/26 at 4:28 p.m., which indicated each resident diet order must contain a therapeutic, texture, and liquid consistency component to ensure clarity in each order. A No Added Salt (NAS) diet order replaced physician orders for low sodium/low salt, 3G or 4 G sodium, or Cardiac/Heart Healthy diets. This Citation relates to Intake 2964186. 410 Indiana Administrative Code (IAC) 16.2-3.1-46

Based on observation, interview, and record review, the facility failed to provide dignified, timely meal service for 1 of 8 residents observed (Resident 60).Findings include:In a continuous observation, beginning on 03/09/2026 at 1:04 PM, Resident 60 was assisted to her table in the restorative dining room. Another resident was eating her lunch at the table. On 03/09/2026 at 1:17 PM, Certified Nurse Aide (CNA) 2 indicated to Resident 60 staff members were looking for her lunch tray. Resident 60 indicated she did not want to be a bother and would go back to her room without eating. CNA 2 indicated Resident 60's lunch tray would arrive soon and encouraged Resident 60 to stay. On 03/09/2026 at 1:24 PM, CNA 3 offered Resident 60 a cup of watermelon indicating Resident 60 could eat the watermelon while waiting for the meal tray to be delivered. Resident 60 again indicated she did not want to be a bother and could return to her room. CNA 6 then assisted Resident 60 to fill out a lunch order on a menu form. On 3/9/2026 at 1:33 PM, Resident 60's lunch tray was delivered. In an interview on, 03/09/2026 at 1:33 PM, Registered Nurse (RN) 4 indicated residents should be served promptly at mealtime. RN 4 indicated Resident 60 should not have had to wait so long to be served. In an interview on, 03/09/2026 1:35 PM, CNA 3 indicated she did not know what went wrong with Resident 60's meal service, CNA 3 indicated 2 staff members were asked to look for the tray on the hall tray cart or the kitchen and no one returned with the tray or any update on when the tray could be expected. CNA 3 indicated Resident 60 waited an excessive amount of time to receive her tray. Resident 60's record was reviewed on 03/09/2026 at 11:08 AM. Diagnoses included displaced intertrochanteric fracture of the left femur. A Basic Interview for Mental Status (BIMS) assessment, dated 03/07/2026 at 10:07 AM, indicated Resident 60 had a BIMS score of 13 (cognitively intact). A current care plan, titled Profile Care guide, with a goal date of 6/6/2026 indicated Resident 60 required set up assistance with meals. In an interview on, 3/11/2026 at 11:40 AM, the Director of Nursing indicated the facility did not have a policy addressing timely meal service. A current policy, titled Resident Rights Guidelines, dated 12/08/2025, provided by the Administrator on 03/11/2026 at 11:47 AM, indicated residents have a right to be treated with dignity and respect. 410 IAC 16.2- 3.1-3(a)

Based on observation, interview, and record review the facility failed to ensure showering was completed for 1 of 6 residents reviewed (Resident 65). During an interview, on 3/9/26 at 10:32 AM, Resident 65 indicated she had not had a shower since before her admission.A review of an admission BIMS (Basic Interview for Mental Status) Assessment for Resident 65 dated 3/5/26, indicated her BIMS score was 15 (cognitively intact).A review of bathing notes, dated 3/5/26-3/10/26, indicated Resident 65 had not received a shower on Saturday, 3/7/26. A partial bed bath was completed on 3/6/26, 3/7/26, 3/8/26, 3/9/26, and 3/10/26. In an interview, on 3/10/26 at 2:30 PM, Resident 65 indicated she had not showered yet and needed a shower badly.In an interview, on 3/10/26 at 2:40 PM, QMA 12 indicated Resident 65 needed 1 staff member to assist her with a shower. QMA 12 indicated they did not know when Resident 65 was due for a shower. In an interview, on 3/10/26 at 2:44 PM, RN 10 indicated they did not know when Resident 65 was due for a shower. RN 10 indicated they reviewed the electronic record, but scheduled shower days had not been assigned.A review of the Shower Schedule Binder on 3/10/26 at 2:50 PM, indicated Resident 65 was scheduled to shower on Saturdays and Wednesdays, during the day shift.A review of Resident 65's current Care plan titled Profile Care Guide, indicated the resident was to have showers twice a week, per schedule. In an interview, on 3/12/2026 at 11:22 AM, the Director of Nursing indicated showers are ordered two days a week for every resident, unless contraindicated. The Executive Director indicated in an interview on 3/12/26 at 11:28 AM, the facility did not have a policy about shower frequency.A current admission agreement indicated residents had a right to receive services in the facility with reasonable accommodation of resident needs and preferences. 410 IAC 3.1-38(a)(3)

Based on observation, interview, and record review, the facility failed to ensure choices for dining and dressing were upheld for 1 of 6 residents reviewed (Resident 60).Findings include:In an observation, on 03/09/2026 at 1:04 PM, Resident 60 was observed seated in the Restorative Dining room, fully dressed, awaiting lunch service. In an observation, on 03/10/2026 at 1:06 PM, Resident 60 was observed sitting in her bed leaning to the right with her lunch tray positioned on a tray table in front of her. In an interview, on 03/10/2026 at 1:07 PM, Resident 60 indicated she was very upset. Resident 60 indicated staff told her she could not get out of bed. Resident 60 asked if she had a terrible disease that confined her to bed she had not been told about. Resident 60 indicated she preferred to eat in the dining room, but she was not allowed to get out of bed. Resident 60 indicated she was not in a comfortable position to eat and kept falling to the right side. Resident 60's record was reviewed om 03/09/2026 at 11:08 AM. Diagnoses included displaced intertrochanteric fracture of the left femur. A Basic Interview for Mental Status (BIMS) assessment, dated 3/7/2026 at 10:07 AM, indicated Resident 60 had a BIMS score of 13 (cognitively intact). Resident 60's Inventory of Personal Items, dated 3/6/2026 at 3:34 PM, had no marks or notations recording any clothing or personal items had been inventoried for Resident 60. In an interview, on 03/10/2026 at 1:08 PM, Licensed Practical Nurse (LPN) 5 indicated Resident 60 could not get out of bed because Resident 60's family had not brought in enough clothes. LPN 5 indicated the facility has no clothing to offer to assist her to get up, only a hospital gown. In an interview, on 03/10/2026 1:11 PM, the Social Services Director (SSD) indicated staff should reach out to family to see if someone had anything they could bring when a resident did not have enough clothes. The SSD indicated the facility had donated items of all sizes that were kept on hand for occasions of clothing shortages. The SSD indicated Resident 60 had a family member who visited daily, so she did not know why Resident 60 did not have adequate clothing. The SSD indicated staff should come to the SSD office to obtain clothes when shortages occurred, but no staff had notified her of a shortage. She indicated she would notify the staff of the clothing supply in case they were not aware. In an interview, on 03/11/2026 11:44 AM, Certified Nurse Aide (CNA) 6 indicated on the morning of 3/10/2026, no pants were available in Resident 60's closet. CNA 6 indicated she checked the lost and found supply and was unable to find any pants for Resident 60. CNA 6 indicated she did not contact the SSD for additional assistance in finding clothes. CNA 6 indicated Resident 60 was positioned upright in the bed to eat her lunch, but needed frequent repositioning due to falling to the right side. A current policy, titled Resident Rights Guidelines, dated 12/08/2025, provided by the Administrator on 3/11/2026 at 11:27 AM, indicated residents had a right to enjoy full use of all areas of the campus, including dining rooms. The policy indicated residents have the right to exercise choice in daily activities. 410 IAC 16.2- 3.1-3(u)(1)

Based on interview and record review the facility failed to follow physician orders for 1 of 23 residents reviewed. (Resident 8)Findings include: Resident 8's record review, began on 03/09/2026 at 11:04 AM diagnosis included diabetes, Alzheimer's, and epilepsy. A physician order, dated 1/13/26 indicated Resident 8 was at risk for malnutrition related to comorbidities. Nursing was to monitor weight and intakes as ordered, monitor dental status to ensure ability to chew was adequate, follow up with dietitian as recommended, monitor meds for adverse effects nausea/vomiting/diarrhea, decreased appetite, monitor for any negative outcomes such as decreased oral intakes or weight loss and notify the physician every shift. Resident 8's weights documentation indicated on 2/9/26 Resident 8 weighed 175lbs and on 03/04/26 she weighed 168.8. This was a loss of 3.54% in 23 days. Resident 8's progress notes, dated March 2026, indicated there was no documentation the physician was notified of Resident 8's weight loss. In an interview, on 03/11/2026 at 8:42 AM, the Director of Nursing (DON) indicated the nursing staff fax or call the medical provider regarding resident changes or needs or place concerns in an internal communication book for the following day. The DON indicated the facility nursing staff document physician notification in a progress note. The physician communication book, dated 3/4/26 through 3/10/26, contained no documentation of physician notification for Resident 8's weight loss. In an interview, on 03/11/2026 at 10:12 AM, Qualified Medication Assistant (QMA) 7, indicated Resident 8 ate in the restorative dining room so the staff could assist him when needed and monitor his intakes. QMA 7 indicated the staff documents intakes in the medical record under intakes and outputs. QMA 7 indicated if she were to notice a change in resident eating, she would inform a nurse. In an interview, on 3/11/2026 at 10:16AM, Licensed Practical Nurse (LPN) 9 indicated when staff enter weights into the computer, nursing gets an alert in red when nursing needs to notify the dietician. LPN 9 indicated staff become concerned when residents lose 5% of body weight in 30 days and 10% of body weight in 6 months. Resident 8's intakes were reviewed between 2/9/26 and 03/04/26. The following intakes were documented as 50% or less: 3/4 lunch 26-50%2/24 breakfast zero2/20 dinner 26-50%2/19 lunch 1-25%2/18 breakfast and lunch 1-25%2/13 dinner 1-25%There was no documentation to indicate the resident was offered alternatives or supplements. In an interview, on 03/11/2026 at 10:52 AM, the DON indicated there was no documentation regarding a physician had been notified regarding Resident 8's weight loss in the communication book or in his medical record. A policy titled, Provider Notification Guidelines dated 9/12/17 last updated 12/8/25, was provided by the Executive Director on 3/11/25 at 11:31AM. The policy indicated 11. Attempts to notify the physician/provider and their response should be documented in the resident electronic health record. This policy did not include to follow physician orders. 410 IAC 16.2 3.1-37

Based on observation, interview, and record review, the facility failed to ensure food that was at proper temperature in 2 of 2 observations. Food prepared in the kitchen was consumed by 57 of 57 residents who resided in the facility. Findings include: During a continuous observation on 1/6/25 from 09:24 AM to 10:00 AM the following observation was made: The temperature of the alcohol cooler was 62 deg. Several bottles of various types of alcohol, one case of bottled water, and a cheese tray were found to be inside. Employee 2, indicated the cheese tray would be thrown away. In an interview on 01/06/25 at 02:17 PM, a resident's family member indicated the resident had complained her food was served cold sometimes. During an observation on 1/8/25 from 10:47 AM - 11:00 AM, the following observation was made: Two of three plates of pureed food, sitting on a shelf above steam table under warming lights, had a temperature measurement of 89 degrees. Resident Counsel minutes, dated 10/28/24, indicated menu changes hadn't improved much since the before month. Food was coming out cold during meal services. Dietary Aids were reaching across other plates to drop off other resident food. Resident Counsel minutes, dated 11/25/24, indicated food was coming out cold during meal services. Dietary Aides were continuing to reach across other plates to drop off resident food. Resident Counsel minutes, dated 12/30/24, indicated cold food was being served and vegetables were not being cooked all the way. A current policy, dated 1/2024, titled Hot and Cold Food Temperature Holding Guideline was provided by an administrator on 1/8/15 at 1:28 PM. The policy indicated hot food in the steam table should be at least 135 or higher degrees Fahrenheit and arrive approximately at greater than or equal to 120 degrees Fahrenheit when the resident is served. 3.1-21 (a)(1)(2)

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and serving practices for 3 of 3 observations. Food prepared in the kitchen was consumed by 57 of 57 residents who resided in the facility. Findings include: During a continuous observation on [DATE] from 09:24 AM - 10:00 AM the following observations were made: The drying rack had clear, round, lids stacked with moisture in between lids. The floor in the dishwashing area and dry pantry had dry, brown, particles in sizes from grains of sand to grains of rice. , Observations of the dry pantry included the following: An opened bottle of molasses had must a use by date of [DATE]. There were 2 onions sprouting green leaves, one with 4 inches of green growth. One onion was brown, black, and was soft. A yellow cake mix had an expired date of [DATE]. Observations in the walk-in refrigerator included the following: Six bowls of cottage cheese were uncovered and undated. There were quarter-sized areas of a white, fuzzy substance, on top of 2 strawberries. The received on date was [DATE]. There was a broken eggshell, whites, and yolk spread to a softball sized area on the floor. Observations in the walk-in freezer included the following: A frozen leftover turkey with a use by date of [DATE], was not sealed. A bag with 2 pork patties was not labeled or sealed. In an interview on [DATE] at 09:40 AM, the Director of Food Service indicated a deep floor clean was completed at the end of each day, the egg was broken during the delivery. In an interview, on [DATE] 02:53 PM, the facility administrator indicated 57 residents of 57 residents residing in the facility consumed food that was prepared in the kitchen. A current policy, dated ,d+[DATE], titled Food Labeling and Dating Policy was provided by an administrator on [DATE] at 3:24 PM. The policy indicated any product removed from its original container, has a broken seal, has been processed in any way must have a label . that contains the following: . Date and Time the food was labeled . Use by date .Securely cover the food item. A current policy, dated ,d+[DATE], titled Storage Procedures was provided by an administrator on [DATE] at 3:24 PM. The policy indicated open packages are labeled, dated, and stored in closed containers. Refrigerated storage temperature will be at 41 degrees F or below. Prepared perishables such as salads, puddings, milk, etc., are stored in a refrigerator and covered, labeled, and dated until used. All foods in the freezer are wrapped in a moisture proof wrapping or placed in suitable containers, to prevent freezer burn. Items are labeled and dated. 3XXX,d+[DATE](i)(3)

Based on observation, interview, and record review the facility failed to ensure sanitary handling of personal protective gowns for 2 of 8 residents reviewed (Resident 34 and Resident 45) and proper hand hygiene in meal service in the assisted dining room. This practice affected 7 of 10 residents who ate their meals in the assisted dining room. Findings include: 1. During an observation, on 1/7/24 at 10:32 AM, upon opening the door to Resident 45's room a yellow, disposable gown drifted into the doorway of Resident 45's door touching the doorframe, handle and door. The gown was hanging on the wall on Resident 45's roommate's side of the room near his belongings. Resident 45's bed was empty. Water was heard running in the shower of the attached bathroom. Certified Nurse Aide (CNA) 19 opened the bathroom door, and indicated Resident 45 was in the shower. CNA 19 was not wearing a gown. Resident 45s record was reviewed on 1/7/24 at 1:50 PM. Diagnoses included presence of urogenital implants, and neuromuscular dysfunction of the bladder. Resident 45's current quarterly Minimum Data Set (MDS) indicated their Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). The MDS indicated Resident 45 used an indwelling catheter. A physician's order dated 1/7/25 indicated Resident 45 should receive levofloxacin (an antibiotic) 750 mg daily for 7 days for a urinary tract infection. Resident 45's current care plan titled: Resident requires enhanced barrier precautions, indicated the resident had a problem of suprapubic catheter use, with a goal date of 4/2/25. Interventions included don/doff and dispose of PPE systematically and appropriately utilize gown and gloves per EPB policy during high contact ADL care. In an interview, on 1/7/25 at 10:32 AM, Licensed Practical Nurse (LPN) 20 indicated used gowns should not hang in the doorway of the room due to contamination risk. During an interview, on 1/7/25 at 10:35 AM, the Assistant Director of Nursing (ADON) indicated staff should be wearing gloves and a gown when performing showers for Resident 45. She indicated disposable gowns are stored in a closet in the hallway and should not be stored hanging in the doorway after use. 2. During an observation, on 1/7/24 at 10:33 AM, upon opening the door to Resident 34's room a yellow, disposable gown was observed wadded up and stuffed into the inside door handle. Resident 34's record was reviewed on 1/7/24 at 1:50 PM. Diagnoses included neuromuscular dysfunction of the bladder and gastrostomy status. Resident 34's current annual Minimum Data Set (MDS) dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). The MDS indicated Resident 34 used an indwelling catheter and a gastric tube. Resident 34's current care plan titled, Resident requires enhanced barrier precautions, indicated the resident had a problem of feeding tube and indwelling catheter use, with a goal date of 4/1/25. Interventions included don/doff and dispose of PPE systematically and utilize gown and gloves during high contact ADL care. A physician's order dated 1/7/25 indicated Resident 34 should receive cephalexin (an antibiotic) 500 mg three times daily for 7 days for a urinary tract infection. In an interview, on 1/7/25 at 10:33 AM, LPN 20 indicated used gowns should not be placed on the inside of the door handle due to contamination risk. During an interview, on 1/7/25 at 10:35 AM, the ADON indicated disposable gowns are stored in a closet in the hallway and should not be stored after use in the door handle. She indicated disposable gowns should be discarded after use. A current policy, titled Standard Precautions Guidelines, dated 5/11/16 provided by the Administrator on 1/8/24 at 12:07 PM indicated equipment or items in the resident's environment likely to have been contaminated with potentially infectious matter should be handled in such a manner to prevent transmission of infectious agents. 3. During an observation, on 1/9/25 at 9:06 AM, Qualified Medicine Aide (QMA) 21 passed trays to 6 residents seated in the assisted dining room. As she passed the trays she touched each resident's silverware, cut up and prepared residents' food and handed utensils to the residents, frequently contacting their hands, clothing and belongings. No hand hygiene was performed. Certified Nurse Aide (CNA) 22 assisted an unidentified male resident to apply a sweater and then washed her hands with 12 seconds of scrubbing. QMA 21 washed her hands with a 5- second hand scrub and returned to resident care. QMA 21 washed her hands two additional times during observation with durations of 5 and 7 seconds of scrubbing. During an interview, on 1/9/25 at 9:47 AM, CNA 22 indicated staff should sanitize their hands between each tray and perform handwashing after every third tray or when they touch a resident or contaminate their hands. She indicated scrubbing should last 20 seconds. She indicated she was in a hurry and should have washed her hands correctly. During an interview, on 1/9/25 at 9:48, QMA 21 indicated staff should scrub their hands for 60 seconds each time they washed their hands. She indicated she should have washed her hands while passing the trays but was in a hurry to get all the food out and forgot. A current policy titled Guidelines for Handwashing/Hand Hygiene, dated 5/11/16, provided by the ADON on 1/9/25 at 11:07 AM indicated hand hygiene should be performed before and after serving meals and before and after having direct contact with residents. The policy indicated handwashing should include 20 seconds of friction. 3.1-18(l)

Based on interview and record review the facility failed to ensure freedom from verbal and physical abuse for 2 of 24 residents reviewed (Resident A, and Resident B). Findings include: In a review of a written complaint on 1/6/25 at 9:24 AM, a Complainant indicated Qualified Medicine Aide (QMA) 7 had been verbally abusive to Resident A in Complaint IN00450607. The Complainant indicated a facility vendor had witnessed and reported the abuse to the Administrator. The Complainant indicated the Administrator and Assistant Director of Nursing (ADON) were aware of the abuse and did not report it to Resident A's family or the State Department of Health. The Complainant indicated QMA 7 had previous occurrences of witnessed abuse and was eligible to be rehired. During an interview on 1/7/25 at 11:27 AM, Facility Vendor 6 indicated they were present in the assisted dining room on 11/15/24 during breakfast. Vendor 6 indicated QMA 7 came into the assisted dining room with an agitated demeanor, verbally indicating displeasure about being assigned to assist in feeding residents. Vendor 6 indicated Resident A made a statement she was unable to hear to QMA 7, who was seated next to Resident A assisting him with his meal. Vendor 6 indicated QMA 7 became upset and raised her voice to Resident A. She told the resident she only disrespected him because he had disrespected her. QMA 7 then abruptly stood up, grabbed Resident A's meal tray and slammed it on the tray cart. Vendor 6 indicated QMA 7's body language appeared angry and escalated as she went over to Resident B. Resident B had been seated at a table with her clothing protector in her mouth. QMA 7 forcibly pulled the clothing protector out of Resident B's mouth verbally indicating she should not be eating laundry detergent. Vendor 6 indicated an unidentified employee came in the room and asked QMA 7 to leave the dining room and finish her medication pass. Vendor 6 indicated they had emailed the Administrator requesting a phone call since she was not present in the building at the time. Vendor 6 indicated they verbally reported the incident as described to the Administrator over the phone on 11/19/24. 1. During an interview on 1/7/25 at 3:52 PM, Resident A's Power of Attorney (POA) indicated they were not aware of any occurrences of disrespectful, rude or abusive conduct toward Resident A. The POA indicated Resident A would not have the ability to recall any abusive event that may have occurred. Resident A's record was reviewed on 1/8/24 at 11:52 AM. Diagnoses included diffuse traumatic brain injury with loss of consciousness, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and depression. Progress notes between 11/15/24 and 11/19/24 did not include any assessments or interviews with Resident A pertaining to recollection or psychosocial effects from verbal abuse. 2. Resident B's record was reviewed on 1/8/25 at 12:59 PM. Diagnoses included dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, personal history of traumatic brain injury, and mild intellectual disabilities. Resident B was unable to be interviewed about abuse. Progress notes between 11/15/24 and 11/19/24 did not include any assessments or interviews with Resident B pertaining to recollection or psychosocial effects from abuse. In an interview, on 1/8/25 at 1:51PM, Certified Nurse Aide (CNA) 11 indicated rude or inappropriate speech toward a resident should be reported to the person in charge of the shift, or the nurse management. In an interview, on 1/8/24 at 1:53 PM, Licensed Practical Nurse (LPN)12 indicated verbal abuse could include derogatory or disrespectful speech and physical abuse could include rough physical touch during care. She indicated a nurse's first action upon witnessing abuse was to call the corporate compliance hotline posted on the wall near the front office. LPN 12 walked to the sign and pointed at the phone number. In an interview, on 1/8/24 at 1:56 PM, Life Enrichment Aide (LEA) 13 indicated rough handling of a resident during care, yelling and using downgrading or derogatory speech toward residents were examples of abuse. LEA 13 indicated any witnessed abuse should be reported to the ADON or the Administrator. In an interview, on 1/8/24 at 2:01 PM, CNA 14 indicated any staff member witnessing abuse should make sure the resident was safe and then immediately report the abuse directly to the Administrator. If the Administrator was not available, staff should report to the nurse manager in charge. In a confidential interview, on 1/9/24 at 9:58 AM, Employee 18 indicated QMA 7 had contacted them and indicated she had been terminated for being verbally inappropriate with a resident and roughly pulling a clothing protector out of a resident's mouth. Employee 18 indicated they were on duty the day of the incident and no person from management had requested a statement from them about any knowledge of the incident. In an interview, on 1/9/25 at 2:49 PM, The Administrator indicated QMA 7 was disciplined on 11/19/24 because she had reportedly slammed a breakfast tray down in front of a student. She indicated this incident had been the final incident for this employee concerning conduct. She indicated she had received a report over the phone from the instructor of the CNA class, who performed clinical work in the building, QMA 7 had slammed a tray down in front of a student. She indicated the instructor did not mention anything to indicate any verbal or physical abuse had occurred. She indicated she had no reason to suspect abuse, so she did not conduct an abuse investigation. She indicated she had no statements or notes describing the incident or behavior regarding rough treatment of residents. A witness statement given by the Administrator, dated 11/19/24, presented by the ADON on 1/10/25 at 8:53 AM, indicated the CNA instructor had reported QMA 7 having negative interactions in front of residents in the dining room. The note further indicated she would have jumped in if the situation had gotten physical or abusive. A witness statement given by the ADON, dated 11/19/24, presented by the ADON on 1/10/25 at 8:53 AM indicated she interviewed QMA 7 had asked Resident A to show her respect because she showed him respect. She indicated QMA 7 denied slamming a tray down. During an interview, on 1/10/25 at 11:30 AM, Registered Nurse (RN) 19 indicated she was not aware of any inappropriate behavior at any time in the assisted dining room by any staff member. She indicated when a student or instructor noticed any inappropriate behavior, they should report it to her or an administrative staff member immediately. A current policy dated 7/2/24, titled Abuse and Neglect Procedural Guidelines, provided by the Administrator on 1/6/24 at 9:29 AM indicated physical abuse can include corporal punishment, involving physical punishment to control behavior. Mental abuse involves the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. The policy indicated occurrences of suspected abuse should be reported to the Administrator or the Administrator's designee immediately after resident safety was secured. The policy indicated physicians, consultants, volunteers and other contracted employees and providers should be provided with the Abuse and Neglect Procedural Guidelines for awareness of protocols. The policy indicated the Administrator should identify and interview all involved persons including the alleged victim, perpetrator, witnesses and all others who may have knowledge of the allegation. The Administrator should provide complete, thorough documentation of the investigations. This citation is related to complaint IN00450607. 3.1-27(b)

Based on interview and record review the facility failed to ensure an allegation of abuse was reported to the Department of Health for 2 of 24 residents reviewed (Resident A, and Resident B). Findings include: In a complaint review, on 1/6/25 at 9:24 AM, a Complainant indicated Qualified Medicine Aide (QMA) 7 had been verbally abusive to Resident A in Complaint IN00450607. The Complainant indicated a facility vendor had witnessed and reported the abuse to the Administrator. The Complainant indicated the Administrator and Assistant Director of Nursing (ADON) were aware of the abuse and did not report it to Resident A's family or the State Department of Health. During an interview, on 1/7/25 at 11:27 AM, Facility Vendor 6 indicated they were present in the assisted dining room on 11/15/24 during breakfast. Vendor 6 indicated QMA 7 came into the assisted dining room with an agitated demeanor, verbally indicating displeasure about being assigned to assist in feeding residents. Vendor 6 indicated Resident A made a statement she was unable to hear to QMA 7, seated next to Resident A assisting him with his meal. Vendor 6 indicated QMA 7 became upset and raised her voice to Resident A. She told Resident A she only disrespected him because he had disrespected her. QMA 7 then abruptly stood up, grabbed Resident A's meal tray and slammed it on the tray cart. Vendor 6 indicated QMA 7's body language appeared angry and escalated as she went over to Resident B. Resident B had been seated at a table with her clothing protector in her mouth. QMA 7 forcibly pulled the clothing protector out of Resident B's mouth. She told Resident B she should not be eating laundry detergent. Vendor 6 indicated an unidentified employee came in the room and asked QMA 7 to leave the dining room and finish her medication pass. Vendor 6 indicated they had emailed the Administrator requesting a phone call since she was not present in the building at the time. Vendor 6 indicated they verbally reported the incident to the Administrator over the phone on 11/19/24. 1. During an interview on 1/7/25 at 3:52 PM, Resident A's Power of Attorney (POA) indicated they were not aware of any occurrences of disrespectful, rude or abusive conduct toward Resident A. The POA indicated Resident A would not have the ability to recall any abusive event that may have occurred. Resident A's record was reviewed on 1/8/24 at 11:52 AM. Diagnoses included diffuse traumatic brain injury with loss of consciousness, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and depression. 2. Resident B's record was reviewed on 1/8/25 at 12:59 PM. Diagnoses included dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, personal history of traumatic brain injury, and mild intellectual disabilities. Resident B was unable to be interviewed about abuse. In an interview, on 1/9/25 at 2:49 PM, The Administrator indicated QMA 7 was disciplined on 11/19/24 because she had reportedly slammed a breakfast tray down in front of a student. She indicated this incident had been the final incident for this employee concerning conduct. She indicated she had received a report over the phone from the instructor of the CNA class, who performed clinical work in the building, QMA 7 had slammed a tray down in front of a student. She indicated the instructor did not mention anything to indicate any verbal or physical abuse. She indicated she had no reason to suspect abuse, so she did not conduct an abuse investigation, or report the incident. She indicated she had no statements or notes describing the incident or QMA 7's behavior. A current policy dated 7/2/24, titled Abuse and Neglect Procedural Guidelines, provided by the Administrator on 1/6/24 at 9:29 AM indicated the Administrator was accountable for investigating and reporting. The policy indicated the Administrator should identify and interview all involved persons including the alleged victim, perpetrator, witnesses and all others who may have knowledge of the allegation. The Administrator should provide complete, thorough documentation of the investigations. All alleged violations should be reported to the Department of Health within 24 hours of the report. This citation is related to complaint IN00450607. 3.1-28 (c)

Based on interview and record review the facility failed to ensure documentation requirements for transfer or discharge were met for 1 of 5 residents reviewed (Resident 26). Findings include: Resident 26's record was reviewed on 1/22/24 at 1:43 PM. Diagnoses included diffuse large B-cell lymphoma, unspecified site, neoplasm of uncertain behavior of the parotid salivary glands and acquired hemolytic anemia, unspecified. A review of Resident 26's current quarterly Minimum Data Set (MDS) dated [DATE] indicated her Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). An MDS dated [DATE] indicated Resident 26 had been discharged from the facility with a return anticipated. A review of progress notes dated 9/19/23 at 11:20 AM indicated Resident 26 went to a physician's office for an appointment. The next chronological progress note entry dated 9/23/23 at 9:23 PM indicated Resident 26 had returned from a hospital stay. No documentation of Resident 26's condition, documents sent, or report given was available for review. A review of a Notice of Transfer and Discharge form dated 9/19/23 indicated Resident 26 had been discharged to another health facility because her health had improved sufficiently, and she no longer needed the services provided by the facility. There was no indication on the transfer form the residnet had been transferred to the hospital. An MDS dated [DATE] indicated Resident 26 had been discharged from the facility with a return anticipated. A review of progress notes dated 10/11/23 at 3:52 PM indicated Resident 26 had a large BM that day. There was no indication the residnet had been sent to the hospital. The next chronological progress note entry dated 10/19/23 at 9:40 PM indicated Resident 26 had returned from a hospital stay. No documentation of Resident 26's condition, documents sent, or report given was available for review. A review of a Notice of Transfer and Discharge form dated 10/12/23 indicated Resident 26 had been discharged to another health facility because her health had improved sufficiently, and she no longer needed the services provided by the facility. There was no indication in the form the residnet had been sent to the hospital. In an interview on 1/24/24 at 1:43 PM, the Clinical Support Nurse (CSN) indicated nursing staff should document transfers from the facility in the medical record. She indicated documentation should include notification of family, assessment of current condition, report given to receiving facility staff, and any other pertinent information. She indicated the information should be found in progress notes, observations, or the event section of the medical record. During a record review conducted with the CSN on 1/24/23 at 1:50 PM, she indicated she was unable to find any discharge documentation in the progress notes, observations, or event section of the EMR for Resident 26 on 9/19/23 or 10/12/23. A current policy dated 7/11/23 provided by the CSN on 1/26/24 at 9:11 AM indicated nursing staff should document information regarding the transfer in the medical record. The policy indicated a discharge summary should be completed with a copy printed, signed, and scanned into the medical record. 3.1-12(a) 3

Based on observation, record review and interview the facility failed to ensure a resident's ted hose were on every morning per physician's order for 1 of 2 reviewed. (Resident 1). Findings include: During an observation on 1/22/24 at 11:25 AM Resident 1 was not wearing her TED hose on either leg. During an observation on 1/25/24 at 10:53 AM Resident 1 was not wearing her TED hose on either leg. During an observation on 1/26/24 at 9:26 AM Resident was not wearing her TED hose on either leg. During an observation on 1/26/24 at 11:45 AM Resident was not wearing her TED hose on either leg. Resident 1's record was reviewed on 01/22/24 1:30 PM, diagnoses included a history of traumatic brain injury, hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, and a history of venous thrombosis and embolism. Resident 1's current quarterly Minimum Data Set (MDS), dated [DATE], indicated her Basic Interview for Mental Status (BIMS) score was a 9 (moderate cognitive impairment). The MDS indicated the resident required substantial/maximal assistance (helper does more than half the effort) when lower body dressing and putting on and taking off footwear (socks, shoes, and other footwear). A Physician order dated 3/6/19 indicated bilateral TED hose were to be applied to the Resident 1's lower extremities (legs) every morning between 6:00 AM and 10:00 AM. There was no indication what time the TED hose were to be removed. Resident 1's current care plan titled pertinent ADLs (Activities of Daily Living) indicated the resident required staff assistance to complete ADL tasks completely and safely. The care plan indicated Resident 1 would complete ADL tasks completely and safely with a goal date 3/24/24. Interventions did not include applying bilateral TED hose to the resident's lower legs every morning. Resident 1's current care plan titled pertinent ADLs (Activities of Daily Living) indicated the resident had a potential for decline in ADL's related to chronic pain, dementia, a traumatic brain injury, hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, osteoporosis, seizures, a history of venous thrombosis and embolism, constipation, rash, cough, and dermatitis. The care plan indicated Resident 1 would be free of an ADL decline with a goal date 3/24/24. Interventions did not include applying bilateral TED hose to the resident's lower legs every morning. The Medication Administration Record (MAR) dated 1/1/24 - 1/26/24, indicated no documentation by nursing staff Resident 1's TED hose being applied or refusal by the resident every morning between 6:00 AM - 10:00 AM. The Treatment Administration Record (TAR) dated 1/1/24 - 1/26/24, indicated no documentation of Resident 1's TED hose being applied or refusal by the resident every morning between 6:00 AM - 10:00 AM. Progress notes dated 1/1/24 to 1/26/24, received 1/26/24 at 10:30 AM, indicated no documentation by nursing staff of Resident 1's TED hose being applied or refusal by the resident every morning between 6:00 AM - 10:00 AM. In an interview on 1/26/24 at 9:26 AM, QMA 1 indicated Resident 1 was not wearing TED hose. In an interview on 1/26/24 at 9:32 AM, RN 2 indicated the night shift puts on Resident 1's TED hose. A current policy, reviewed 12/31/23, titled Guidelines for Physician Services, provided by the Clinical Support Nurse on 1/26/24 at 10:30 AM, indicated physician orders should be maintained in accordance with current OBRA (Omnibus Budget Reconciliation Act - federal act setting standards of how care should be provided to nursing home residents) and campus policy. 3.1-37

Based on observation, record review and interview, the facility failed to ensure oxygen tubing was properly labeled for 2 of 2 residents reviewed. (Resident 89 and Resident 19). Findings include: 1) During an observation on 2/7/23 at 2:21 PM, Resident 89 had oxygen on at 1 liter per minute (LPM) per nasal cannula (NC) (oxygen tubing used to deliver supplemental oxygen directly through the nostrils) via a portable oxygen tank. The oxygen tubing was not labeled with a date when it had been initiated/changed. During an observation on 2/8/23 at 9:44 AM, the resident had oxygen on at 1 LPM NC via a portable oxygen tank. The oxygen tubing was not labeled with a date when it had been initiated/changed. During an observation on 2/8/23 at 1:51 PM, the resident had oxygen on at 1 LPM NC via a portable oxygen tank. The oxygen tubing was not labeled with a date when it had been initiated/changed. On 2/8/23 at 2:39 PM, Resident 89's record was reviewed. Diagnoses included bilateral pleural effusion, acute respiratory failure with hypoxia, pulmonary fibrosis, anemia in other chronic diseases, hypertensive chronic kidney disease, type 2 diabetes mellitus, peripheral vascular disease, solitary pulmonary nodule and edema. A review of Resident 89's order, dated 2/6/23, indicated she was to be on oxygen at 1 LPM NC continuous. Her oxygen tubing was to be changed monthly on the 1st day of the month. A review of the Resident 89's admission care plan, dated 2/6/23, indicated she was on oxygen at 1 LPM NC, had potential to get short of breath when lying flat, acute respiratory failure with hypoxia and pulmonary fibrosis with a goal to be free of complications from shortness of breath. One approach to this care plan was to administer oxygen per the Medical Doctor's order and as needed. In an interview on 02/08/23 at 2:15 PM, the Director of Nursing (DON) indicated Resident 89 arrived at the facility wearing 1 liter/minute (LPM) of oxygen NC and continued to wear 1 LPM of oxygen NC. In an interview on 2/8/23 at 1:51 PM, LPN 3 indicated, Resident 89's NC tubing was oxygen tubing from when the resident was in the hospital. She indicated the oxygen tubing was not labeled with a date when initiated/changed. 2) During an observation on 2/8/23 at 1:44 PM, Resident 19 had oxygen on at 2 LPM NC via a portable oxygen tank. The oxygen tubing was not labeled with a dated when initiated/changed. On 2/9/23 at 10:30 AM, Resident 89's record was reviewed. Diagnoses included chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, hypertensive heart and chronic kidney disease with heart failure, paroxysmal atrial fibrillation, shortness of breath, hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right dominant side, and edema. Resident 89's quarterly MDS assessment, dated 12/6/22, indicated the resident's Brief Interview for Mental Status (BIMS) score was 15, the resident was alert, oriented and interviewable. A review of Resident 19's order, dated 2/8/23, indicated he could use oxygen at 2 LPM per NC prn and his oxygen tubing was to be changed monthly on the 1st day of the month. A review of the Resident 19's care plan, last updated 2/7/23, indicated, he was on oxygen at 2 LPM per NC prn. The care plan indicated the resident had a potential to get short of breath when lying flat with a goal to be free of complications from shortness of breath. One approach to this care plan was to administer oxygen per the Medical Doctor's order and as needed. In an interview on 2/8/23 at 1:44 PM, LPN 3 indicated, Resident 19's NC oxygen tubing was not labeled with a date when initiated/changed. In an interview on 2/8/23 at 2:15 PM, the DON indicated the facility policy indicated oxygen tubing should be dated when it is initiated, changed monthly and as necessary (prn). On 2/7/23 at 2:50 PM, a current procedure titled Administration of Oxygen, revised 12/31/22, provided by the Executive Director, indicated oxygen tubing should be dated when it was initiated and should be changed monthly and prn. 3.1-47(a)(4)

Based on observation, interview, and record review, the facility failed to ensure safe medication storage in 1 of 1 resident room reviewed (Resident 11). During an observation on 2/7/23 at 11:06 AM 3 packets of Stimulen advanced wound healing collagen and 2 packets of skin prep were found on the sink leaning on the back of the faucet it Resident 11's bathroom. A bottle of nystatin powder was also found on the back of the toilet in Resident 11's bathroom. During an observation on 2/8/23 at 9:27 AM with the Director of Nursing (DON), a packet of Stimulen advanced wound healing collagen and two packets of skin prep were noted on bathroom sink against the back of the faucet. The DON indicated those items should not be stored in the resident's bathroom. During a record review on 2/8/23 at 11:24 AM, the record indicated Resident 11 had diagnoses including unspecified atrial fibrillation, gastro-esophageal reflux without esophagitis, and chronic pain syndrome. A Minimum Data Set (MDS) dated [DATE] included a Basic Interview for Mental Status (BIMS) score of 14 out of 15, indicating she was alert and interviewable. The MDS also indicated Resident 11 had a stage 2 pressure ulcer. A physician's order dated 1/18/23 indicated collagen powder should be applied to Resident 11's coccyx wound and covered with a foam dressing after cleansing. No order for nystatin powder was available for review. During an interview on 2/7/23 at 11:06 AM, Resident 11 indicated staff had applied a powder to a rash in her groin area. A current policy titled Medication Storage in the Facility, last revised 10/19, indicated medication supplies should be accessible to only licensed facility personnel, pharmacy personnel, and facility personnel lawfully authorized to administer medications. 3.1-25(m)

Based on record review and interview; the facility failed to ensure ongoing communication regarding [CONDITION(S)] care and services for 1 of 1 resident reviewed. (Resident 32) Findings include: A record review completed on February 24, 2022, at 4:15PM, indicated Resident 32's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 32's physician orders indicated to give a renal diet, pre-[CONDITION(S)] assessment, complete weight before and after [CONDITION(S)], and a post [CONDITION(S)] assessment. There was no order for fluid restrictions. Resident 32's care plan dated 1-21-22 indicated a problem of [CONDITION(S)] with the goal of not exhibiting signs of fluid excess. The approach on care plan included assess for fluid excess, fluid restriction per orders and to monitor weights as ordered. The care plan included the problem of renal failure which resulted in need for [CONDITION(S)]. The approach for this problem included assess access site for problems, and to coordinate care with the [CONDITION(S)] center. Other problems addressed nutrition and constipation the approach was to encourage oral intake of food and to encourage fluids. A review of Resident 32's [CONDITION(S)] center communication form indicated several details left blank in the observation detail list report. The reports were missing information. Blank areas on the [CONDITION(S)] communication forms were as follows: On 1/10/22, labs, pre weight, condition of shunt, nutrition and fluids, medications, medication changes, diet/fluid, new orders or order changes and [CONDITION(S)] center vital signs. The information from the [CONDITION(S)] center which was sent back with Resident 32 included vital signs, shunt details, medications and most recent labs and values. There was no indication from [CONDITION(S)] center regarding fluids, nutrition, or any medication changes. On 1/12/22, labs, condition of shunt, nutrition and fluids and vital signs. The post treatment form from [CONDITION(S)] center included date of last labs with results, shunt care, and vital signs. There was no information regarding nutrition and fluids from [CONDITION(S)] center. The [CONDITION(S)] center communication indicated medications were given; the form from the facility indicated none were given. On 1/14/22, pre [CONDITION(S)] weight, labs, condition of shunt, [CONDITION(S)] concerns, nutrition and fluids, medications, changes, new orders, medications given and [CONDITION(S)] center vital signs. On 1/17/22 condition of shunt, fluid restrictions, nutrition, condition changed and medications. The communication from [CONDITION(S)] center portion of form had the following blanks; labs, condition of shunt, [CONDITION(S)] concerns, nutrition and fluids, medications, changes, and vital signs. The information the facility received from [CONDITION(S)] center included a lab with the value, vitals, shunt condition, medications given, and vitals throughout session. There was no information regarding; any concerns, changes, or nutrition and fluids from [CONDITION(S)] center. On 1/19/22 fluid restrictions, condition change, and medications. On the portion of the form, communication from [CONDITION(S)] center, nutrition and fluids, new orders or changes and vital signs. The same portion of facility assessment indicated no medications were given during [CONDITION(S)]. The post treatment form did provide vital signs throughout session; it further indicated medications were given during [CONDITION(S)] ([MEDICATION(S)]). On 1/21/22 communication from [CONDITION(S)] center lacked medications, post weight and vital signs. The assessment tool did not include vital signs upon return from [CONDITION(S)]. The post treatment from [CONDITION(S)] provider included weights, medications, and vital signs. On 1/24/22 pre [CONDITION(S)] metal status or medications. On communication from [CONDITION(S)] center the following blanks occurred: medications, post weight, and vital signs. The post treatment form from [CONDITION(S)] included medications (more than just typical [MEDICATION(S)] and dressing changes), post weight, and vital signs. On 1/26/22 medications prior to [CONDITION(S)]. Communication from the [CONDITION(S)] center post weight and vital signs. The portion assessment upon return lacked new orders, vitals, and indicated no medications were given during [CONDITION(S)]. The post treatment form from [CONDITION(S)] indicated Resident 32 received medications during [CONDITION(S)], vitals and weights. On 1/28/22 communication from [CONDITION(S)] center post [CONDITION(S)] weight, medication, and vital signs. The post treatment information from the [CONDITION(S)] provider included post [CONDITION(S)] weight, medication given and vital signs. On for 1/31/22 completed on 2/22/22 the following blanks were noted: nutrition prior to [CONDITION(S)]. On the portion of the form indicated communication from [CONDITION(S)] center the following blanks occurred: labs, condition of shunt, nutrition and fluids, medications, changes, [CONDITION(S)] center vital signs. The post treatment information from the [CONDITION(S)] provider indicated last lab and value, vital signs, condition of shunt, and medications given. On 2/2/22 communication from the [CONDITION(S)] center, condition of shunt, medications, new orders, and [CONDITION(S)] center vital signs. The post treatment information from [CONDITION(S)] center indicated the condition of the shunt, medications given, and their vital signs were taken. On 2/4/22 communication from the [CONDITION(S)] center, post weight, new orders, medications, and vital signs. The post treatment information from [CONDITION(S)] center indicated the post weight, medications given during [CONDITION(S)] and vital signs. On 2/7/22 communication from the [CONDITION(S)] center, post weight and [CONDITION(S)] center vital signs. Under medications it was marked none were given at [CONDITION(S)], under labs it was marked none were drawn. The information from [CONDITION(S)] provider indicated medications were given, a lab was drawn, the value reported, the post weight, and the vital signs. On 2/9/22 communication from the [CONDITION(S)] center, the condition of the shunt and medications, and vital signs upon return. Information from the [CONDITION(S)] center included the condition of the shunt and medications given. On 2/11/22 communication from the [CONDITION(S)] center, medications and [CONDITION(S)] center vital signs. The information provided by [CONDITION(S)] center indicated the medications were given, and vital signs taken at the center. On 2/14/22 communication from the [CONDITION(S)] center; pre [CONDITION(S)] weight, medications, labs, new orders, medication changes, and [CONDITION(S)] center vital signs. The information from [CONDITION(S)] center indicated pre [CONDITION(S)] weight, medication given during [CONDITION(S)], labs last done and value, and vital signs taken at the center. On 2/16/22 communication from the [CONDITION(S)] center; medications and [CONDITION(S)] center vital signs. The information from [CONDITION(S)] center included medications given during [CONDITION(S)] and vital signs taken. On 2/18/22 the entire section titled communication from the [CONDITION(S)] center was not filled out. The information from the [CONDITION(S)] center included last lab taken and value, pre and post vital signs included weights, shunt condition, and medications given. On 2/21/22 indicated Resident 32 was on 1500ml per day fluid restriction. Communication from the [CONDITION(S)] center, [CONDITION(S)] concerns, medications, and [CONDITION(S)] center vital signs. The form further indicated no labs were drawn during the visit. The information provided by [CONDITION(S)] center included medications given, vital signs taken at the center, and a lab test was drawn on this date with value. A note to the [CONDITION(S)] center dated 2/9/22 indicated Resident 32 was on a 1500ml fluid restriction. There was no physician's order nor was the fluid restriction addressed on the care plan. In an interview, the Director of Nursing (DON) on 2/25/22 at 8:15AM, indicated the process for [CONDITION(S)] residents was for the nurse to send information with resident. This information was recorded at the facility in an observation detail form. Upon return from the [CONDITION(S)] center,the nurse should enter the information from the [CONDITION(S)] center into the observation detail form as well as their return assessment. The DON indicated the forms from the [CONDITION(S)] center were kept in her office not as part of resident chart. The DON indicated all the information on the observation detail form was to be filled out. The reports were to be filled out with information from assessment prior to the resident leaving for [CONDITION(S)]; from information reported by [CONDITION(S)] center and lastly by assessment upon return from the [CONDITION(S)] center. A policy, provided by DON on 2/25/22 at 11:16AM, indicated .4) a report (may be written or verbal) shall be requested from the [CONDITION(S)] provider will alert campus regarding. A) tolerance to procedure b) vital signs c) medications administered d) other information deemed necessary for the ongoing provision of care 3.1-37 (a)

Based on observation, interview, and record review, the facility failed to ensure infection prevention procedures regarding personal protective equipment (PPE) to prevent the potential spread of COVID-19 according to current Centers for Disease Control (CDC) guidelines. This had the potential to affect 33 of 49 residents residing in the facility. Findings include The facility policy titled COVID-19 Guideline for PPE Standard of Practice (SOP), indicated A. Guidelines for Approved facemasks . 2. All staff are always required to wear Approved Facemasks . while they are in the the facility. Yellow Zone . Staff should leave the resident care area if they need to remove the facemask. Green Zone . Staff should leave the resident care area if they need to remove the facemask During observation on 1/4/2021 at 10:19 A.M., Employee 3 was observed at the 300 hall nurses' station with her mask under her chin. Employee 3 failed to wear a mask. Employee 3 indicated she cared for 12 residents on the 300 hall. During observation on 1/4/2021 at 10:20 A.M., Employee 4 was observed at the 200 hall nurses' station with her N95 mask just under her nose. Employee 4 failed to wear the mask properly. Employee 4 indicated she cared for 20 residents on the 200 hall. During observation on 1/4/2021 at 10:21 A.M., Employee 2 was heard in the therapy room explaining to a resident the reason employees needed to be wearing face shields and indicated she, herself, did not have her mask on yet. Employee 2 was observed to be wearing a mask, but had her shield in her hand. Only one residnet was observed to be present at the time within 6 feet of the therapist. During observation on 1/4/2021 at 11:04 A.M., Employee 1 was observed sitting in the assisted living dining area with her surgical mask below her nose. Employee 1was not observed to be wearing a face shield or goggles. Employee 1 failed wear required PPE appropriately, or at all. No residnets were observed to be in the area. During an interview on 1/4/2021 at 1:30 P.M., the Executive Director indicated his expectation is that masks should be above noses, unless eating. 3.1-18(a)

The facility failed to ensure a designated charge nurse had worked in the building. This deficiency had the potential to affect 46 of 46 residents residing in the facililty. Findings include: On 8/18/19 at 3:10 P.M., during an interview Registered Nurse (RN) 2 and Licensed Practical Nurse (LPN) 4 both indicated they were not the charge nurse on duty and they were the only 2 nurse's currently on duty in the facility. On 8/18/19 at 4:00 P.M., during an interview the RN Consultant indicated one of the nurses should had been designated the charge nurse. On 8/19/19 at 11:00 [NAME]M., received from the RN Consultant the nurse's schedule dated 8/18/19 indicated RN 2 was the designated charge nurse on the evening shift. On 8/19/19 at 3:07 P.M., during an interview RN Consultant indicated the Assistant Director of Nursing should had designated a charge nurse when she had completed the nurse's schedule. The RN Consultant indicated before she had provided the evening shift nurse's schedule dated 8/18/19 neither RN 2 or LPN 4 were identified as the charge nurse. 3.1-17(b)(3)

Based on observation, interview and record review, the facility failed to ensure a restroative program was in place for 2 of 2 residents reviewed. (Resident 4, and Resident 43) This deficiency also had the potential to affect 27 of 46 residents residing in the facility. Findings include: 1. Resident 4's clinical record was reviewed on 8/19/19, at 9:50 AM and indicated he had a physician's orders [REDACTED]. A care plan for Resident 4 from 5/22/18 indicated a limited range of motion to the left hand related to a contracture. One of the approaches to be used was to apply a splint/brace per physician's orders [REDACTED]. On 8/19/19, at 10:00 AM, Resident 4 was observed in his room in a Broda chair without a splint to his left hand. On 8/19/19, at 3:44 PM, Resident 4 was observed in his room in a Broda chair without a splint to his left hand. On 08/20/19, at 9:20 AM, an observation was made with the DNS (Director of Nursing Services) of Resident 4 in his Broda chair in the common area, without a brace on his left hand. On 8/21/19, at 3:34 PM, an interview with the DNS and Nurse Consultant indicated Resident 4 should have been wearing a splint to his left hand as ordered by a physician. 2. On 8/18/19, at 5:49 PM, an interview was conducted with Resident 43. Resident 43 indicated he used to be in therapy but he wasn't anymore. Resident 43 indicated he used to walk in therapy but hasn't walked since he was discharged from therapy. Resident 43's clinical record was reviewed on 8/19/19 at 1:50 PM and indicated he was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Resident 43 had a BIMS (brief interview of mental status) score of 15, which indicated he was cognitively intact. On 8/19/19, at 2:06 PM, an interview was conducted with the Therapy Department Director who indicated the facility does not have a restorative program. The Therapy Department Director indicated the facility has a functional maintenance program. The Therapy Department Director indicated Resident 43 was in therapy from 4/30/19 to 6/28/19. On 8/19/19, at 2:28 PM, an interview was conducted with the Therapy Department Director who indicated Resident 43 was not discharged on a functional maintenance program, instead he was discharged with a home exercise program. On 8/19/19 at 2:38 PM, an interview was conducted with Resident 43. Resident 43 indicated he does not do a home exercise program. Resident 43 indicated there is a paper in his room with exercises which he indicated he does not do. On 8/19/19, at 2:47 PM, an interview was conducted with Physical Therapist (PT) 6. PT 6 indicated Resident 43 had [MEDICAL CONDITION] and his gait training, while in physical therapy from 4/30/19-6/28/19, was up and down, day by day. PT 6 indicated when Resident 43 was discharged from physical therapy on 6/28/19 he was not recommended for a walking program due to him being a fall risk. PT 6 indicated the facility had no restorative program that he could discharge Resident 43 to. PT 6 indicated while in physical therapy from 4/30/19-6/28/19, Resident 43 did make some progress in areas of transfers and upon discharge he was able to transfer with contact guard or stand by assist. PT 6 indicated he did not know if direct care staff were doing Resident 43 transfers with contact guard or stand by assist. On 8/20/19, at 11:13 AM, an interview was conducted with the DNS who indicated the facility does not have a restorative program. The DNS indicated the facility has a functional maintenance program. The DNS indicated she would provide the policy for the functional maintenance program. On 8/21/19, at 9:22 AM, an interview was conducted with the DNS who brought a policy titled Restorative/Functional Maintenance Plan and Summary, dated 5/15/16. The policy stated: Procedures: 1. The designated restorative nurse shall set an achievement goal for each program, approaches to accomplish the goal and a time frame for the goal to be accomplished. 2. The designated restorative nurse shall observe the resident's function and/or communicate with the restorative aid to assess progress towards the program goals. 3. The nurse shall document: a. Response to interventions b. Progress towards goal(s) c. Continuation of current program plan or changes to the plan. 4. Each entry shall be signed and dated by the nurse completing the form. 5. The plan of care shall be updated with the new interventions when applicable. 5. The program plan shall be evaluated with the summary written quarterly or as required by regulation. 6. The form shall be filed in the medical record upon completion. The DNS indicated the facility could not follow the policy as there is no restorative program or restorative nurse in the facility. On 8/21/19, at 10:01 AM, an interview was conducted with PT 6 who indicated Resident 43's [MEDICAL CONDITION] prevents him from remembering things from day to day. PT 6 indicated if the facility had a restorative program he would have recommended a restorative program for Resident 43. PT 6 indicated if the facility had a restorative program he would recommend all residents for the program when discharged from physical therapy. On 8/21/19 at 11:15 AM, an interview with the Therapy Department Director indicated there were 27 residents in the facility currently in physical therapy, not including Resident 43. The Therapy Department Director indicated Resident 43 had a new physical therapy evaluation completed on 8/21/19. The initial assessment indicated Resident 43's prior level (when discharged from Physical therapy on 6/28/19) for transfers, wheelchair<>mat was contact guard assist (contact with patient due to unsteadiness). The initial assessment for Resident 43 indicated his current level for transfers, wheelchair<>mat, was maximum assistance (76-99% assist). The initial assessment indicated Resident 43's prior level (when discharged from Physical therapy on 6/28/19) for transfers, stand to sit was stand by assistance (close enough to reach patient if assist needed) The initial assessment for Resident 43 indicated his current level for transfers, stand to sit was maximum assistance (76-99% assist). 3.1-42(a)(2)

Based on observation, interview and record review, the facility failed to ensure foods were properly labeled and stored, potentially affecting 45 of 46 residents in the facility. Findings include: On 8/18/19, at 5:22 PM, an observation was made in the kitchen of a box of beef patties in the freezer in an unsealed bag, open to air. In addition, a meatloaf was observed in an unclosed container, open to air, and was noted to have ices crystals on it. In the refrigerator there were 2 undated bags of chicken in a pan. On 8/18/19, at 5:30 PM, an interview was conducted with Cook 7 who indicated the chicken in the refrigerator should have been dated. Cook 7 indicated the box of beef patties and the meatloaf in the freezer should have been in closed containers.Cook 7 indicated 45 of 46 residents ate in the facility, as one resident did not eat food prepared in the kitchen. On 8/18/19, at 5:40 PM, an undated, untitled policy was provided by the nurse consultant, which indicated under the section Frozen Storage .3. All foods in the freezer are wrapped in moisture proof wrapping or placed in suitable containers, to prevent freezer burn. On 8/18/19, at 5:45 PM, the nurse consultant provided an undated policy titled: Food Labeling and Dating Policy. Under Procedures, Any food product removed from its original container, has a broken seal, has been processed in any way must have a label. 1. Item Name; 2. Date and Time the food was labeled. 3. Use by date. 3.1-21(i)(3)

Based on interview and record review, the facility failed to notify 1 of 3 family members (Resident 4) interviewed, of a significant change. Findings include. On 8/20/19, at 10:07 AM, an interview was conducted with Resident 4's wife who indicated she was not notified of a stomach x-ray which had been done a couple of months before. Review of Resident 4's clinical record indicated on 5/17/19, at 10:32 AM, a physician's orders [REDACTED]. On 5/17/19, 10:24 AM, a nurse's progress note indicate the KUB had been completed. There was no documentation Resident 4's wife was notified of the KUB physician's orders [REDACTED]. An interview with the Director of Nursing Services (DNS) was conducted on 8/21/19 at 8:55 AM. The DNS indicated there was no documentation noting Resident 4's wife had been informed before or after the KUB was done on 5/17/19. The DNS indicated Resident 4's wife should have been informed of the KUB before it was completed. On 8/21/19, at 9:00 AM, the DNS brought a policy titled Guidelines for Responsible Party Notification dated 8/1/2016. The policy indicated: Purpose: To ensure the resident's responsible party is aware of all diagnostic testing results or change in condition in a timely manner. Procedures: 1. Resident assessments for change in condition, suspected injury, event of unknown origin or ordered lab and/or other diagnostic tests should be completed immediately. 2. The responsible party should be notified of change in condition or diagnostic testing results immediately.5. Documentation of notification or notification attempts should be recorded in the EHR. (electronic health record). 3.1-5(a)(3)

Based on observation, interview, and record review, the facility failed to provide care and services to meet the physical needs for 1 of 3 residents reviewed (Resident S). The deficient practice resulted in a bowel obstruction requiring hospitalization . Findings include: On 12/19/18 at 12:35 P.M., Resident S's record was reviewed. [DIAGNOSES REDACTED]. The resident admitted to the facility from the hospital following hospitalization for a fall that occurred at home. An admission MDS (Minimum Data Set) assessment, dated 11/13/18, indicated Resident S required extensive assistance from 2 staff members for transfers and toileting. A Medicare MDS assessment, dated 11/20/18, indicated a BIMS score of 15 which signified the resident had no cognitive impairment. On 12/19/18 at 11:11 A.M., Resident S was observed sitting in a w/c (wheelchair) in his room. In an interview, he indicated he was admitted to the facility after he had fallen at home, broke his hip and hurt his right hand. He indicated his rehabilitation was going slower than expected and expressed frustration with the whole ordeal. He indicated he had pain in his lower back and right hip that was not getting better. On 12/19/18 at 1:53 P.M., Resident S was observed lying in bed. In an interview, he indicated he had recently been hospitalized for [REDACTED]. He indicated he had always had constipation and generally had a bowel movement every 2 to 3 days. Resident S stated he had been very sick and had vomited several times prior to being sent to the ER (emergency room ). He stated I never want that to happen again! He indicated the doctor had to manually remove the impaction. He indicated he did not know a bowel could stretch that far and hold so much. He stated he experienced extreme pain during and after the procedure. He stated he had screamed in pain during the entire procedure. A Care Plan, dated 11/9/18, indicated the resident had the potential for constipation. The goal was for the resident to have regular soft-formed stools. Interventions were: administer medications/enemas/suppository as ordered, document frequency and character of BM's (bowel movements), educate resident regarding the importance of responding to, rather than delaying, the urge to defecate, encourage dietary fiber intake, encourage fluid intake, encourage physical activity, position resident upright as able on bed pan for BM's, position resident upright on toilet for BM's, and provide privacy for BM's. Review of Resident Progress Notes indicated the following: On 11/24/18 at an unknown time, Physical therapy noted the resident was not feeling well and had complaints of nausea along with dry heaves. The note indicated the resident was very lethargic. He was encouraged to stay hydrated even if he didn't feel like eating. The note also indicated nursing staff had been consulted, the residents vital signs were fine, and he did not have a temperature. The note also indicated family was very concerned and didn't understand what was going on with the resident. On 11/25/18 at 1:04 p.m., the resident vomited a moderate amount of undigested food. He stated the feeling just came on all of sudden, and he was given prn (as needed) nausea medication. On 11/26/18 at 3:40 a.m., a fleets enema was given and resulted in a large BM. There were no notes related to the residents bowel status between 11/25/18 and 12/3/18. On 12/3/18 at an unknown time, Occupational therapy noted the resident had significant confusion which was unusual for the resident. On 12/3/18 at 3:18 p.m., the notes indicated the resident had increased confusion, asking repetitive questions, not recalling what had happened to him or why he was there. On 12/4/18 at 3:03 p.m., the resident continued with low appetite. New orders were obtained for [MEDICATION NAME] (appetite stimulant) 30 mg (milligrams) at bedtime and to decrease [MEDICATION NAME] (pain reliever) to 50 mg 2 times per day prn pain. On 12/8/18 at 6:36 a.m., the resident started vomiting around 5:45 a.m. He was given prn [MEDICATION NAME] (anti-vomiting/nausea). The resident had coffee ground like emesis in trash can and urinal (he had spit into). His skin was flushed, warm, and dry. He stated he felt awful and had vomited twice since given [MEDICATION NAME]. The NP (Nurse Practitioner) was notified and resident was sent to the ER. 12/8/18 at 6:56 a.m., The resident's family had been made aware of his transport to the ER. The notes indicated he left with EMT's in guarded condition. Hospital records indicated the resident was hospitalized from [DATE] until 12/12/18 for a fecal impaction in the rectum, abdominal pain secondary to constipation, and nausea and vomiting. The records indicated the following: A CT scan of the abdomen and pelvis, dated 12/8/18 at unknown time, indicated the following: No dilated loop of bowel is seen. There is a large stool ball in the rectum. Large amount of stool in the distal colon and rectum. A Physician Note, dated 12/8/18 at 2:20 p.m., indicated fecal impaction. After verbal consent, manual disimpaction was performed by the physician with copious soft and some hard stool obtained. Will give [MEDICATION NAME] (stool softener) enema and then oral [MEDICATION NAME] to soften stool. Will add [MEDICATION NAME] when the patient begins to tolerate po (by mouth) again. A Physician Note, dated 12/8/18 at 3:52 p.m., indicated patient is seen today with family at bedside. He continues to complain of abdominal pain and constipation. He denies nausea/vomiting since admission. He does not have much of an appetite; family states he is unable to consume a normal sized meal without getting sick and throwing up; this has been going on for a few weeks, at least. His last BM was 8 days ago; his regular pattern is every 2-3 days; he does have chronic constipation. He did have a few episodes of coffee ground emesis at the rehab facility yesterday. He denies bloody stools but believes there were some streaks of blood in his vomit at one point recently. He is [MEDICAL CONDITION] (high heart rate) at this time which is unusual for the patient; he is in a considerable amount of pain and feels this could be the cause. Physical assessment indicated his abdomen had bowel sounds but was tender and distended. He is alert and oriented, cognition is intact. Assessment and Plan were to give Mag [MEDICATION NAME] and if not effective, may try another enema. Consult general surgery due to impaction. Resident S's documented BM records, provided by the Clinical Support Nurse on 12/19/18 at 2:47 p.m., indicated the following: 11/19/18 at 2:25 a.m.-extra large BM 11/22/18 at 8:01 p.m.-medium BM 11/26/18 at 4:10 a.m.-large BM (after administration of enema) 11/26/18 at 9:47 a.m.-medium BM 11/26/18 at 7:45 p.m.-small BM 11/29/18 at 1:08 p.m.-medium BM 12/6/18 at 9:02 p.m.-large BM Resident S had no documented bowel movements from 11/29/18 at 1:08 p.m. until 12/6/18 at 9:02 p.m. On 12/19/18 at 2:37 P.M., LPN 2 (Licensed Practical Nurse) and RN 3 (Registered Nurse) were interviewed. During the interview, RN 3 indicated the facility had a bowel management program. She indicated if a resident did not have a BM in 3 days, the staff would intervene and implement the program. LPN 2 indicated nurses are made aware of residents lack of BM and need for intervention via a CQI report given to them every day, Monday through Friday. She indicated the third shift nursing staff reviewed the BM records and would write on the report which residents needed medications to treat constipation. Residents would be administered PRN medications as ordered for constipation which would then be documented in the MAR (Medication Administration Record). Daily CQI Reports, provided by the Clinical Support Nurse on 12/19/18 at 2:47 P.M., indicated the following: The reports for Monday 12/3/18, Tuesday 12/4/18, and Friday 12/5/18 did not indicate Resident S hadn't had a BM and he was not listed as needing prn medication for constipation. The report for Wednesday, 12/5/18, indicated Resident S was on the list for prn medication due to the lack of BM. The list indicated the residents last BM was 11/29/18. There were no Daily CQI Reports available for 11/30 or 12/6/18. The (Medication Administration Record) MAR's for (MONTH) (YEAR) indicated the resident had PRN orders for the following: [MEDICATION NAME] (stool softener) 10 mg 1 rectally every day as needed for constipation (ordered 11/25/18), and [MEDICATION NAME] 17 gms (grams)/dose; administer 17 gms by mouth once a day as needed for constipation (ordered 11/7/18). A Physician order, dated 11/6/18 at an unknown time, was to utilize bowel protocol as needed. Special instructions attached to the order indicated: When needed, enter bowel protocol order set. Bowel Protocol-If no bowel movement within 72 hours; give 2 tablespoons (30 ml) of Natural Laxative by mouth once a day as needed for constipation (ordered 11/9/18). If no results within 24 hours, after Natural Laxative, give 30 ml Milk of Magnesia (MOM) by mouth once a day as needed for constipation (ordered 11/10/18). If no results within approximately 12 hours of above MOM administration, give [MEDICATION NAME] suppository once a day as needed for constipation (ordered 11/10/18). The (MONTH) (YEAR) MAR indicated [REDACTED]. On 12/19/18 at 4:45 P.M., the DHS (Director of Health Services) was interviewed. During the interview, she indicated it was her understanding that the resident had been having BM's however, they were not documented. She indicated nursing staff should have followed the bowel protocol per the facility policy. On 12/19/18 at 2:47 P.M., the Clinical Support Nurse provided a current copy of the facility's policy titled Bowel Protocol Guidelines updated 11/9/17 which stated the following: Purpose: To provide guidance for the use of bowel stimulants for residents with constipation. Procedures: 1. Upon admission, an order may be obtained to Utilize Bowel Protocol as needed. 2. If the resident needs to utilize the bowel protocol, the Bowel Protocol order may be opened and orders entered from order set. 3. The Ineffective Bowel Pattern Event should be initiated for any resident not having a BM with 72 hours (unless this has been determined to be a usual bowel pattern for the individual). a. A progress note associated to the Ineffective Bowel Event, should be completed until the resident has a BM or the bowel pattern returns to normal for the resident. The progress note should include abdominal distention, pain and bowel sounds. 4. Nursing staff shall assess for effectiveness, orders my be written as follows: a. If no bowel movement within 72 hours, 2 tablespoons (30 cc) of 'Natural Laxative'. b. If no results within 24 hours, after 'natural laxative' give 30 cc of Milk of Magnesia. c. If no results within approximately 12 hours after MOM administer [MEDICATION NAME] suppository. d. If results of suppository are not satisfactory within 2 hours give Fleets enema. 5. If at any time there are indications of a bowel blockage the physician should be notified to receive instructions to proceed with the protocol or to intervene with further testing .7. Nursing staff will enter bowel movements, in the CareTracker system shiftly. This Federal tag relates to Complaint IN 432. 3.1-37(a)