Every finding on record at Waters of Dunkirk Skilled Nursing Facility, The

A. Based on observation, interview, and record review, the facility failed to ensure food was prepared and served under safe and sanitary conditions regarding food handling, lack of hair restraint use, dented can handling, and hand washing. This deficient practice had the potential to impact 44 of 44 residents who received their meals from the kitchen.B. Based on observation, interview, and record review, the facility failed to ensure food was distributed in a sanitary manner when meal trays prepared for room delivery were left uncovered during random observations.Findings include: A.1.During an initial kitchen observation, on 5/26/26 at 10:01 a.m., the following was observed: To the left of the kitchen door, numerous bowls and plates were stored face up on a small two-shelf wheeled cart. There was a sign taped to the cart indicating items needed to be stored face down. In the dry storage room, two cans of beans, with dented top seals, were in the serving area mixed in with other canned items. A large freezer, on the back side of the prep table, had an opened cardboard box on the bottom shelf. Inside the cardboard box was an open plastic bag containing a cheese pizza, which was not covered and opened to air. During the observation, the Dietary Manager (DM) indicated all stored items should be covered. The dented cans should not have been mixed in with other cans in the serving area. Those cans should have been pulled off the shelf. All plates, bowls, and pans should be stored face down. A.2.During a continuous lunch observation, on 5/26/26 from 11:50 a.m. to 12:45 p.m., the following was observed: Facial hair coverings were not worn by the dietary staff while plating food. The DM had a beard and Dietary Employee 4 (DE 4) had a mustache. The DM dropped a paper towel he had used to dry his hand onto the floor. The DM picked up the piece of paper towel from the floor and discarded it into a trashcan. Without rewashing his hands, the DM applied gloves and began to plate food. DE 4 placed his gloved hands on the top and the sides of an open-faced, slotted, metal food cart and turned the cart around. DE 4 slid uncovered pieces of cake between the slots onto the meal trays. DE 4's left hand rested on his knee and the back of his upper pants leg during this process. DE 4's right-gloved thumb touched several pieces of cake as he slid them between the slots on the food cart. DE 4 performed hand hygiene and put on clean gloves. With his gloved hands, DE 4 retrieved a bread bag from the prep station, untwisted the opening of the bag, reached into the bag, and removed a slice of bread. DE 4 held the slice of bread in his right hand and used his left hand and arm to twist the bread bag closed against his shirt. DE 4 handed the piece of bread to the DM, who grasped the bread with his gloved hand and placed the slice of bread into a container above the steam table. Without changing gloves, DE 4 retrieved a nutritional shake, opened the carton, and poured it into a plastic cup. DE 4 took the empty carton and walked across the kitchen to the trash can. He lifted the trash can lid with his hand, discarded the empty carton, and replaced the trash lid with his hand. DE 4 returned to the serving line. No hand hygiene or change of gloves was done before DE 4 went back to the serving line. DE 4 touched meal trays and the back of his shirt as he waited to plate food items. With his gloved hands, DE 4 touched the front of his apron and placed both gloved hands into his pant pockets. DE 4 plated bread sticks with his (same) gloved hands. With gloved hands, the DM took a stack of meal tickets from the dining staff and handed them to DE 4. The DM continued to plate food with the same gloved hands. The DM touched the food portion areas of plates as he laid them in a row on the serving counter. The DM plated food items onto the areas he had touched. The DM instructed DE 4 to retrieve more bowls. DE 4 carried a stack of bowls in each of his gloved hands. The bottom of the bowls rested in DE 4's palms and his thumbs touched the inside food portion of the bowls. The DM placed the bowls on the previously plated plates. The outside of the bowls touched the already plated items. The DM plated food into the bowls where DE 4 had touched. The DM carried a bowl over to the prep table. The DM's gloved thumb touched the food portion of the bowl. The DM opened a utensil drawer on the prep table and retrieved a scoop. As he retrieved the scoop, a pair of tongs fell to the floor. The DM picked up the tongs from the floor and tossed them onto the prep table. The DM proceeded to walk over to the steam table, placed the scoop into the prepared food, and plated the food into the bowl where his thumb had previously touched. Wearing the same gloves, DE 4 reached underneath a countertop, obtained condiments, and placed them on a meal tray. DE 4 continued to assist with plating and serving items. He retrieved two cloth napkins and clean silverware. He wrapped two sets of silverware and took them over to the serving area. Without changing gloves, the DM, touched the outside of the bread bag, opened the bag, a reached in the bread bag with his gloved hand, and retrieved two slices of bread. The DM placed a food item between the two slices of bread and then pushed down on the bread with his palm of his gloved hand. The dining staff informed the DM they needed more pureed food. The DM performed hand hygiene and put on gloves. The DM retrieved two bowls from the dishwasher rack. He touched the food portion of the bowls. The DM retrieved a gallon of white milk from the dining staff. Using his gloved hands, the DM tore up a breadstick and placed it into the blender. The DM removed the milk container's lid and poured a small portion of milk into the blender. The blender lid was placed on the blender and turned on. The DM rested his left gloved hand on his left hip. The DM opened a utensil drawer and retrieved two spatulas. He touched the food portion of the spatulas. Once the mixture was the correct consistency, the DM scooped the mixture into the food portion of the bowl where he had touched and handed it to the dining staff. The DM took the blender and spatula to the dishwasher and ran them through a cycle. The DM then took the blender back to the prep table. The DM placed a piece of cake in the blender, poured a small amount of milk in with the cake, placed the lid on the blender, and turned it on. He placed both gloved hands on his hips as he waited for the blender. Once the mixture was the correct consistency, the DM scooped the mixture into the food portion of the bowl he had touched and handed it to the dining staff. The same gloves were worn by the DM throughout the puree observation. During an interview, on 5/26/26 at 12:45 p.m., the DM indicated he should not have touched the food portion of the plates. He should have washed his hands and changed his gloves after he touched the clipboard and pen, and after he picked up the tongs that fell onto the floor. During an interview, on 5/26/26 at 1:29 p.m., DE 4 indicated hand hygiene was to be performed anytime he went from one task to another. Gloves were considered contaminated if any part of your body or clothing was touched. Floors, drawers, trash can lids, the outside of containers, and the outside of bread bags were considered dirty and he should have changed his gloves before he touched and served food items. He was unsure if a facial hair covering was to be worn since he had a mustache. During a lunch observation, on 5/27/26 at 12:01 p.m., DE 5 wore gloves as he plated and served food. He touched the plates and scoop handles. DE 5 grasped a slice of bread with his left gloved hand and placed the slice of bread on a plate. DE 5 then picked up a plate and walked over to the toaster where he grasped a piece of toas with his right gloved hand and placed it on plate. He exited the kitchen and took the plate of toast into the dining room and served it to a resident. DE 5 performed hand hygiene and put on a clean pair of gloves. He removed a steam table lid, obtained plate, touched utensil handles, and with the same gloved hand grasped a piece of bread and placed it onto a plate. During an interview, on 5/29/26 2:54 p.m., with the DON indicated all residents who resided in the facility eat meals prepared in the facility kitchen. A current facility policy, dated 6/2025, titled Proper Use of Hairnets and [NAME] Guard for Food Safety Compliance, provided by the Administrator, on 5/28/26 at 3:08 p.m., indicated: .1. General Requirements. All personnel must wear approved hairnets or beard guards when in food preparation, processing, or storage areas. A current, undated, facility policy titled Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices, provided by the Administrator, on 6/1/26 at 2:48 p.m., indicated: . Gloves and Direct Food Contact. 1. Contact between food and bare (ungloved) hands is prohibited. Gloves are considered single-use items and must be discarded after completing the task for which they are used. Hair Nets: Hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens. A current facility policy, dated 12/2025, titled Sanitation and Food Safety, provided by the Administrator, on 6/1/26 at 2:48 p.m., indicated: .6. Dented, leaky, rusted and swelling cans that could affect food safety are returned to the vendor but stored in a designated area away from other food. These items will not be used. Tongs must be used when serving rolls, pickles, etc., cakes and pies must be placed on a plate with a spatula. Opened packages of food are resealed tightly to prevent contamination of the food item. B. During a lunch observation, on 5/26/26 at 11:50 a.m., the following was observed: A total of 23 trays were placed on two opened-wheeled carts. [NAME] cake with icing was left open to air and uncovered while being transported out of the kitchen and down the hallway for room tray delivery. During an interview, on 5/26/26 at 12:45 p.m., the DM indicated the cake should have been covered before leaving the kitchen and transporting the trays down the hallway. During a lunch observation, on 5/27/26 at 11:40 a.m., the following was observed: Twenty-two glasses of water and fruit medley cups were left uncovered while being transported on an open cart down the hallway for room tray delivery. During an interview, on 5/26/26 at 1:29 p.m., DE 4 indicated food items were to be covered on the hall trays. Items were usually covered but dietary staff ran behind today. During an interview, on 5/27/26 at 11:44 a.m., DE 5 indicated the glasses of water and fruit cups should have been covered before being transported down the hallway. During an interview, on 5/27/26 at 4:55 p.m., the Corporate Consultant and the Administrator indicated staff should not touch any food barehanded. All items on room trays should be covered before leaving the kitchen. Hair and/or beard nets should be worn while in the kitchen. 410 Indiana Administrative Code (IAC) 16.3-3.1-21(i)(1) IAC 16.2-3.1-21(i)(2) IAC 16.2-3.1-21(i)(3)

Based on observation and interview, the facility failed to ensure food was served under safe and sanitary conditions regarding food handling during meal service for 2 of 21 residents who received meals in the dining room. (Residents 5 and 42)Findings include:During a lunch observation, on 5/27/26 at 11:40 a.m., the following was observed:CNA 8 delivered a meal tray to Resident 5. CNA 8 picked up a slice of bread from the resident's plate with her bare hands. As she held the slice of bread in her bare hand, CNA 8 spread butter on one side of the slice of bread, folded the bread in half, and placed it back on Resident 5's plate.CNA 8 washed her hands with soap and water before she retrieved another meal tray. CNA 8 delivered the meal tray to Resident 42. CNA 8 picked up a slice of bread from Resident 42's plate with her bare hands. As she held the slice of bread in her bare hand, CNA 8 spread butter on one side of the slice of bread and handed it to Resident 42.During an interview, on 5/27/26 at 12:05 p.m., CNA 8 indicated she touched both Resident 5's and Resident 42's bread with her bare hands.During an interview, on 5/27/26 at 4:55 p.m., the Administrator indicated staff members were not to touch any food with their bare hands.During an interview, on 5/28/26 at 12:50 p.m., LPN 9 indicated food should not be touched bare handed and gloves should be applied if food needed to be touched.Resident 42's clinical record was reviewed on 5/29/26 at 12:36 p.m. Diagnoses included dementia and muscle weakness.Resident 5's clinical record was reviewed on 5/29/26 at 3:55 p.m. Diagnoses included dementia and Alzheimer's disease.A current, undated facility policy, titled Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices, provided by the Administrator,on 6/1/26 at 2:48 p.m., indicated: . Gloves and Direct Food Contact. 1. Contact between food and bare (ungloved) hands is prohibited. Gloves are considered single-use items and must be discarded after completing the task for which they are used. Hair Nets: Hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens.A current facility policy, dated 12/2025 and titled Sanitation and Food Safety, provided by the Administrator, on 6/1/26 at 2:48 p.m., indicated: .6. Dented, leaky, rusted and swelling cans that could affect food safety are returned to the vendor but stored in a designated area away from other food. These items will not be used. Tongs must be used when serving rolls, pickles, etc., cakes and pies must be placed on a plate with a spatula. Opened packages of food are resealed tightly to prevent contamination of the food item.410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure daily menus were posted for 3 of 5 days observed during the survey dates. Finding includes: During an observation, on 5/26/26 at 10:00 a.m., the posted daily menu was dated 5/24/26.During an observation, on 5/28/26 at 4:00 p.m., the posted daily menu was dated 5/27/26.During an observation, on 5/29/26 at 9:35 a.m., the posted daily menu was dated 5/27/26.During a review of the resident council minutes and grievance logs, on 5/29/26 at 8:18 a.m., a titled facility form, I Would Like To Know, dated 2/17/26, indicated the Resident Council voiced concerns about the daily menu not yet being posted on that day. The concern was reviewed during a morning meeting on 2/18/26. The concern was assigned to the dietary department. The Administrator and Dietary Manager were made aware of the concern.During an interview, on 5/29/26 at 10:18 a.m., the Resident Council group indicated, in February 2026, they had mentioned daily menus were not posted daily. This topic had been discussed again at the monthly resident council meetings since the concern was voiced in February. Seven of ten residents present for the interview indicated menus not being posted continued to be an ongoing problem and the issue had not been resolved.During an interview, on 5/29/26 at 11:13 a.m., CNA 6 indicated menus were to be changed each day by the dietary cook. She had frequently observed the menus not being changed. Due to the menus not being changed daily, she was unable to tell the residents what the menu was until the food was served. On more than one occasion, she had asked the dietary staff to post the menu and they always responded with they would get to it, but it did not get posted. The lack of posted menus had occurred for months. During an interview, on 5/29/26 at 11:37 a.m., the Activity Director indicated she worked the previous weekend and noticed the menu had not been changed for three days. Dietary staff was responsible for changing the menus.During an interview, on 5/29/26 at 12:39 p.m., Dietary Employee 5 indicated the menu was posted every morning before breakfast. He did not know why the menu was not posted on 5/28/26 because he did not work that day. He posted today's menu after breakfast because he had forgotten to change it prior. He was not aware of concerns regarding the menus not getting posted daily or timely. During an interview, on 6/1/26 at 2:13 p.m., the Administrator indicated menus were changed out daily before the first meal by the cook. The folder contained daily menus for the week. She went into the kitchen daily and made sure the menu was changed. She felt the issue was resolved. Menus had been changed daily, except during this past week because staff were flustered and stressed. During an interview, on 6/1/26 at 2:17 p.m., the Administrator indicated the Dietary Manager changed the process of menu posting and she was just made aware of it.During an interview, on 6/1/26 at 2:17 p.m., the Dietary Manager indicated on 5/31/26 he changed the process from having a week worth of menus in the menu folder to having daily folders that contained a reminder to post the menu at 6:30 a.m. and a copy of the menu. These folders were placed in the kitchen. A current, undated facility policy titled, Displaying The Menu, provided by the Administrator on 6/1/26 at 3:36 p.m., indicated the following: Policy: The finalized menus will be posted each week, and the daily menus will be posted daily in an area where residents, staff, and visitors can see them. Procedure: 1. Tje food and nutrition services staff will post finalized written menus in a designated area that is easily viewed by all individuals listed. 2. Daily menus will be clearly posted outside each dining area on a menu board 410 Indiana Administrative Code 16.2-3.1-20(k)

Based on observation, interview, and record review, the facility failed ensure residents were protected from sexual abuse when Resident B, who had moderate cognitive impairment, was found performing oral sex on Resident C, who had severe cognitive impairment and a known history of sexually inappropriate behaviors. The facility failed to assess the residents' capacity to consent to sexual activity prior to the incident and did not implement interventions in place to mitigate Resident C's sexually inappropriate behaviors. Using the reasonable person concept, it can be determined this deficient practice resulted in severe psychosocial harm, including dehumanization and humiliation for 1 (Resident B) of 2 residents (Resident C) of 5 residents reviewed for abuse.The immediate jeopardy began on 3/22/26 when Resident B was found performing oral sex on Resident C, who was known to exhibit sexually inappropriate behaviors. The acting Administrator, DON, and Nurse Consultant were notified of the immediate jeopardy on 3/27/26 at 1:42 p.m. The immediate jeopardy was removed on 3/28/26, but noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy.Findings include:Resident B's clinical record was reviewed on 3/26/26 at 9:44 a.m. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder, single episode, and cognitive communication deficit.A 1/31/26 admission Minimum Data Set (MDS) assessment indicated she had moderate cognitive impairment and no behaviors were exhibited. Her medications included donepezil hydrochloride (treat dementia) 10 milligram (mg) daily.She had a current order, dated 1/28/26, for behavior monitoring every shift related to signs and symptoms of depression, tearfulness, or self-isolation. Interventions included attempting redirection, snack, offering fluid, an activity for diversion, toileting, changing environment, pain assessment, offering a nap or rest period, and providing comfort measures. A current care plan, revised 1/30/26, indicated a problem of impaired cognition/function or impaired thought process related to dementia with poor short and long-term memory. Interventions included cuing, reorientation, and supervision as needed (1/28/26), presenting one thought, idea, question or command at a time (1/28/26), and using task segmentation to support short term memory deficits, and break tasks into one step at a time (1/28/26).A current care plan, dated 2/2/26, indicated a problem that she required the use of a position change alarm related to poor safety awareness and impulsiveness with attempts to stand or self-transfer without assistance despite repeated direction, verbal cues and/or re-education.A current care plan, created on 3/20/26 and revised on 3/23/26, for the promotion of Safe Practices (Intimate/ Sexual Relationships) indicated she was alert, aware, coherent, in choosing to exercise her right to engage in an intimate/sexual relationship. She enjoyed companionship with a male peer within the facility. She enjoyed social engagement which may include affectionate acts such as hand holding or putting her arm around the male peer. Interventions included acknowledging the residents' need for connection to make them feel valued (3/20/26), assessing her to determine her understanding of the nature of the act and her ability to refuse (3/20/26), encouraging appropriate touch such as hand holding, hugs, etc., if residents were being affectionate in a public setting, offering privacy to ensure dignity was maintained (3/20/26), encouraging participation in activities to reduce boredom which was often a reason for attention seeking (3/20/26), helping her maintain and preserve her dignity, integrity, and confidentiality by discussing these matters in a room that afforded privacy (3/20/26), offering psychosocial visits to ensure she continued to be comfortable with her level of interaction and interactions with male peers (3/20/26), and remind her that intimate/sexual partners must be able to provide consent and the consent must be mutual (3/20/26).A social service note, dated 3/20/26 at 2:52 p.m., indicated her Power of Attorney (POA) and Emergency Contact was notified regarding Resident B seeking companionship with a male resident of the facility. She ate meals with the male resident and sat in lounge with him. Resident B's representatives were both in agreement with Resident B's actions. The facility would continue to monitor the relationship.A nurses note, dated 3/21/26 at 10:35 p.m., indicated she had short- and long-term memory problems. She had moderate impairment with decisions regarding tasks of daily living. She was alert and oriented with occasional confusion noted. She continued with a pressure alarm due to poor safety awareness and needed reminders to use call light and wait for assistance with transferring and ambulating. She required the assistance of one staff member with ambulating with walker.A nurses note, dated 3/22/26 at 10:11 a.m., indicated she had short- and long-term memory problems. She had moderate impairment with decisions regarding tasks of daily living. She was alert to self and could recognize certain peers. She continued to self-transfer often, sounding her pressure alarm. Reminders were given about safety, but she had short term memory impairment. A Situation, Background, Assessment, Recommendation (SBAR) summary, dated 3/23/26 at 2:56 p.m., indicated she was being sent to the emergency room for an evaluation of sexual assault per facility protocol related to staff observation of Resident B performing oral sex on a male resident. The staff intervened and the male resident was directed out of her room. Close supervision was maintained to ensure the male resident did not re-enter her room.A nurse's note, dated 3/23/26 at 3:30 p.m., indicated Resident B was spoken to regarding the (oral sex) incident. She would not/could not talk about incident. She reported that she was friends with the male resident and that he lost his wife recently and they were lonely. She denied the male resident ever touching her in unwanted and inappropriate manner. She adamantly denied the male resident touching her in an unwanted manner.A nurse's note, dated 3/23/26 at 4:00 p.m., indicated at 2:00 p.m., staff reported observing Resident B in her room with a male resident, and Resident B performed oral sex on the male resident the previous evening. The staff asked the male resident to leave the room immediately; he was agitated but complied. Staff provided close monitoring to ensure the male resident did not re-enter the room. The Administrator, family, and physician were notified.A nurse's note, dated 3/23/26 at 8:15 p.m., indicated the hospital called and stated they would not perform the exam because they did not feel it was necessary for Resident B to go through the procedure and that the exam would be necessary only if legal action was pursued. A nurses note, dated 3/23/26 at 10:53 p.m. indicated Resident B returned to the facility.Resident C's clinical record was reviewed on 3/26/26 at 11:39 a.m. Diagnoses included unspecified dementia, mild, with other behavioral disturbance, and delusional disorders.A 1/25/26, quarterly, MDS assessment indicated he had severe cognitive impairment and no behaviors were exhibited. His medications on 3/22/26 included donepezil hydrochloride (medication to treat confusion and memory loss)5 mg daily (started 8/22/24) and risperidone (antipsychotic) 0.25 mg twice daily (started 3/5/26).He had a current order, dated 5/16/25, for behavior monitoring every shift related to delusions and paranoia, thoughts of his wife having an affair, self-picking of skin, insomnia, and difficulty sleeping. Interventions included attempting redirection, snack, offering fluid, an activity for diversion, toileting, changing environment, pain assessment, offering a nap or rest period, and providing comfort measures. A resolved care plan, created on 11/21/25 and resolved on 1/21/26, indicated a problem of inappropriate personal boundaries. He demonstrated behavior symptoms concerning inappropriate personal boundaries due to cognitive impairment secondary to Alzheimer's disease or dementia. The symptoms were manifested by inappropriate touching (i.e., attempting to rub another person's back, reaching for a leg, shoulder rubbing or bump). His goals included that he would refrain from making inappropriate remarks (resolved 1/21/26), he would demonstrate respect for personal boundaries during interaction with staff and peers (resolved 1/21/26), he would ask appropriate questions (resolved 1/21/26), he would behave with respect towards staff and peers (resolved 1/21/26), documenting, as appropriate, behavior symptoms such as disrespecting boundaries and assertively communicating to him that each person was expected to behave with dignity and respect (resolved 1/21/26), staff needed to be assertive when interacting with people who did not respect boundaries. It was important to: (A) establish clear boundaries, (B) reinforce the boundaries, do not waiver, do not show flexibility; enforce strict limits, (C) communicate how to set these limits with fellow staff members and (D) communicate how to handle this behavior to him, who were approached by peers, who did not respect boundaries (resolved 1/21/26), using phrases to clearly communicate what behavior was unacceptable and inappropriate, for example: Assertively tell him to respect your personal space and step back prior to speaking with you and I am concerned about your wellbeing and I will help you function at your best. (resolved 1/21/26)A current care plan, dated 1/21/26, indicated he had a companionship with some female peers within the facility. He enjoyed social engagement which may include affectionate acts such as hand holding or putting his arm around female peers. His goal was that he would exercise safe, respectful and appropriate practices, and his preference for social engagement/personal touch with female peers would be honored through next review. (1/21/26) Interventions included acknowledging the residents' need for connection to make them feel valued (1/21/26), assessing him to determine his understanding of the nature of the act and his ability to refuse (1/21/26), encouraging appropriate touch such as hand holding, hugs, etc. If residents were being affectionate in a public setting, offering privacy to ensure dignity was maintained (1/21/26), encouraging participation in activities to reduce boredom which was often a reason for attention seeking (1/21/26), helping him maintain and preserve his dignity, integrity and confidentiality by discussing these matters in a room that affords privacy (1/21/26), offering psychosocial visits to ensure that he continued to be comfortable with his level of interactions with female peers (1/21/26).A nurses note, dated 7/31/25 at 10:50 a.m., indicated Resident C was noted to have increased friendliness towards female residents (patting arms and hand holding). Education and re-enforcement on appropriate behaviors was provided to Resident C. The Nurse Practitioner (NP) recommended starting medroxyprogesterone (used in men to manage aggressive, sexually inappropriate behaviors in patients with dementia). The physician and the family agreed. A social service note, dated 8/7/25 at 9:56 a.m., indicated it was reported Resident C was sitting on his rollator walker in front of a female resident talking in a female resident's room. He indicated that they were talking, then got up, and indicated that it was time to go. The female resident was asked if she was ok and comfortable. The female resident indicated that they were just talking. A nurse's note, dated 8/25/25 at 12:46 p.m., indicated he was visiting in another resident's room, and when asked to leave the room, he became agitated and cursed at staff. He remained friendly. He frequently used his hands when talking with staff and residents. He touched hands and rubbed arms, etc. He indicated that he always used his hands to talk and was able to get his point across when he used his hands and felt it was respectful. He was unable to understand he shouldn't touch other residents, even in a friendly innocent manner, and not all residents were able to make decisions for themselves. No improvement was noted since starting medroxyprogesterone. New orders were received to increase the medroxyprogesterone to 15 mg daily.A nurse's note dated 10/2/25 at 10:37 a.m. indicated Interdisciplinary (IDT) behavior meeting recommended to decrease his medroxyprogesterone. A nurse's note, dated 1/21/26 at 9:43 a.m., indicated the resident sought companionship with another female resident. The residents sought each other out and the relationship was mutual. His care plan was updated.A care plan meeting note, dated 1/26/26 at 10:15 a.m., indicated that he was alert to self and place. He sought companionship with female residents. He enjoyed spending time talking and holding hands. His family was aware and in agreement. His care plan was appropriate.An IDT note, dated 2/3/2026 at 7:51 p.m., indicated he continued with his usual affect, daily routine, and seeking out female companionship. He had no signs or symptoms of delusions, irritability, or social withdrawal. He was due for a gradual dose reduction (GDR) of medroxyprogesterone. IDT recommended decreasing to 5 mg daily.An IDT note, dated 3/11/26 at 12:51p.m., indicated the pharmacist recommended discontinuing the medroxyprogesterone. The physician and IDT agreed to discontinue. The resident continued with his usual routine but decreased interaction with other female residents. The IDT would continue to monitor.His medication history indicated he received medroxyprogesterone acetate for hypersexuality (persistent sexual impulses). He had the following medication adjustments related to medroxyprogesterone acetate:On 8/1/25, he was started on 10 mg that was discontinued on 8/25/25. On 8/26/25, the medication was increased to 15 mg and was discontinued on 10/2/25. On 10/2/25, the medication was decreased to 10 mg and was discontinued on 2/5/26. On 2/6/26, the medication was decreased to 5 mg and was discontinued on 3/12/26. A social service note, dated 3/18/26 at 12:31p.m., indicated he was observed holding hands with a female resident in the central lounge after breakfast, then observed talking with different female resident in main dining room after lunch.A social service note, dated 3/19/26 at 8:57 a.m., indicated he had increased aggravation when staff attempted to redirect or orientate him. Yesterday afternoon, he was visiting with another female resident in the main dining room and began to get angry with staff because they would not leave them alone. The female resident required assistance and could walk by herself. A social service note, dated 3/19/26 at 9:33 a.m., indicated the DON felt that Resident C was failing his GDR of medroxyprogesterone due to increased interactions with female residents.A behavior note, dated 3/22/26 at 3:20 p.m., indicated that he had increased agitation and interactions with female peers. He was asked to visit females in the public lounge and not in their rooms. He became angry and said, I'll just fix this and angrily walked away, cursing at staff. Interventions were effective for a short moment. He had a short-term memory problem.A behavior note, dated 3/22/26 at 8:11 p.m., indicated he became very agitated with staff upon redirection from female residents. He had an inappropriate behavior with a confused female resident, and he was redirected from the room.A SBAR summary, dated 3/23/26 at 3:04 p.m., indicated staff observed Resident C in another female resident's room receiving oral sex. The staff immediately asked him to leave the room; he was agitated with leaving but did comply. Staff monitored closely to ensure that he did not re-enter the room or any other rooms. The provider was notified and recommended Resident B to be sent for a psychiatric evaluation and treatment. Fifteen-minute checks and one on one supervision were initiated until he could be sent for an evaluation.During an interview on 3/26/26 at 1:51 p.m. Qualified Medication Aide (QMA) 7 indicated, on 3/22/26 between 7:00 p.m. and 8:00 p.m., she was passing medication and as she walked by Resident B's room, Resident B's roommate was seated in her wheelchair in the hall, and she saw half of Resident C's body in Resident B's room. Resident C was standing in front of Resident B with his walker between him and her and his pants were partially down, exposing his buttocks. Resident B was seated in her recliner leaning forward and Resident C's right knee was propped up on the seat of his walker as he leaned forward towards Resident C. Resident B was performing oral sex on Resident C. QMA 7 asked Resident C to leave the room. He got mad, pulled up his pants and left the room. He asked why he had to leave and told QMA 7 that she thought she was the boss. Resident B really didn't say anything and after Resident C left. Resident B had forgotten that anything had happened. The QMA reported what she observed to the charge nurse, and they kept Resident C away from Resident B and other female residents. QMA 7 indicated that about a week ago, Resident B and Resident C began being fond of each other, but he did not normally go into her room. They sought each other out and held hands during activities and talked a lot. There were three other female residents that Resident C held hands with or rubbed their arm. Resident B and Resident C were both confused. Resident B had a positioning alarm due to unsteadiness, and she was not supposed to get up by herself.During an interview, on 3/26/26 at 2:32 p.m., Resident B's representative indicated the facility contacted them on 3/16/26 about Resident B holding hands, spending time with, and walking and talking with a male resident. The resident's representative told the facility that they were okay with just holding hands, but nothing else. The facility reassured them that nothing more would happen and staff would keep an eye on the residents. The resident representative was not happy with the situation and were completely thrown off guard by Resident B performing oral sex on Resident C. Resident B had moderate to severe dementia and didn't recognize family at times. She had thought her son was a soda salesman during a visit because he brought her a soda. Resident B often asked where she was and when she was going home. During an interview on 3/26/26 at 2:43 p.m. Registered Nurse (RN) 16 indicated QMA 7 reported to her that she observed Resident B performing oral sex on Resident C and had told Resident C to leave the room. Resident C told RN 16 that he might not be doing things right, but he was not as stupid as they thought he was. Resident C did not have much memory recall. RN 16 had seen Resident C sitting in the lounge with his penis out of his pants before and had asked a female resident to put their hands in his pants, which was his last girlfriend prior to Resident B. He would go into another female resident's room and lay in her bed and rub her arm. RN 16 did not feel those actions were inappropriate, but oral sex was inappropriate. When QMA 7 reported the observation, RN 16 did not report it to anyone, but she made a behavioral note. Staff had been told that it was okay for the residents to have a sexual relationship.During a follow up interview, on 3/26/26 at 3:27 p.m., Resident B's representative indicated performing oral sex was not normal behavior for Resident B. Resident B was very [NAME] and proper and always dressed to the nines. Resident B would never have done this. Resident B and Resident B's husband held hands or pecked on the lips. They were not ever even observed hugging. Resident B would be appalled to know this had happened, if she was not confused.During an interview, on 3/27/26 at 9:56 a.m., Resident G indicated she had a concern related to Resident C. She had heard in the halls and from staff that Resident C was doing things to female residents in the facility. She heard through staff and in the hallway that a female resident performed oral sex on Resident C. She was worried and fearful that he would come into her room and touch her, and she did not want to be touched. He had never come into her room and if he did, she would kick in his groin.Resident G's clinical record was reviewed on 3/30/26 at 10:34 a.m. Diagnoses included major depressive disorder, single episode.A 2/3/26, quarterly, MDS assessment indicated she was cognitively intact. During an interview, on 3/27/26 at 12:15 p.m., the DON indicated Resident C's care plan for inappropriate behaviors had been resolved due to the direction of the Long-Term Care Ombudsman. The Ombudsman told the facility it was the residents' right to have sexual contact, and it was not a maladaptive or inappropriate behavior.During an interview, on 3/27/26 at 12:22 p.m., the Psychiatric NP indicated, initially in September 2025, the facility was concerned with Resident C's sudden focus on female residents. He was rubbing their arms and inappropriately touching them. To prevent that from escalating, he started taking medroxyprogesterone. His dose was decreased then discontinued due to the Ombudsman indicating that it was appropriate for Resident C to hold hands and rub legs of other female residents. There was a discussion with him and the female residents involved at the time and the ability to consent. All three residents had dementia but were able to verbalize inappropriate touch or touch they didn't want. The NP felt that Resident C had the capacity to consent and believed he knew what he was doing. Resident B did not receive psychiatric services. The NP was not aware that Resident C was sent to an inpatient psychiatric hospital or that Resident C was involved in an oral sex incident. The facility staff had to redirect Resident C several times related to female residents. He would get agitated and if not redirected, it was not known what would happen. This is why prevention was important. Resident C's risperidone was decreased, then the NP was notified on 3/19/26 that the resident failed his dose reduction due to agitation related to increased promiscuity. The NP suggested that staff just monitor Resident C and to document the behaviors, since what was reported did not warrant increasing the risperidone or restarting the medroxyprogesterone.During an interview, on 3/27/26 at12:54 p.m. the acting Administrator indicated there was not any behavior documentation, as behaviors were monitored only if they were considered maladaptive.During an interview, on 3/27/26 at 1:24 p.m., the acting Administrator indicated a Sexual Consent Capacity Assessment was not completed prior to the incident between Resident B and Resident C. An assessment was completed as part of the facility investigation.During an interview on 3/28/26 at 9:13 a.m., Resident B sat in her recliner in her room in a reclined position with a blanket covering her. She indicated that she was at the health department. She did not know what town she was in and did not know what year it was. She indicated there were no male residents who had been in her room and she did not have a male friend or boyfriend.During an interview on 3/28/26 at 10:44 a.m. Housekeeper 9 indicated Resident C would get touchy feely. He caressed the female resident's legs or around their breast area, and if you tried to separate him from the female resident, he would get hostile. The housekeeper reported her observations to the DON and other supervisors and had told the CNAs to watch him. About a month ago, she witnessed Resident C in Resident F's room. Resident C pulled Resident F's hand to his private area on the outside of his clothing. Another time, the housekeeper observed Resident C and Resident B in the dining room together after lunch, and Resident C was touching Resident B's breast. Housekeeper 9 reported the incident to her supervisor. During an interview on 3/30/26 at 9:43 a.m., the Social Service Director (SSD) indicated Resident C was social with everyone, male or female. He normally sat at the dining room drinking coffee and females gravitated toward him. Resident F walked around with him at times, and during her peak confusion, he would get slightly annoyed with her. She would ask Where do you want to go? and What do you want to do? Resident D sat in the lounge, and Resident C stopped to talk to her, and that was how their friendship developed. Resident E played BINGO with Resident F and they would argue who was going to sit with Resident C. Resident B sat at the dining table for meals and Resident B and Resident C started talking. The facility resolved care plans regarding sexual behaviors after speaking with the Ombudsman to determine whether the behaviors were inappropriate or the residents' rights. Resident C's hypersexuality increased with the number of females that he was making friends with. When Resident C was redirected, he was aggravated and asked why he could not talk to the female resident. He held hands and patted Resident E's and Resident D's legs. Resident C held hands with Resident B. The staff completed behavior tools and then the SSD would put a note in the electronic health record. The behavior sheets were located in a behavior tool folder at each nurse's station. The CNAs were unable to read the care plans in the health record but could see the behaviors on the behavior sheets. Resident C was on medroxyprogesterone, and psychotropic behavior monitoring would be located on the Medication Administration Record (MAR). The DON or ADON added the psychotropic medication monitoring to the MARs. The behaviors were reviewed monthly. The behaviors were a fine line between being appropriate or infringing on their rights. The Ombudsman indicated it was an infringement on their rights to not allow a relationship and the residents' cognitive impairment didn't matter as long as they had similar cognitive function. The SSD felt that if a resident was cognitively intact, and another resident was severely cognitively impaired, then that would be inappropriate. She felt the residents had the mental capacity to consent to sexual behaviors, but maybe not physically. They did not currently have an assessment for sexual behaviors. Resident F's clinical record was reviewed on 3/30/26 at 9:09 a.m. Diagnoses included major depressive disorder, single episode, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and Alzheimer's disease.A 2/17/26 annual MDS assessment indicated she had severe cognitive impairment and no behaviors were exhibited.Her medications included escitalopram oxalate (treats depression) 20 mg daily, buspirone (treats anxiety)10 mg three times daily, and memantine (treats dementia) 5 mg twice daily.A resolved care plan, created on 1/19/26 and resolved on 1/21/26, for inappropriate personal boundaries indicated she demonstrated behavior symptoms concerning inappropriate personal boundaries related to cognitive impairment secondary to Alzheimer's disease or dementia. These symptoms were manifested by: inappropriate touching (i.e., attempting to rub another person's back, reaching for a leg, shoulder rubbing or bump). Her goals included demonstrating respect for personal boundaries during interaction with staff and peers and behaving with respect towards staff and peers (resolved 1/21/26). Interventions resolved on 1/21/26 included documenting, as appropriate, behavior symptoms such as disrespecting boundaries and assertively communicating to her that each person was expected to behave with dignity and respect, staff needed to be assertive when interacting with people who did not respect boundaries. It was important to: (A) establish clear boundaries, (B) reinforce the boundaries, do not waiver, do not show flexibility; enforce strict limits, (C) communicate how to set these limits with fellow staff members and (D) communicate how to handle this behavior to her who were approached by peers who did not respect boundaries, using phrases to clearly communicate what behavior was unacceptable and inappropriate, for example: Assertively tell him to respect your personal space & step back prior to speaking with you. and I am concerned about your well-being and I will help you function at your best. A current care plan, created on 1/21/26 and revised on 3/16/26, indicated she enjoyed companionship with a male peer within the facility. She enjoyed social engagement which may include affectionate acts such as hand holding or putting her arm around male peer. Her goals included exercising safe, respectful and appropriate practices, and her preference for social engagement/personal touch with male peer will be honored through next review. (revised 3/16/26) Her interventions included acknowledging the residents need for connection to make them feel valued (1/21/26), assessing her to determine her understanding of the nature of the act and her ability to refuse (1/21/26), encouraging appropriate touch such as hand holding, hugs, etc. If residents were being affectionate in a public setting, offering privacy to ensure dignity was maintained (1/21/26), encouraging participation in activities to reduce boredom which was often a reason for attention seeking (1/21/26), helping her maintain and preserve her dignity, integrity and confidentiality by discussing these matters in a room that afforded privacy (1/21/26), and offering psychosocial visits to ensure that she continued to be comfortable with her level of interaction with interactions with male peers (1/21/26).A nurses note, dated 8/27/25 at 12:34 p.m., indicated Resident F's Power of Attorney (POA) was notified regarding a male resident was friendly with Resident F. They spent a lot of time together and sought each other out for company. The POA was aware of the friendship and aware the male resident used his hands to talk with (i.e. patting hands and legs during conversations). Possible interventions were discussed with the POA to prevent possible progression for inappropriate behaviors, such as a stop sign or possible room move. The POA did not want Resident F moved and had concerns regarding a stop sign across the door of her room, as Resident F was unable to understand what the stop sign was for, fall risks, and it would cause agitation. The POA believed Resident F had adjusted to the facility and no longer indicated that she wanted the POA to talk her home. The POA did not want Resident F to be unhappy. An agreement was made related to an attempt at using stop sign but if Resident F did not adjust to or did not agree with stop sign then it needed to be removed. The POA indicated that her mother enjoyed conversations and interactions with the other resident and did not want to take that away from her.A nurses note, dated 1/21/26 at 9:52 a.m., indicated Resident F sought companionship with a male resident. The residents sought each other out and the relationship was mutual. The HCP was aware of the relationship and had no concerns. Her care plan was updated.Resident E's clinical record was reviewed on 3/28/26 at 9:32 a.m. Diagnoses included major depressive disorder, single episode and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.A 1/6/26 quarterly MDS assessment indicated she had moderate cognitive impairment and no behaviors were exhibited.Her medications included donepezil 10 mg daily. She had an order, dated 1/2/26, for behavior monitoring related to signs and symptoms of depression. Interventions included attempting to redirect, snack, offering fluid, activity for diversion, toileting, changing environment, pain assessment, offering a nap or rest period, and providing comfort measures.Her clinical record lacked monitoring and individualized interventions for intimate or sexual behaviors.A resolved care plan, created on 1/19/26 and resolved on 1/21/26, for inappropriate personal boundaries indicated she demonstrated behavior symptoms concerning inappropriate personal boundaries related to cognitive impairment secondary to Alzheimer's disease or dementia. These symptoms were manifested by: inappropriate touching (i.e., attempting to rub another person's back, reaching for a leg, shoulder rubbing or bump). Her goal

Based on observation, interview, and record review, the facility failed to monitor for and develop individualized interventions for cognitively impaired residents with sexually focused behavior expressions for 5 of 5 residents reviewed for behavioral services. (Residents B, C, D, E and F)Findings include:1.Resident B's clinical record was reviewed on 3/26/26 at 9:44 a.m. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder, single episode, and cognitive communication deficit.A 1/31/26, admission, Minimum Data Set (MDS) assessment indicated she had moderate cognitive impairment and no behaviors were exhibited. Her medications included donepezil hydrochloride (treat dementia) 10 milligram (mg) daily.She had an order, dated 1/28/26, for behavior monitoring every shift related to signs and symptoms of depression, tearfulness, or self-isolation. Interventions included attempting redirection, snack, offering fluid, an activity for diversion, toileting, changing environment, pain assessment, offering a nap or rest period, and providing comfort measures. A social service note, dated 3/20/26 at 2:52 p.m., indicated her Power of Attorney (POA) and Emergency Contact was notified regarding Resident B seeking companionship with a male resident of the facility. She ate meals with the male resident and sat in lounge with him. Both representatives were in agreement with Resident B's actions. The facility would continue to monitor the relationship.A Situation, Background, Assessment, Recommendation (SBAR) summary, dated 3/23/26 at 2:56 p.m., indicated Resident B was being sent to the emergency room for an evaluation of sexual assault per protocol related to staff observation of Resident B performing oral sex on a male resident. The staff intervened and the male resident was directed out of her room. Close supervision was maintained to ensure the male resident did not re-enter her room.A nurse's note, dated 3/23/26 at 3:30 p.m., indicated that Resident B was spoken to regarding the incident. She would not/could not talk about incident. She reported that she was friends with the male resident and that he lost his wife recently and they were lonely. She denied the male resident ever touching her in unwanted and inappropriate manner. She adamantly denied the male resident touching her in an unwanted manner.A nurses note, dated 3/23/26 at 4:00 p.m., indicated at 2:00 p.m., staff reported observing Resident B in her room with a male resident, and Resident B performed oral sex on the male resident the previous evening. Staff asked the male resident to leave the room immediately; he was agitated but complied. Staff provided close monitoring to ensure the male resident did not re-enter the room. The Administrator, family, and physician were notified.A current care plan, revised 1/30/26, for impaired cognition/function or impaired thought process related to dementia with poor short and long-term memory. Interventions included cuing, reorientation, and supervision as needed (1/28/26), presenting one thought, idea, question or command at a time (1/28/26), and using task segmentation to support short term memory deficits, and break tasks into one step at a time (1/28/26).A current care plan, dated 2/2/26, indicated she required the use of a position change alarm related to poor safety awareness and impulsiveness with attempts to stand or self-transfer without assistance despite repeated direction, verbal cues and/or re-education.Resident B's clinical record lacked monitoring and individualized interventions for intimate or sexually focused behaviors prior to 3/20/26. 2.Resident C's clinical record was reviewed on 3/26/26 at 11:39 a.m. Diagnoses included unspecified dementia, mild, with other behavioral disturbance, and delusional disorders.A 1/25/26, quarterly, MDS assessment indicated he had severe cognitive impairment and no behaviors were exhibited. His current orders included risperidone (antipsychotic) 0.25 mg twice daily for delusional disorder and donepezil hydrochloride 5 mg daily. He had an order, dated 5/16/25, for behavior monitoring every shift related to delusions and paranoia, thoughts of his wife having an affair, self-picking of skin, insomnia, and difficulty sleeping. Interventions included attempting redirection, snack, offering fluid, an activity for diversion, toileting, changing environment, pain assessment, offering a nap or rest period, and providing comfort measures. His medication orders indicated he received medroxyprogesterone acetate (synthetic female hormone) for hypersexuality. He had the following medication adjustments related to medroxyprogesterone acetate:On 8/1/25, he was started on 10 mg that was discontinued on 8/25/25. On 8/26/25, the medication was increased to 15 mg and was discontinued on 10/2/25. On 10/2/25, the medication was decreased to 10 mg and was discontinued on 2/5/26. On 2/6/26, the medication was decreased to 5 mg and was discontinued on 3/12/26. A resolved care plan, created on 11/21/25 and resolved on 1/21/26, for inappropriate personal boundaries. He demonstrated behavior symptoms concerning inappropriate personal boundaries due to: cognitive impairment secondary to Alzheimer's disease or dementia. The symptoms were manifested by inappropriate touching (i.e., attempting to rub another person's back, reaching for a leg, shoulder rubbing or bump). His goals included that he would refrain from making inappropriate remarks (resolved 1/21/26), he would demonstrate respect for personal boundaries during interaction with staff and peers (resolved 1/21/26), he would ask appropriate questions (resolved 1/21/26), he would behave with respect towards staff and peers (resolved 1/21/26), documenting, as appropriate, behavior symptoms such as disrespecting boundaries and assertively communicating to him that each person was expected to behave with dignity and respect (resolved 1/21/26), staff needed to be assertive when interacting with people who did not respect boundaries. It was important to: (A) establish clear boundaries, (B) reinforce the boundaries, do not waiver, do not show flexibility; enforce strict limits, (C) communicate how to set these limits with fellow staff members and (D) communicate how to handle this behavior to him, who were approached by peers, who did not respect boundaries (resolved 1/21/26), using phrases to clearly communicate what behavior was unacceptable and inappropriate, for example: Assertively tell him to respect your personal space and step back prior to speaking with you and I am concerned about your wellbeing and I will help you function at your best. (resolved 1/21/26)A current care plan, dated 1/21/26, indicated he had a companionship with some female peers within the facility. He enjoyed social engagement which may include affectionate acts such as hand holding or putting his arm around female peers. His goal was that he would exercise safe, respectful and appropriate practices, and his preference for social engagement/personal touch with female peers would be honored through next review. (1/21/26) Interventions included acknowledging the residents' need for connection to make them feel valued (1/21/26), assessing him to determine his understanding of the nature of the act and his ability to refuse (1/21/26), encouraging appropriate touch such as hand holding, hugs, etc. If residents were being affectionate in a public setting, offering privacy to ensure dignity was maintained (1/21/26), encouraging participation in activities to reduce boredom which was often a reason for attention seeking (1/21/26), helping him maintain and preserve his dignity, integrity and confidentiality by discussing these matters in a room that affords privacy (1/21/26), offering psychosocial visits to ensure that he continued to be comfortable with his level of interactions with female peers (1/21/26).Resident C's clinical record lacked monitoring and individualized interventions for intimate or sexual behaviors. A nurses note, dated 7/31/25 at 10:50 a.m., indicated Resident C was noted to have increased friendliness towards female residents (patting arms and hand holding). Education and re-enforcement on appropriate behaviors was provided to Resident C. The Nurse Practitioner (NP) recommended starting medroxyprogesterone. The physician and the resident's family were in agreement. A social service note, dated 8/7/25 at 9:56 a.m., indicated that it was reported Resident C was sitting on his rollator walker in front of a female resident talking in a female resident's room. He indicated that they were talking, then got up, and indicated that it was time to go. The female resident was asked if she was ok and comfortable. The female resident indicated that they were just talking. A nurses note, dated 8/25/25 at 12:46 p.m., indicated he was visiting in another resident's room. When asked to leave the room, he became agitated and cursed at staff. He remained friendly. He frequently used his hands when talking with staff and residents. He touched hands and rubbed arms, etc. He indicated that he always used his hands to talk and was able to get his point across when he used his hands and felt it was respectful. He was unable to understand that he needed to not touch other residents, even in a friendly innocent manner, and not all residents were able to make decisions for themselves. No improvement was noted since starting medroxyprogesterone. New orders were received to increase medroxyprogesterone to 15 mg daily. A nurses note, dated 10/2/25 at 10:37 a.m. indicated Interdisciplinary (IDT) behavior meeting recommended to decrease his medroxyprogesterone. A nurses note, dated 1/21/26 at 9:43 a.m., indicated he sought companionship with another female resident. The residents sought each other out and the relationship was mutual. His care plan was updated.A care plan meeting note, dated 1/26/26 at 10:15 a.m., indicated that he was alert to self and place. He sought companionship with female residents. He enjoyed spending time talking and holding hands. His family was aware and in agreement. He was care planned appropriately.An IDT note, dated 2/3/26 at 7:51 p.m., indicated he continued with usual affect, daily routine, and seeking out female companionship. He had no signs or symptoms of delusions, irritability, or social withdrawal. He was due for a gradual dose reduction (GDR) of medroxyprogesterone. IDT recommended decreasing to 5 mg daily.An IDT note, dated 3/11/26 at 12:51p.m., indicated pharmacy recommended discontinuing medroxyprogesterone. The physician and IDT were in agreement to discontinue. He continued with usual routine but decreased interaction with other female residents. The IDT would continue to monitor.A social service note, dated 3/18/26 at 12:31p.m., indicated he was observed holding hands with a female resident in the central lounge after breakfast, then observed talking with different female resident in main dining room after lunch.A social service note, dated 3/19/26 at 8:57 a.m., indicated he had increased aggravation when staff attempted to redirect or orientate him. Yesterday afternoon, he was visiting with another female resident in the main dining room and began to get angry with staff because they would not leave them alone. The female resident required assistance and could walk by herself. A social service note, dated 3/19/26 at 9:33 a.m., indicated the DON felt that Resident C was failing his GDR of medroxyprogesterone due to increased interactions with female residents.A behavior note, dated 3/22/26 at 3:20 p.m., indicated that he had increased agitation and interactions with female peers. He was asked to visit females in the public lounge and not in the room. He became angry and said, I'll just fix this and angerly walked away cursing at staff. Interventions were effective for a short moment. He had a short-term memory problem.A behavior note, dated 3/22/26 at 8:11 p.m., indicated he became very agitated with staff upon redirection from female residents. He had an (unspecified) inappropriate behavior with a confused female resident and he was redirected from the room.A nurses note, dated 3/23/26 at 1:09 p.m., the Psychiatric NP was updated related to increased interactions with a female resident since medroxyprogesterone was discontinued. The medroxyprogesterone seemed to inhibit his desires, now that the medication was stopped, desires seemed to be escalated. New orders were received to restart at previous dose of medroxyprogesterone as the GDR failed.A SBAR summary, dated 3/23/26 at 3:04 p.m., indicated staff observed Resident C in another female resident's room receiving oral sex. The staff immediately asked him to leave the room; he was agitated with leaving but did comply. Staff monitored closely to ensure that he did not re-enter the room or any other rooms. The provider was notified and recommended Resident B to be sent for a psychiatric evaluation and treatment. Fifteen minute checks and one on one supervision were initiated until he could be sent for an evaluation.3. Resident D's clinical record was reviewed on 3/27/26 at 9:11 a.m. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A 1/25/26, quarterly, MDS assessment indicated she had severe cognitive impairment and no behaviors were exhibited. Her medications included escitalopram oxalate (treat depression) 20 mg daily.She had an order, dated 10/15/25, for behavior monitoring related to tearfulness, being withdrawn, anxiety, restlessness, and agitation. Interventions included attempting to redirect, snack, offering fluid, activity for diversion, toileting, changing environment, pain assessment, offering a nap or rest period, and providing comfort measures. A resolved care plan, created on 1/19/26 and resolved on 1/21/26, for inappropriate personal boundaries indicated she demonstrated behavior symptoms concerning inappropriate personal boundaries related to cognitive impairment secondary to Alzheimer's disease or dementia. These symptoms were manifested by: inappropriate touching (i.e., attempting to rub another person's back, reaching for a leg, shoulder rubbing or bump). Her goals included demonstrating respect for personal boundaries during interactions with staff and peers and behaving with respect towards staff and peers (resolved 1/21/26). Interventions resolved on 1/21/26 included documenting, as appropriate, behavior symptoms such as disrespecting boundaries and assertively communicating to her that each person was expected to behave with dignity and respect, staff needed to be assertive when interacting with people who did not respect boundaries. It is important to: (A) establish clear boundaries, (B) reinforce the boundaries, do not waiver, do not show flexibility; enforce strict limits, (C) communicate how to set these limits with fellow staff members and (D) communicate how to handle this behavior to her, who were approached by peers and who did not respect boundaries, using phrases to clearly communicate what behavior was unacceptable and inappropriate, for example: Assertively tell him to respect your personal space and step back prior to speaking with you and I am concerned about your well-being and I will help you function at your best. (1/21/26)A care plan, created on 1/21/26 and revised on 3/16/26, indicated she enjoyed companionship with a male peer within the facility. She enjoyed social engagement which may include affectionate acts such as hand holding or putting her arm around male peer. Her goals included exercising safe, respectful and appropriate practices, and her preference for social engagement/personal touch with male peer will be honored through next review (1/21/26). Her interventions included acknowledging the resident's need for connection to make them feel valued (1/21/26), assessing her to determine her understanding of the nature of the act and her ability to refuse (1/21/26), encouraging appropriate touch such as hand holding, hugs, etc. If residents were being affectionate in a public setting, offering privacy to ensure dignity was maintained (1/21/26), encouraging participation in activities to reduce boredom which was often a reason for attention seeking (1/21/26), helping her maintain and preserve her dignity, integrity and confidentiality by discussing these matters in a room that offers privacy (1/21/26), and offering psychosocial visits to ensure that she continued to be comfortable with her level of interactions with male peers (1/21/26). A nurses note, dated 1/21/26 at 9:42 a.m., indicated she sought companionship with a male resident. They sought each other out and the relationship was mutual. The provider was aware of the relationship and had no concerns. Her care plan was updated.Her clinical record lacked monitoring and individualized interventions for intimate or sexual behaviors. 4. Resident E's clinical record was reviewed on 3/28/26 at 9:32 a.m. Diagnoses included major depressive disorder, single episode and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A 1/6/26, quarterly, MDS assessment indicated she had moderate cognitive impairment and no behaviors were exhibited. Her medications included donepezil 10 mg daily. She had an order, dated 1/2/26, for behavior monitoring related to signs and symptoms of depression. Interventions included attempting to redirect, snack, offering fluid, activity for diversion, toileting, changing environment, pain assessment, offering a nap or rest period, and providing comfort measures. A resolved care plan, created on 1/19/26 and resolved on 1/21/26, for inappropriate personal boundaries indicated she demonstrated behavior symptoms concerning inappropriate personal boundaries related to cognitive impairment secondary to Alzheimer's disease or dementia. These symptoms were manifested by: inappropriate touching (i.e., attempting to rub another person's back, reaching for a leg, shoulder rubbing or bump). Her goals included demonstrating respect for personal boundaries during interaction with staff and peers and behaving with respect towards staff and peers (resolved 1/21/26). Interventions resolved on 1/21/26 included documenting, as appropriate, behavior symptoms such as disrespecting boundaries and assertively communicating to her that each person was expected to behave with dignity and respect, staff needed to be assertive when interacting with people who did not respect boundaries. It was important to: (A) establish clear boundaries, (B) reinforce the boundaries, do not waiver, do not show flexibility; enforce strict limits, (C) communicate how to set these limits with fellow staff members and (D) communicate how to handle this behavior to her who were approached by peers and who did not respect boundaries, using phrases to clearly communicate what behavior was unacceptable and inappropriate, for example: Assertively tell him to respect your personal space and step back prior to speaking with you. and I am concerned about your well-being and I will help you function at your best. A current, 1/21/26, care plan indicated she enjoyed companionship with a male peer within the facility. She enjoyed social engagement which may include affectionate acts such as hand holding or putting her arm around male peer. Her goals included exercise safe, respectful and appropriate practices, and her preference for social engagement/personal touch with the male peer would be honored through next review (1/21/26). Her interventions included acknowledging the resident's need for connection to make them feel valued (1/21/26), assessing her to determine her understanding of the nature of the act and her ability to refuse (1/21/26), encouraging appropriate touch such as hand holding, hugs, etc. If residents were being affectionate in a public setting, offering privacy to ensure dignity was maintained (1/21/26), encouraging participation in activities to reduce boredom which was often a reason for attention seeking (1/21/26), helping her maintain and preserve her dignity, integrity and confidentiality by discussing these matters in a room that afforded privacy (1/21/26), and offering psychosocial visits to ensure that she continued to be comfortable with her level of interaction with interactions with male peers (1/21/26).A nurses note, dated 1/21/26 at 10:52 a.m., indicated she sought companionship with a male resident. The residents sought each other out and the relationship was mutual. The HCP was aware of the relationship and had no concerns. Her care plan was updated.A behavior note, dated 3/11/26 at 1:22 a.m., indicated she talked very inappropriately to staff during evening meal. She called one of the Certified Nurse Aides (CNA) over and loudly made comments about the CNA's breasts. The CNA attempted to redirect the resident's comments, but she continued to loudly talk about the CNA's breasts in the dining room. When returning to her room, the CNA was assisting a resident across hall. Resident E indicated that she was ready to go to bed. The CNA explained to Resident E that she was currently assisting another resident to the bathroom, cleaning him up and when she was finished, she would help her. Resident E indicated to make sure the CNA kissed him down there and pointed at her peri area then indicated he would really like that. An attempt was made for Resident E to be verbally redirected and educated that talking like that was not appropriate. When staff assisted Resident E to bed, she asked the CNA if she would kiss her down there and pointed at her peri area. The CNA indicated for her to stop talking like that and that it was not appropriate. Resident E then indicated that she would get Resident C to do it and he would do it. The CNA attempted to redirect Resident E without success. A behavior note, dated 3/11/26 at 4:00 a.m., indicated she was being verbally inappropriate when a CNA entered the room to assist Resident E's roommate with care. Resident E asked the CNA to get in bed with her and give her some love and she would give the CNA some good love. Verbal redirection was given that her comments were inappropriate. Resident E's clinical record lacked monitoring and individualized interventions for intimate or sexual behaviors. 5. Resident F's clinical record was reviewed on 3/30/26 at 9:09 a.m. Diagnoses included major depressive disorder, single episode, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and Alzheimer's disease. A 2/17/26, annual, MDS assessment indicated she had severe cognitive impairment and no behaviors were exhibited. Her medications included escitalopram oxalate (treats depression) 20 mg daily, buspirone (treats anxiety)10 mg three times daily, and memantine (treats dementia) 5 mg twice daily.She had an order, dated 1/7/26, for behavior monitoring related to signs and symptoms of depression (tearfulness, self-isolation, anxiety, picking at skin and repetitive questions and statements. Interventions included attempting to redirect, snack, offering fluid, activity for diversion, toileting, changing environment, pain assessment, offering a nap or rest period, and providing comfort measures. A resolved care plan, created on 1/19/26 and resolved on 1/21/26, for inappropriate personal boundaries indicated she demonstrated behavior symptoms concerning inappropriate personal boundaries related to cognitive impairment secondary to Alzheimer's disease or dementia. These symptoms were manifested by: inappropriate touching (i.e., attempting to rub another person's back, reaching for a leg, shoulder rubbing or bump). Her goals included demonstrating respect for personal boundaries during interaction with staff and peers and behaving with respect towards staff and peers (resolved 1/21/26). Interventions resolved on 1/21/26 included documenting, as appropriate, behavior symptoms such as disrespecting boundaries and assertively communicating to her that each person was expected to behave with dignity and respect, staff needed to be assertive when interacting with people who did not respect boundaries. It was important to: (A) establish clear boundaries, (B) reinforce the boundaries, do not waiver, do not show flexibility; enforce strict limits, (C) communicate how to set these limits with fellow staff members and (D) communicate how to handle this behavior to her who were approached by peers who did not respect boundaries, using phrases to clearly communicate what behavior was unacceptable and inappropriate, for example: Assertively tell him to respect your personal space & step back prior to speaking with you. and I am concerned about your well-being and I will help you function at your best. A current care plan, created on 1/21/26 and revised on 3/16/26, indicated she enjoyed companionship with a male peer within the facility. She enjoyed social engagement which may include affectionate acts such as hand holding or putting her arm around male peer. Her goals included exercising safe, respectful and appropriate practices, and her preference for social engagement/personal touch with male peer will be honored through next review. (revised 3/16/26) Her interventions included acknowledging the residents need for connection to make them feel valued (1/21/26), assessing her to determine her understanding of the nature of the act and her ability to refuse (1/21/26), encouraging appropriate touch such as hand holding, hugs, etc. If residents were being affectionate in a public setting, offering privacy to ensure dignity was maintained (1/21/26), encouraging participation in activities to reduce boredom which was often a reason for attention seeking (1/21/26), helping her maintain and preserve her dignity, integrity and confidentiality by discussing these matters in a room that afforded privacy (1/21/26), and offering psychosocial visits to ensure that she continued to be comfortable with her level of interaction with interactions with male peers (1/21/26).A nurses note, dated 8/27/25 at 12:34 p.m. indicated Resident F's Power of Attorney (POA) was notified regarding a male resident was friendly with Resident F. They spent a lot of time together and sought each other out for company. The POA was aware of the friendship and aware the male resident used his hands to talk with (i.e. patting hands and legs during conversations). Possible interventions were discussed with the POA to prevent possible progression for inappropriate behaviors such as a stop sign or possible room move. The POA did not want Resident F moved and had concerns regarding a stop sign across the door of her room as Resident F was unable to understand what the stop sign was for, fall risks, and it would cause agitation. The POA believed Resident F had adjusted to the facility and no longer indicated that she wanted the POA to talk her home. The POA did not want Resident F to be unhappy. An agreement was made related to an attempt at the stop sign but if Resident F did not adjust to or did not agree with stop sign then it needed to be removed. The POA indicated that her mother enjoyed conversations and interactions with the other resident and did not want to take that away from her.A nurses note, dated 1/21/26 at 9:52 a.m. indicated she sought companionship with a male resident. The residents sought each other out and the relationship was mutual. The HCP was aware of the relationship and had no concerns. Her care plan was updated.Resident F's clinical record lacked monitoring and individualized interventions for intimate or sexual behaviors. During an interview on 3/30/26 at 9:43 a.m., the Social Service Director (SSD) indicated Resident C was social with everyone, male or female. He normally sat at the dining room drinking coffee and females gravitated toward him. Resident F walked around with him at times, during her peak confusion he would get slightly annoyed with her, she would ask Where do you want to go? and What you want to do? Resident D sat in the lounge, and Resident C stopped and talk to her, that was how their friendship developed. Resident E played Bingo with Resident F and they would argue who was going to sit with Resident C. Resident B sat at the dining table for meals and Resident B and Resident C started talking. The facility resolved care plans after speaking with the Ombudsman to determine whether the behaviors were inappropriate or the residents' rights. Resident C's hypersexuality increased with the number of females that he was making friends with. When Resident C was redirected, he was aggravated and asked why he could not talk to the female resident. He held hands and patted Resident E's and Resident D's legs. Resident C held hands with Resident B. The staff completed behavior tools and then she would put a note in Point Click Care (PCC). The behavior sheets were located in a behavior tool folder at each nurse's station. The CNAs were unable to read the care plans in PCC but could see the behaviors on the behavior sheets. Resident C was on medroxyprogesterone, and psychotropic behavior monitoring would be located on the Medication Administration Record (MAR). The DON or ADON added the psychotropic monitoring to the MARs. The behaviors were reviewed monthly. The behaviors were a fine line between being appropriate or infringing on their rights. The Ombudsman indicated it was an infringement on their rights, there BIMS score did not matter and as long as their BIMS score were similar. The SSD felt that if a resident had a BIMS of 15 (intact cognition) and another resident had a BIMS score of 3 (severe cognitive impairment) that would be inappropriate. She felt the residents had the mental capacity to consent to sexual behaviors but maybe not physically. They did not currently have an assessment for sexual behaviors. Behavior sheets were reviewed on 3/30/26 at 10:27 a.m. and indicated the following:Resident B had no behaviors that were monitored.Resident C had behaviors related to irritability with other residents, increased episodes of anxiety which included indicating that he missed a flight, had an appointment which he was late for, and he searched for his family member. Interventions included providing reassurance, calling family, and offering him a cup of coffee or ice cream. Resident D had no behaviors that were monitored. Resident E had no behaviors that were monitored. Resident F had behaviors related to increased anxiousness, asking where her daughter was and what she should do, and pacing. Interventions included calling her daughter, providing one on one, assessing Activities of Daily Living (ADL) needs and talking about where she grew up. A current facility policy, titled Guidelines for Behavior Management Meetings Psychotropic Medication (Behavior Management Meetings), provided by HFA 2 on 3/30/26 at 10:36 a.m. indicated the following: Policy .These meetings are held monthly or more often as needed. The purpose is to review residents who have behaviors and who are being monitored for these behaviors. Further, to discuss and review residents who have newly developed behaviors to ensure that all appropriate interventions are in place to manage the behaviors with non-pharmacological interventions or the least dosage of psychoactive med(s) possible to promote and maintain the highest degree of psychosocial well-being and quality of life . Roles-Responsibilities .Nursing .2) Monitors for presence of target behaviors on a daily basis and documenting same . 5) Assist in developing behavior care plans .Social Services 1) Maintains a list of residents with behaviors .5) Assists in behavior care plans This citation relates to Intake 2962257.410 Indiana Administrative Code (IAC) 16.2-3.1-43(a)(2)

Based on record review and interview, the facility failed to ensure staff reported an allegation of abuse immediately to the Administrator, resulting in a delay in ensuring the allegation of abuse was reported to the State Agency within the required timeframe for 1 of 3 reportable incidents reviewed. (Resident B and Resident C) Findings include:Resident B's clinical record was reviewed on 3/26/26 at 9:44 a.m. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder, single episode, and cognitive communication deficit.A 1/31/26, admission, Minimum Data Set (MDS) assessment indicated she had moderate cognitive impairment. A Situation, Background, Assessment, Recommendation (SBAR) summary, dated 3/23/26 at 2:56 p.m., indicated she was being sent to the emergency room for an evaluation of sexual assault per protocol related to staff observation of Resident B performing oral sex on a male resident. Staff intervened and the male resident was directed out of her room. Close supervision was maintained to ensure the male resident did not re-enter her room.Resident C's clinical record was reviewed on 3/26/26 at 11:39 a.m. Diagnoses included unspecified dementia, mild, with other behavioral disturbance, and delusional disorders.A 1/25/26, quarterly, MDS assessment indicated he had severe cognitive impairment.An SBAR summary, dated 3/23/26 at 3:04 p.m., indicated staff observed Resident C in another female resident's room receiving oral sex. Staff immediately asked him to leave the room; he was agitated with leaving but did comply. Staff monitored closely to ensure that he did not re-enter room or any other rooms. The provider was notified and recommended Resident B to be sent out for a psychiatric evaluation and treatment. Fifteen minutes checks and one on one supervision were completed until resident was sent for evaluation.During an interview on 3/26/26 at 1:51 p.m., Qualified Medication Aide (QMA) 7 indicated, on 3/22/26 between 7:00 p.m. and 8:00 p.m., she was passing medication and as she walked by Resident B's room, Resident B's roommate was seated in her wheelchair in the hall, and she saw half of Resident C's body in Resident B's room. Resident C was standing in front of Resident B with his walker between him and her, his pants were partially down exposing his buttocks. Resident B was seated in her recliner, leaning forward, and Resident C's right knee was propped up on the seat of his walker as he leaned forward towards Resident C. Resident B was performing oral sex on Resident C. QMA 7 asked Resident C to leave the room. He got mad, pulled up his pants, and left the room. She reported what she observed to the charge nurse, and they kept Resident C away from Resident B and other female residents. During an interview on 3/26/26 at 2:43 p.m. Registered Nurse (RN) 16 indicated QMA 7 reported to her that she observed Resident B performing oral sex on Resident C and told Resident C to leave the room. When QMA 7 reported the observation, RN 16 did not report it to anyone. She made a behavioral note. At the time, they had been told that it was okay for the residents to have a sexual relationship.During an interview on 3/27/26 at 10:20 a.m., the Administrator indicated she did not report the incident between Resident B and Resident C to the State Agency until the day after the incident. RN 16 reported the incident to the DON the following morning and then the DON reported the incident to the Administrator. A current facility policy, titled Abuse Prevention Program, provided by the Administrator on 3/30/26 at 10:36 a.m., indicated the following: .Abuse Reporting Policy .Procedure .the person(s) observing an incident of resident abuse or suspecting resident abuse must immediately report such incidents to the Charge Nurse, regardless of the time lapse since the incident occurred. The Charge Nurse will immediately report the incident to the Administrator .When an alleged or suspected case of abuse or neglect is reported to the Administrator, the Administrator, or person in charge of the facility, will notify the following persons or agencies of such incident immediately. State Licensing and Certification Agency (i.e. ISDH) This citation relates to Intake 2962257.410 Indiana Administrative Code (IAC)16.2-3.1-28(c)

Based on observation, record review, and interview, the facility failed to ensure menus and the resident's preferences were followed for 3 of 5 residents reviewed for dining services. (Resident 12, 14, and 26) This deficiency had the potential to affect 31 of 31 residents who receive meals from the facility's dining services. Findings include: 1. During an observation, on 3/18/25 at 2:11 p.m., a sign on the wall by the kitchen indicated the following lunch and dinner options were available: grilled cheese sandwich, hamburger on bun, hot dog on bun, peanut butter and jelly sandwich on bread, mashed potatoes, potato chips, alternate fruit, cottage cheese (as a protein substitute), and green beans. During an observation, on 3/19/25 at 11:27 a.m., the sign on the wall listing the lunch and dinner options remained as listed above. The menu for 3/19/25 lunch was baked ham, sweet potato casserole, French cut green been, and chocolate cake with icing. During an observation, on 3/19/25 at 11:58 a.m., Resident 14 sat in her recliner in her room and did not have a tray in front of her. All trays had been delivered on the hall. During an interview, on 3/19/25 at 12:05 p.m., LPN 8 indicated Resident 14 often refused her meals. She would almost always eat a hot dog. The kitchen did not have hot dogs today. The facility kitchen ran out of items frequently. The kitchen staff had to go get milk the other day before they could serve meals because they had run out. The facility kitchen often ran out of items. During an observation, on 3/19/25 at 12:16 p.m., the lunch meal was sampled. The meal consisted of ham with brown gravy, sweet potatoes, cut green beans, and spice cake with whipped topping. During an observation, on 3/20/25 at 7:34 a.m., Resident 14 sat in her recliner in her room with her feet elevated and did not have a breakfast tray. During an interview, on 3/19/25 at 7:47 a.m., the ADON indicated the resident had refused her tray, and she had been offered alternatives. The staff had been getting her to eat a hot dog for lunch and dinner as she would often eat the hot dog. During an interview, on 3/20/25 at 2:53 p.m., the Administrator indicated she had just started a Performance Improvement Plan (PIP) for the kitchen in February 2025 for the residents not getting what they ordered. The residents had been more concerned about the wastefulness of the food being thrown away than anything else. During an interview, on 3/20/25 at 3:31 p.m., LPN 6 indicated the kitchen frequently did not serve what was on the menu. They don't have what the residents want or what is on the menu. They run out of something at least once a week for example they ran out of [NAME] Krispies and hot dogs recently. The dining service has changed since being outsourced. Resident 14's clinical record was reviewed on 3/18/25 at 2:29 p.m. Diagnoses included vitamin D deficiency, hyponatremia (low sodium blood level), vitamin B12 deficiency, and gastroesophageal reflux disease (a condition where stomach contents flow back up into the esophagus) without esophagitis (inflammation of the esophagus). Current physician's orders included the following: Regular texture general diet with super cereal in the morning, a protein and caloric supplement three times a day, and mirtazapine 15 milligrams (mg) at bedtime for appetite stimulant. 2. During an interview, on 3/17/25 at 2:37 p.m., Resident 12 indicated the staff went over the menu with her the day before it is served. The day the meal was served, half the time, they didn't have what was on the menu. They served her something different than what she ordered lots of times. The facility ran out of eggs frequently. During an interview, on 3/19/25 at 12:11 p.m., Resident 12 indicated she was supposed to get a hot dog. The kitchen did not have any. She requested a salad, and she received her salad in a small pudding dish. She had wanted more salad since she had not gotten her hot dog. She didn't really like spice cake very well and would have preferred the chocolate cake on the menu. She was so upset with the meal; she no longer had an appetite. During an observation, on 3/20/35 at 7:38 a.m., the resident sat in her recliner looking at her plate of scrambled eggs with cheese. At the same time, she indicated she was supposed to get her scrambled eggs in a bowl, because it was easier for her to eat them that way. She indicated her meal ticket was clearly written out to have her eggs in a bowl not on a plate. Review of Resident 12's meal ticket, provided by Resident 12 on 3/20/25 at 7:38 a.m., indicated the resident wanted two scrambled eggs with cheese in a big white bowl. NO PLATE was written on the meal ticket Resident 12's clinical record was reviewed on 3/18/25 at 1:52 p.m. Diagnoses included anemia, gastroparesis (a condition where the stomach muscles do not function properly, resulting in delayed emptying of food into the small intestine), hypokalemia (low potassium blood level), and type 2 diabetes mellitus with diabetic neuropathy (a complication of diabetes that damages the nerves throughout the body). Current physician's orders included the following: consistent carbohydrate with no added salt diet and regular diet with ground meats if the resident requests. A quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated the resident was cognitively intact. 3. During a dining room observation, on 3/19/25 at 11:55 a.m., RN 4 requested cottage cheese for a resident. Dietary Manager 2 indicated they were out of cottage cheese. During an interview, on 3/20/25 at 8:23 a.m., the Regional Operational Manager indicated another kitchen staff member had been ordering the food supplies since the facility dietary manager had been on leave. During an interview, on 3/20/25 at 8:47 a.m., QMA 10 indicated sometimes the meals provided were not what was on the menu. During an interview, on 3/20/25 at 9:08 a.m., Resident 26 indicated she had ordered a hot dog as an alternative last night for dinner as she did not like what they had. The staff told her they didn't have any hot dogs last night. She ordered cottage cheese and didn't get it. She thought they probably didn't have that either as the facility did not have cottage cheese lots of times. She had asked for salad with ranch dressing six times. Five of the six times she got Italian dressing which she did not like, she had been told the facility was out of ranch dressing. Yesterday's meal was supposed to have sweet potato casserole, but they only had sweet potatoes. She preferred chocolate cake, but they had spice cake. During an observation, on 3/20/25 at 11:47 a.m., the lunch meal consisted of French style green beans, mashed potatoes, cubed steak with brown gravy, and cheesecake. The menu posted outside the kitchen door indicated the lunch menu was Italian baked chicken, garlic mashed potatoes, cauliflower, and vanilla pudding. During an interview, on 3/20/25 at 11:54 p.m., the resident indicated she did not care for what was on the menu and had ordered a hot dog. She decided not to eat the hot dog as she wasn't in the mood for it. A review of Resident 26's meal ticket, provided by Resident 26, on 3/20/25 at 11:54 AM, indicated the lunch menu was Italian baked chicken, garlic mashed potatoes, cauliflower, and vanilla pudding. During an interview, on 3/21/25 at 10:52 a.m., the Administrator indicated the company that provided the dining services ordered the food supplies. Items that were missing were not always communicated with the nursing staff. If items were not on the supply truck, they went to the store. They did not have salad and hot dogs on the truck this week. She was uncertain why these items were not received. She instructed the kitchen staff to go to the store to get the missing items. Resident 26's clinical record was reviewed on 3/18/25 at 1:45 p.m. Diagnoses included type 2 diabetes mellitus without complication. Current physician's orders included consistent carbohydrates with no added salt diet. An admission MDS, dated [DATE], indicated the resident was cognitively intact. A current facility policy, dated 2/6/20, titled Menus, provided by the Administrator, on 3/21/25 at 11:43 a.m., indicated the following: .Menus are planned in advance and are followed as written to meet the nutritional needs of the residents 3.1-20(i)(4)

A. Based on observation, interview, and record review, the facility failed to ensure the high-temperature dishwasher functioned at a level to maintain proper sanitization requirements. This deficient practice had the potential to impact 31 of 31 residents who received meals from the facility kitchen. B. Based on observation and interview, the facility failed to properly store and distribute food under sanitary conditions while maintaining equipment cleanliness. This deficient practice had the potential to impact 31 of 31 residents who received meals from the facility kitchen. Findings include: During the initial kitchen tour, on 3/17/25 at 9:59 a.m., the following concerns regarding inaccurate high temperature dishwashing were observed: A. The high temperature dishwashers washing temperature was 113 Fahrenheit degrees (F) instead of the requirement of 150 degrees F or higher. During an interview, on 3/17/25 at 10:34 a.m., the Maintenance Director indicated the wash temperature would not get above 113 F degrees. The wash temperature should be above 150 degrees F. The wash temperature, the Friday before, was ranging between 146-148 degrees F. The facility had been using the dishwasher since Friday with temperatures below range. The facility should have used the three-compartment sink for sanitation instead. During an interview, on 3/17/25 at 10:38 a.m., Dietary Manager 2 indicated the dishwasher was safe to use prior to Maintenance servicing the dishwashing machine. During an interview, on 3/17/25 at 10:54 a.m., the Maintenance Assistant indicated the dishwasher had a loose thermostat wire that tripped the reset button. A current facility policy, dated 9/27/18, titled, Mechanical Ware Washing, provided by the Administrator, on 3/21/25 at 11:43 a.m., indicated the following: .When the dish machine is not washing/sanitizing properly, stop the process and contact the Director of Food and Nutrition Services and/or the Maintenance Director. Food may not be served on dinnerware that has not been sanitized per guidelines B. During the initial kitchen tour, on 3/17/25 at 9:59 a.m., the following concerns regarding food storage were observed: An upright refrigerator was observed with the following: Uncovered individual drinks sitting on top of a tray. Fresh fruit in uncovered individual plastic cups in the refrigerator. An upright freezer was observed with the following: An uncovered, undated bowl of fruit was on the bottom shelf of the freezer. Six biscuits were laying loose on top of another pack of biscuits. The toaster had crumbs all over the top of the toaster. The toaster was smeared with a white substance on the top right side. The toaster also had a brown, crumb-like substance inside the dial of the toaster. During an interview, on 3/17/25 at 10:03 a.m., Dietary Manager 2 indicated the six biscuits should have been covered and labeled. During an interview, on 3/18/25 at 10:32 a.m., Dietary Manager 7 indicated all items in the refrigerators and freezers needed to be labeled and covered. A current facility policy, dated 11/25/19, titled, Food Storage, provided by the Administrator, on 3/21/25 at 11:43 a.m., indicated the following: .Food is stored and prepared in a clean and safe sanitary manner that complies with state and federal guidelines 3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure the palatability of the meals served for 7 of 7 residents reviewed for palatable meals. (Resident 77, 12, 26, 15, 23, 17, and 19). Findings include: 1. During an interview, on 3/17/25 at 2:37 p.m., Resident 12 indicated she was disgusted with the food. The food was horrible. She had green meatloaf. She had a taco salad made with hash browns not lettuce. The eggs were often watery and were not done. At times, the hot chocolate tasted like coffee was mixed in with it. She ate a lot of grilled cheese sandwiches because the food was not good. They even messed up the grilled cheese at times. The food tasted like slop. During an interview, on 3/17/25 at 3:40 p.m., Resident 26 indicated the food was terrible. She ate peanut butter and jelly sandwiches on more than one occasion. She was often uncertain what the meats were until she looked at the menu. The eggs were nasty and watery. They had almost no taste. She tried the eggs three different times and was not going to eat them again. The vegetables were mushy too. During an interview, on 3/19/25 at 10:30 a.m., Resident 26 indicated she had sausages so hard at breakfast she couldn't cut them with a fork. The food was consistently not good. During an interview, on 3/19/24 at 12:05 p.m., LPN 8 indicated the food was not good since the kitchen had been outsourced. During an observation, on 3/19/25 at 12:16 p.m., the lunch meal was sampled. The lunch consisted of ham with brown gravy, sweet potatoes, green beans, spice cake, hot chocolate, and lemonade. The brown gravy was very salty making it difficult to discern the flavor of the ham. The spice cake had a hard top and edges that were crunchy and had very little flavor to indicate what the flavor the cake actually was. The lemonade tasted watered down, with little flavor. During an observation, on 3/20/25 at 7:49 a.m., Resident 80's meal tray sat on the meal cart. The eggs were sitting on the plate with watery fluid around them. During an observation, on 3/20/25 at 7:56 a.m., a breakfast meal was sampled. The breakfast consisted of scrambled eggs, a small muffin, oatmeal, hot chocolate, toast, apple juice, and fruit punch. The eggs were wet with no seasoning. The muffin had little flavor, was dark in color, and was hardened on the top and bottom. The oatmeal was mushy. The hot chocolate had an odd odor with a faint smell of coffee. During an interview, on 3/20/25 at 9:08 a.m., Resident 26 indicated she did not want oatmeal again today for breakfast. She was not going to try the eggs again as she had already done that three times. She indicated yesterday's lunch had gravy that was really salty. The sweet potatoes were like mush. The spice cake was burnt on the bottom. The food was either over seasoned or under seasoned most of the time. During an interview, on 3/20/25 at 2:53 p.m., LPN 6 indicated the muffins were very hard today at breakfast. The food had been different, not as good, since the kitchen had been outsourced. During an interview, on 3/21/25 at 10:05 a.m., Resident 77 indicated the food was disgusting. He had only had a couple of good meals since he had been here. Yesterday he had gotten what he thought was supposed to be a muffin. The muffin was so hard it bounced off the table. The food was bad. He was considering getting therapy elsewhere unless the food improved. Resident 26's clinical record was reviewed on 3/18/25 at 1:45 p.m. Diagnoses included type 2 diabetes mellitus without complication. Current orders included consistent carbohydrates with no added salt diet. Resident 26's admission Minimum Data Set (MDS), dated [DATE], indicated the resident was cognitively intact. Resident 12's clinical record was reviewed on 3/18/25 at 1:52 p.m. Diagnoses included anemia, gastroparesis (a condition where the stomach muscles do not function properly, resulting in delayed emptying of food into the small intestine), hypokalemia (low potassium blood level), and type 2 diabetes mellitus with diabetic neuropathy (a complication of diabetes that damages the nerves throughout the body). Current orders included consistent carbohydrates with no added salt diet and regular diet with ground meats if resident requested. Resident 12's quarterly MDS assessment, dated 2/3/25, indicated the resident was cognitively intact. Resident 77's clinical record was reviewed on 3/18/25 at 2:22 p.m. Diagnoses included hypothyroidism and hyperlipidemia. Current orders included no added salt packet on tray with regular diet. Resident 77's admission MDS assessment, dated 3/8/25, indicated the resident was cognitively intact. 51985 2. During an interview, on 3/17/25 at 10:26 a.m., Resident 17 indicated that he had several complaints regarding the facility dining services which included inappropriate food temperatures, missed items on trays, and he had not consistently received extra protein with his meals as ordered. During an observation, on 3/17/25 at 12:25 p.m., several resident plates were observed in the dining room with more than 1/2 of the served food remaining on the plates, which included plates that staff assisted residents with eating. Residents had departed from tables. During an interview, on 3/17/25 at 3:25 p.m., Resident 15 indicated the facility food was bland, contained no flavor, and soups were served cold. Resident 15's clinical record was reviewed on 3/18/25 at 1:48 p.m. Diagnoses included unspecified dementia, hypertension (high blood pressure), iron deficiency anemia, and hyperlipidemia (high levels of fats in the blood). Current physician orders included regular texture, thin liquids diet. Resident 17's clinical record was reviewed on 3/19/25 at 10:53 a.m. Diagnoses included necrotizing fasciitis (an inflammation of the connective tissue surrounding muscles, blood vessels, and nerves), cutaneous abscess (localized collection of pus that forms under the skin) of groin, diabetes mellitus, and unspecified systolic congestive heart failure. Current orders included consistent carbohydrates with no added salt diet, regular texture with thin liquid; with double protein at breakfast for wound healing. Resident 17's quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was cognitively intact. During an interview, on 3/19/25 at 12:06 p.m., Resident 15 indicated she did not like the lunch that was served and was given peanut butter and jelly sandwich as an alternative. She does not like the way the food is prepared or the lack of being prepared and felt it caused her diarrhea. Her family supplied her with snacks and drinks. During an observation, on 3/19/25 at 12:16 p.m., a lunch tray was sampled. Two slices of ham were covered with a thin brown gravy/glaze. The gravy tasted excessively salty. The saltiness of the gravy overpowered the taste of the ham. The spice cake's edges/top/bottom were very hard and crunchy. Increased pressure was applied to the fork to go through the edges of the cake. The inner part of the cake was soft and dry, minimally moist, and bland in flavor. During an observation, on 03/19/25 at 12:40 p.m., most plates that remained in the dining room after lunch had at least 50% -100% of ham eaten. At least six plates and six bowls with uneaten green beans, sweet potatoes, and the outer edging of cake, sitting on the dining room tables. Multiple cups of fluids at least half full were left on four tables. During an observation, on 3/20/25 07:43 a.m., Resident's 15's uncovered meal tray sat on her bedside table, untouched. The meal items were scrambled eggs, toast, and [NAME] Krispie cereal. During an observation and interview, on 3/20/25 at 7:48 a.m., Resident 17 indicated that the eggs were watery, had an odd consistency, and lacked flavor. A watery residue was observed on the resident's plate as he used his fork to push the scrambled eggs from one edge of the plate to the other edge. The top of the scrambled eggs had been covered with pepper; he indicated it had been his attempt to make the eggs edible. He picked up the muffin, flipped it over in his hand, and banged it on his plate and bedside table. The muffin was observed to be dark brown in color and made a thumping noise as he struck it on his plate and bedside table. The resident did not eat the scrambled eggs or the muffin. During an observation, on 3/20/25 at 8:03 a.m., a breakfast tray was sampled. The scrambled eggs had excessive moisture causing eggs to be wet and were very bland. Bread was lightly toasted and was buttered. The oatmeal was very soft and mushy with minimal flavor and was overcooked. The muffin had a darkened and hard top that was crunchy when bitten into. The inner part of the muffin was dry and crumbly. The hot chocolate was very light in color, had a peculiar odor, had a faint odor and taste of coffee,and was poor in flavor. 49411 3. During an interview, on 3/17/25 at 11:16 a.m., Resident 23 indicated his biggest complaint was how the food was inedible and bland tasting. The oatmeal was always cold, the French toast was always soggy, and the hot chocolate tasted like chocolate milk. The resident's representative brought him breakfast every morning because he doesn't like the food the facility serves. During an interview, on 3/17/25 at 11:33 a.m., Resident 19 indicated the food was cold and had little flavor. During a dining room observation, on 3/19/25 at 11:55 a.m., RN 4 requested cottage cheese for a resident. Dietary Manager 2 indicated they were out of cottage cheese. During an observation, on 3/19/25 at 12:14 p.m., the lunch meal was sampled. The sampled tray included spice cake with whipped topping, chunks of sweet potatoes, fresh cut green beans, and ham with brown gravy on top. The ham was overpowered by the saltiness of the brown gravy. The crust of the spice cake was extremely hard and crunchy. The top of the cake was dark brown in color, and was hard to pierce with a fork. The inside of the cake was dry and lacked any spice flavor. The lemonade was very weak in flavor and tasted like lemon water. During a dining room observation, on 3/19/25 at 12:40 p.m., eight residents had large amounts of hard, crusty edges of spice cake left on their plates. The plates also contained large amounts of ham and sweet potatoes. During an interview, on 3/20/25 at 7:53 a.m., Dietary Manager 2 indicated the muffins had hardened while they sat on the counter during the breakfast meal. During an observation, on 3/20/25 at 7:56 a.m., the breakfast meal was sampled. The sampled meal included oatmeal with a small plastic container of brown sugar on the side, scrambled eggs, a brown-colored muffin, white toast, hot chocolate, fruit punch, and apple juice. The scrambled eggs were very moist almost wet tasting, with no seasoning. The brown muffin was hard on the top, outside, and bottom and was dry on the inside. The oatmeal was overcooked and very mushy. The hot chocolate had a faint smell of coffee mixed with another unidentifiable smell. During an interview, on 3/20/25 at 8:20 a.m., Dietary Manager 2 indicated the water used for the hot chocolate came from the water spigot on the side of the coffee maker. During an interview, on 3/20/25 at 8:23 a.m., the Regional Operational Manager indicated the hot water sampled from the coffee pot spigot tasted like well water. They mixed two scoops of hot chocolate mix into the water when preparing it for residents. Prior to serving the residents, he taste tested the food. During an interview, on 3/20/25 at 8:47 a.m., QMA 10 indicated there had been numerous complaints made by residents regarding the food. Sometimes the facility did not have items that were on the menu. During an interview, on 3/20/25 at 8:48 a.m., CNA 11 indicated the food was terrible and lacked flavor. During an interview, on 3/20/25 at 8:52 a.m., RN 4 indicated the food was terrible and lacked flavor. During an interview, on 3/21/25 at 11:43 a.m., the Administrator indicated the residents had a concern regarding the appearance of French fries in December 2024. The fries were checked, and they were served at the correct temperature. The Administrator contacted the outsourced kitchen's regional manager and had discussed ordering a different brand of fries. The kitchen was started on a Performance Improvement Plan (PIP) in February 2025. Resident 23's clinical record was reviewed on 3/19/25 at 1:54 p.m. Diagnoses included unspecified atrial fibrillation, essential hypertension (high blood pressure), hyperlipidemia (high levels of fats in the blood), acute respiratory failure with hypoxia (the body's tissues do not receive enough oxygen), chronic diastolic (congestive) heart failure, type 2 diabetes mellitus without complications, generalized muscle weakness, and major depressive disorder. Current orders included consistent carbohydrates with no added salt diet, regular texture with thin liquids consistency. Resident 23's quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was cognitively intact. Resident 19's clinical record was reviewed on 3/21/25 at 11:34 a.m. Diagnoses included type 2 diabetes mellitus with hyperglycemia (high blood sugar), chronic kidney disease, generalized muscle weakness, and hypertension (high blood pressure). Current orders included consistent carbohydrates with no added salt diet, regular texture with thin liquids consistency. Resident 19's quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was cognitively intact. A current facility policy, dated 3/25/12, titled Presentation of the Meal, provided by the Administrator, on 3/21/25 at 11:43 a.m., indicated the following: .Meals are served attractively, accurately, efficiently, and at the appropriate temperature A current facility policy, dated 2/18/19, titled Resident Satisfaction with Food and Dining, provided by the Administrator, on 3/12/25 at 11:55 a.m., indicated the following: The Director of Food and Nutrition Services monitors the quality of the food served and the level of resident satisfaction regarding their overall dining experience 3.1-21(a)(1)(2)

Based on record review and interview, the facility failed to ensure the resident's representative was notified in writing of the transfer/discharge appeal rights for 3 of 3 hospitalizations. (Resident 17, 77 and 127) Findings include: 1. Resident 77's clinical record was reviewed on 3/18/25 at 3:22 p.m. Diagnoses included encounter for surgical aftercare following surgery on the circulatory system, presence of cardiac pacemaker, paroxysmal atrial fibrillation (rapid irregular heart rhythm), and sick sinus syndrome (irregular heart rhythm). A progress note, dated 3/8/25 at 10:20 a.m., indicated the resident had three large amounts of dark red stool. The physician and the family were notified. Physician's orders were received to send the resident to the hospital for evaluation. The clinical record lacked indication that the resident and the resident's representative were notified of the transfer/discharge appeal rights in writing for the resident's transfer to the hospital. During an interview, dated 3/20/25 at 10:51 a.m., the Assistant Director of Nursing (ADON) indicated when a resident was sent to the hospital, a face sheet, a transfer form, a change of condition form, a medication list, and code status were sent with the resident. A bed hold and a transfer notice, which was attached to the bed hold, was also sent. The family was called and notified of the resident's transfer.3. Resident 127's clinical record was reviewed on 3/18/25 at 1:42 p.m. Diagnoses included type 2 diabetes mellitus without complications, multiple sclerosis (a chronic, autoimmune disease that affects the central nervous system (brain and spinal cord), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body, often affecting the arm and leg) following cerebral infarction (blood flow to the brain was interrupted, causing brain tissue to die) affecting right dominant side, and stage 3 pressure ulcer of sacral region (tailbone). A progress note, dated 1/13/25 at 3:39 p.m., indicated Resident 127 had returned from an appointment and had no urine in her catheter bag or tubing. The irrigation of her catheter was attempted without success. A catheter change was attempted but was unsuccessful. The Medical Director was notified, and new orders were received to send Resident 127 to the emergency room (ER) for evaluation and treatment. The note indicated all appropriate paperwork was sent with the resident. The resident's representative was notified and agreeable with new orders. The clinical record lacked indication that the resident and the resident's representative were notified of the transfer/discharge appeal rights in writing for the resident's transfer to the hospital. During an interview, on 3/20/25 at 10:56 a.m., the Social Services Director (SSD) indicated she was only responsible to notify the ombudsman with transfers and discharges. She was not responsible to notify anyone else of the transfers and discharges. During an interview, on 3/21/25 at 11:51 a.m., the SSD indicated the transfer/discharge appeal rights notice was included in the packet sent to the hospital with the resident for an emergency room visit or a hospital stay. The transfer/discharge paperwork went with the resident to the hospital in a packet. One time, she had mailed the resident's transport/discharge appeal rights form because the family was not available. During an interview, on 3/21/25 at 12:05 p.m., the Director of Nursing (DON) indicated the transfer/discharge appeal rights were sent with the resident to the hospital. The paperwork was not mailed to the resident's representative. During an interview, on 3/21/25 at 2:53 p.m., the Administrator indicated she had a bed hold policy but did not have a policy on transfer/discharge appeal rights. 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(ii) 3.1-12(a)(6)(A)(iii) 2. Resident 17's clinical record was reviewed on 3/19/25 at 10:53 a.m. Diagnoses included necrotizing fasciitis (an inflammation of the connective tissue surrounding muscles, blood vessels, and nerves), cutaneous abscess of groin, diabetes mellitus, and unspecified systolic congestive heart failure. A progress note, dated 9/7/2024 at 10:55 a.m. and 9/17/25 at 3:55 p.m., indicated that the resident complained of chest pain. A physician's order was obtained on both dates to send the resident to the emergency room (ER) for evaluation. A progress note, dated 2/4/25 at 12:54 a.m., indicated that the resident complained of nausea and vomiting and was observed to have had an elevated pulse, low oxygen saturation, increased weakness, dizziness with standing, and brain fog. A physician's order was obtained to send the resident to the ER for evaluation. The clinical record failed to indicate that the resident, who was his own representative, received a copy of the transfer/discharge appeal rights paperwork at the time of each ER transfer. During an interview, on 3/20/25 at 10:50 a.m., LPN 6 indicated that the transfer/discharge process was to complete a resident assessment, documentation of findings, physician notification, receive an order to transfer, family notification to see if they agree with the transfer, and to complete paperwork. The paperwork completed was the eINTERACT outpatient transfer form, eINTERACT change of condition form, bed hold policy, and copied orders, face sheet, and code status. When the paperwork was completed, it was placed in a packet. The packet was sent with the EMT's to the hospital. If the paperwork was not completed when the EMTs arrived at the facility, the facility staff faxed information to the hospital. No paperwork was given to the resident or resident's family.

Based on observation, interview, and record review, the facility failed to ensure the results from their last annual Indiana Department of Health (IDOH) survey report were posted at an accessible height for 1 of 1 residents interviewed (Resident 23). This deficient practice had the potential to impact 31 of 31 residents/or representatives for those residents who resided in the facility. Findings include: During an observation, on 3/17/25 at 12:04 p.m., the State Survey Binder was on the lower shelf of a sofa table, against the wall right outside the Administrator's office, about four inches off the floor. During an observation, on 3/18/25 at 2:03 p.m., the State Survey Binder was on the lower shelf of a sofa table, against the wall right outside the Administrator's office, about four inches off the floor. During an observation, on 3/19/25 at 9:00 a.m., the State Survey Binder was on the lower shelf of a sofa table, against the wall right outside the Administrator's office, about four inches off the floor. During an observation, on 3/20/25 at 7:39 a.m., the State Survey Binder was on the lower shelf of a sofa table, against the wall right outside the Administrator's office, about four inches off the floor. During an interview, on 3/21/25 at 11:11 a.m., Resident 23 indicated that the State Survey Binder had not been reachable by all residents due to their mobility limitations. During an interview, on 3/21/25 at 11:14 a.m., QMA 10 indicated that the State Survey Binder had not been reachable by all resident's due to their mobility limitations. The State Survey Binder usually sat on the top shelf of the sofa table. During an interview, on 3/21/ 25 at 12:15 p.m., the Administrator indicated she was responsible for the State Survey Binder. The binder was generally kept on the top shelf of the sofa table. She had not noticed the binder was moved to the bottom shelf. A current facility policy, dated 8/2017, titled Survey Posted/Accessible, provided by the Administrator, on 3/21/25 at 2:46 p.m., indicated the following: .The location of the most recent annual survey including the facilities response to the findings must be clearly posted in a prominent area easily accessible to residents, their family members and their legal representatives as well as the public 3.1-3(b)(1)

Based on interview and record review, the facility failed to identify the number of staff needed for physical transfers and to ensure physical transfers were provided in a consistent manner for a resident who required extensive assistance for mobility for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted in Resident B sustaining a fracture to her right ankle. Findings include: Review of a facility self reportable, dated 12/9/24, indicated on 12/7/24, Resident B had been transferred to bed from her wheelchair. The resident's right foot had not turned with the rest of her body. The report indicated a head-to-toe assessment had been completed with no injuries noted at that time. The resident had complained of discomfort to her right ankle and right lower leg, but had declined pain medication. Resident B continued to complain of pain throughout the night and early morning hours. The nurse indicated the right ankle had become swollen. An order for x-rays was provided and the result showed an acute ankle fracture. Resident B's clinical record was reviewed on 12/31/24 at 11:03 a.m. Diagnoses included right side hemiplegia and hemiparesis following stroke, peripheral vascular disease, difficulty in walking, major depressive disorder, and chronic pain syndrome. A current care plan, dated 12/22/21, and revised on 10/17/24, indicated Resident B required assistance extensive assistance with transfers. The care plan goal indicated the resident would feel secure with staff providing major support for transfer with some support. Interventions included to explain procedure and reassure safety. A current care plan, dated 11/30/21 and revised on 11/28/23, indicated Resident B required assistance with all activities of daily living (ADL) including transfers, since her recent medical event. The resident had right side hemiplegia following a stroke several years ago. She was unable to care for herself independently and had no voluntary movement to her upper and lower left side. She required extensive to dependent assistance of staff with all ADL tasks. Interventions included to encourage resident to participate in ADLs within her abilities and to assess and honor the resident's preferences. A quarterly Minimum Data Set (MDS) assessment, dated 11/26/24, indicated Resident B had moderate cognitive impairment, was dependent on staff for upper and lower body dressing, and required substantial/maximum assistance of staff (staff completes more than half of the effort) for transferring. The resident felt down, depressed or hopeless half or more days during assessment period. The resident displayed no behaviors or rejection of care, and received no scheduled or as needed pain medications during assessment period. An incident progress note, dated 12/7/24 at 2:06 p.m., indicated CNA 3 had transferred Resident B to bed following lunch. CNA 3 indicated to the nurse that when she was turning the resident the resident's ankle had not turned with the rest of the resident's body, causing pain to the resident's right ankle/lower leg. The resident's right lower extremity had no edema, bruising, or redness. The provider was notified with no new orders given at that time. A nursing progress note, dated 12/7/24 at 8:00 p.m., indicated the resident had requested a dose of pain medication. The resident had complained of pain to her right ankle and the nurse noticed the resident's foot and ankle had become swollen without discoloration present. A change of plan of care/orders progress note, dated 12/8/24 at 12:37 p.m., indicated the resident had complaints of pain and swelling her right ankle. An order was provided to obtain x-rays of the right ankle. An incident progress note, dated 12/8/24 at 3:55 p.m., indicated the x-ray result had been received and reported to the provider. The resident had a right acute fracture of the distal tibia. The medical doctor was notified and provided orders for resident to remain in bed. An incident progress note, dated 12/9/24 at 4:27 p.m., indicated new orders had been received for the resident to remain non-weight bearing to right lower extremity and to apply ice and elevation. Resident B was to be transferred to the orthopaedic walk-in clinic the following day. An Interdisciplinary Team (IDT) note, dated 12/10/24 at 10:53 a.m., indicated staff were transferring Resident B from the wheelchair to the bed. When staff and the resident turned, the resident's right foot had not turned with her body. The resident complained of pain and the CNA reported it to the nurse. The nurse completed a head-to-toe assessment. Resident B was found to have no visible injuries, but did complain of pain. The resident refused pain medication when offered. The complaint of pain remained throughout the night and swelling to area right ankle was observed. The resident's physician was updated and orders obtained for x-ray on 12/8/24. An x-ray was obtained with a finding of an acute fracture. The physician was again updated with multiple new orders, including the resident to be taken to [orthopaedic provider] when open on Monday. A current physician order, dated 12/8/24, included ketorolac tromethamine (to temporarily treat acute pain) 10 mg (milligram), one tablet every six hours as needed for moderate to severe pain. The resident had at least one dose daily since the fracture, with an average pain rating at 7 on a scale of 1-10. During a random observation, on 12/31/24 at 10:43 a.m., Resident B was lying in bed on her back, covered with a blanket. Her eyes were closed and her head was positioned to the left. The resident was dressed in a hospital gown. During an interview on 12/31/24 at 11:39 a.m., the ADON indicated Resident B was a two person assist for transfer prior to her fracture. CNA 3 had just finished her CNA class in June and had recently passed her certification. The ADON was unsure if CNA 3 referenced the CNA assignment sheets prior to providing care, but that was the expectation of staff. The ADON had since educated the staff regarding two person assists and that two staff must assist in care when indicated. The facility had no specific policy regarding staff assisted transfers or where to locate information on resident care needs. During a random observation, on 12/31/24 at 11:40 a.m., Resident B was lying in her bed on her back, covered with a blanket. Her eyes were closed and her head was positioned to the right. The resident was dressed in a hospital gown. During a telephone interview on 12/31/24 at 11:51 a.m., CNA 3 indicated she had been a CNA since the first week of November 2024. She was not aware that Resident B was a two person assist for transfers. She had witnessed staff transferring Resident B independently. She was unaware the facility had CNA Assignment Sheets. She was transferring Resident B and her foot usually slid with her body when turning her to her bed or chair, but this time, her right foot had not turned. The CNA reported it to the nurse as soon as she completed getting the resident settled in bed. During a random observation, on 12/31/24 at 1:10 p.m., Resident B was lying in her bed on her back, covered with a blanket. Her eyes were closed and her head was straight on her pillow. The resident was dressed in a hospital gown. During an interview on 12/31/24 at 1:48 p.m., Resident B indicated she hadn't been out of bed today because she just hadn't felt like it. She had a loss of appetite, but had not felt like an increase in depression or anything like that since her fracture. Staff had always transferred her with just one person and on this occasion, her foot just had not slid as usual. She had pain, but staff were good to provide her medication when she needs the medication. She felt more tired than usual. During an interview on 12/31/24 at 2:10 p.m., CNA 2 indicated she had previously transferred Resident B with another staff member due to her being a two person transfer. The resident currently required a mechanical lift for transfer due to her fractured ankle. CNA 2 reviewed the CNA assignment sheets for resident care needs as well as the Task tab on the electronic health record. She had noticed the resident was not getting out of bed as much as before her injury, but did not appear to be upset or in pain. During an interview on 12/31/24 at 2:10 p.m., CNA 6 indicated she had assisted Resident B frequently and had not noticed any major change in her since fracturing her ankle. The resident had gotten up from bed, maybe not as often, but close to her baseline. The resident had complained to her about discomfort in her ankle. CNA 6 indicated the resident had been a two person transfer prior to her injury because of her right side, specifically her right leg, not moving during transfer and the need for support. She received resident care needs from the CNA Assignment Sheets and from the Task information in the electronic health record. This citation relates to complaint IN00448842. 3.1-45(a)

Based on interview and record review, the facility failed to ensure residents received medications, including insulin injections, from qualified nursing personnel and failed to ensure medications were prepared and administered within professionally accepted standards for 5 of 5 residents reviewed for medication administration (Residents B, C, E, F, and G). These deficient practices had the potential to effect 41 of 41 residents in the facility. Findings include: Review of a facility self reportable, dated 5/26/2023 indicated on 5/25/2023, during job shadowing activity, LPN 1 allowed a nursing student to pass medications to five facility residents. During an interview, on 6/14/2023 at 10:37 a.m., the Administrator indicated they had not been aware of LPN 1's daughter (who was the nursing student named in the report) job shadowing her until they were contacted by concerned staff, who reported witnessing the nurse's daughter administering medications to residents. The Administrator indicated LPN 1 had requested permission to do the job shadowing from the DON. The Director of Nursing was out of the facility during the time of the survey. The facility did not have a contract with a nursing program for clinical rotation. During an interview, on 6/14/2023 at 10:42 a.m., CNA 3 indicated during the evening shift on 5/26/2023, they witnessed LPN 1 and her daughter administering medication to several residents. CNA 3 had witnessed LPN 1's daughter administer insulin to Resident G. CNA 3 and other staff became concerned and called the Administrator. CNA 3 did not know the nursing student personally, but knew she was the daughter of LPN 1. During an interview, on 6/14/2023 at 12:25 p.m., QMA 4 indicated they had been working when LPN 1's daughter was job shadowing her. QMA 4 was insulin qualified, but the facility did not allow QMAs to give insulin. She usually draw up the insulin for LPN 1, to be nice to her. She knew she was not supposed to prepare medication for someone else. The nurse told her not to draw up the insulin that day, because she was going to do it with the student. QMA 4 believed the nursing student was there as part of a clinical rotation. During an interview, on 6/14/2023 at 1:35 p.m., LPN 6 indicated QMAs were not allowed to administer insulin in the facility. They would not allow a QMA to draw up insulin or pre-set any medications. During an interview, on 6/14/2023 at 1:48 p.m., QMA 7 indicated the facility did not allow QMAs to give insulin. QMAs checked the blood sugars, and the nurses administered the insulin. She never drew up the insulin for the nurse. It was not in her scope of practice. During an interview, on 6/14/2023 at 1:56 p.m., Resident E indicated a few weeks ago someone gave her an insulin shot who should not have. They did not work in the facility. At the time, she was told they were here for training. She thought it was a new employee. The next day she found out that was not true. She felt like she was lied to. If she had known the truth, she would not have allowed them to give her the insulin. During a phone interview, on 6/15/2023 at 9:45 a.m., the DON indicated LPN 1 requested to have her daughter job shadow her. She gave LPN 1 permission because the facility had allowed it in the past. In the past, potential new hires would ask to job shadow nurses and aides. The facility did not have a policy for job shadowing. The DON defined job shadowing as observation only. At no time did she give LPN 1 permission for the daughter to provide resident care or administer medications. The DON did not inform the Administrator she gave LPN 1 permission to have the daughter job shadow. The DON did not define the definition of job shadowing with LPN 1 when permission was granted. During an interview on, 6/15/2023 at 11:05 a.m., the Administrator and ADON indicated the facility did not have a policy or any type of guidance for job shadowing. The Administrator and ADON defined job shadowing as observation only - not to perform any duties. Only nurses and QMAs were allowed to administer medication. LPN 1 was no longer employed at the facility, and was unable to be reached for interview. Review of a written statement from LPN 1's daughter/Nursing Student 2 indicated she had administered insulin to five residents. The student believed this to be part of the job shadowing. A list of the resident names was provided by the Administrator on 6/15/23. Review of a written statement from LPN 1, dated 5/26/2023, indicated she had been given permission to have her daughter job shadow her. Her daughter was a RN candidate and she believed she was allowed to administer insulin. The student was also diabetic, and administered insulin to herself. a. The clinical record for Resident B was reviewed on 6/14/2023 at 12:00 p.m. Diagnoses included type 2 diabetes and vascular dementia. b. The clinical record for Resident C was reviewed on 6/14/2023 at 12:11 p.m. Diagnoses included cerebrovascular disease and type 2 diabetes. c. The clinical record for Resident E was reviewed on 6/14/2023 at 12:39 p.m. Diagnoses included chronic heart failure and type 2 diabetes. d. The clinical Record for Resident F was reviewed on 6/14/2023 at 12:43 p.m. Diagnoses included type 2 diabetes and stage 3 chronic kidney disease. e. The clinical record for Resident G was reviewed on 6/14/2023 at 12:46 p.m. Diagnoses included type 2 diabetes and Parkinson's disease. Review of a current, undated, facility policy titled Medication Administration, indicated the following: 1. Licensed professional nurses administer medications according to times documented on the Medication Administration Record Review of an online document, titled Medication Administration: NCLEX-RN, dated 2/15/23 and retrieved from https://www.registerednursing.org/nclex/medication-administration, indicated the following: .Nurses are legally and ethically responsible and accountable for accurate and complete medication administration, observation, and documentation This Federal tag relates to complaint IN00409625. 3.1-14(j) 3.1-25(b)(1) 3.1-47(a)(1)

Based on interview and record review, the facility management team allowed an unqualified individual, who was not employed or contracted with the facility, to provide care and have access to resident information. The facility failed to ensure residents did not receive medications, including insulin injections, from an unqualified individual for 5 of 5 residents reviewed for medication administration. This deficient practice had the potential to affect 41 of 41 facility residents. Findings include: Review of a facility self reportable, dated 5/26/2023 indicated on 5/25/2023, during job shadowing activity, LPN 1 allowed an unlicensed nursing student to pass medications to five facility residents. During an interview, on 6/14/2023 at 10:37 a.m., the Administrator indicated they had not been aware of LPN 1's daughter (who was the nursing student named in the report) job shadowing her until they were contacted by concerned staff, who reported witnessing the nurse's daughter administering medications to residents. The Administrator indicated LPN 1 had requested permission to do the job shadowing from the DON. The Director of Nursing was out of the facility during the time of the survey. The facility did not have a contract with a nursing program for clinical rotation. During a phone interview, on 6/15/2023 at 9:45 a.m., the DON indicated LPN 1 requested to have her daughter job shadow her. She gave LPN 1 permission because the facility had allowed it in the past. In the past, potential new hires would ask to job shadow nurses and aides. The facility did not have a policy for job shadowing. The DON defined job shadowing as observation only. At no time did she give LPN 1 permission for the daughter to provide resident care or administer medications. The DON did not inform the Administrator she gave LPN 1 permission to have the daughter job shadow. The DON did not define the definition of job shadowing with LPN 1 when permission was granted. During an interview, on 6/15/2023 at 11:05 a.m., the Administrator and ADON indicated the facility did not have a policy or guidance for job shadowing. The Administrator and ADON defined job shadowing as observation only - not to perform any duties. Neither were aware of the job shadowing event until contacted by staff with concerns. Cross reference F726. This Federal tag relates to complaint IN00409625. 3.1-13(a)(1)

Based on interview and record review, the facility failed to assess and document bruising of unknown origin to a resident's hand for 1 of 3 residents reviewed for accidents (Resident B). Findings include: Resident B's clinical record was reviewed on 4/24/23 at 9:03 a.m. Diagnoses included Alzheimer's disease with early onset, vascular dementia, unspecified severity, with other behavioral disturbance, other seizures, major depressive disorder, single episode, and epilepsy, unspecified, not intractable, without status epilepticus. Her current medications included, citalopram hydrobromide (treat depression) 20 mg (milligram) daily, levetiracetam (treat seizures) 500 mg twice daily, and mirtazapine (treat depression) 30 mg daily. An admission skin assessment, dated 4/8/23, indicated she had unspecified bruises and three tattoos. A nurses note, dated 4/10/23 at 12:35 p.m., indicated she was not responding to staff. The hospice aide gave her a shower. She was a heavy assist of two staff members with transfers, but the hospice aide indicated she ambulated to bathroom when she was at home. She had no signs or symptoms of pain or discomfort and she had no skin issues. A nurses note, dated 4/11/23 at 9:59 a.m., indicated she was alert to her name. She was restless and walked the hallways with one to two assistance of staff. Her gait was very unsteady. She had anxiety and was given antianxiety medication with some effectiveness. She had been on one on one with staff, and she attempted to walk or transfer without assistance and without regards to safety. On 4/13/23 at 8:15 p.m., she discharged home. During an interview with LPN 23, on 4/24/23 at 9:25 a.m., she indicated on Monday 4/10/23, she had noticed light purple bruising to Resident B's thumb and around to her pointer finger. She was not sure which hand it was. The resident tried to get up a lot while she was at the facility, but she did not have any falls and there was no abuse reported to her. During an interview with LPN 15, on 4/24/23 at 9:36 a.m., she indicated Resident B had dark purple bruising on her hand. The hospice aide had mentioned it to her, and LPN 15 thought she admitted with it, and it could have been from a blood draw. During an interview with the ADON, on 4/24/23 at 9:43 a.m., she indicated she had noticed bruising located on her hand in passing but was not sure which hand it was, but thought it was her right hand. They thought she had a blood draw prior to admitting to the facility. They would normally document bruising. There was no abuse, nor any falls or seizures, while she was at the facility. Resident B was, for the most part, non-responsive and they could barely get her to eat. Then, on Tuesday 4/11/23, she was up and going. During an interview with the hospice aide, on 4/24/23 at 12:22 p.m., she indicated she was Resident B's aide at the facility and at her home. She was at the facility on Monday 4/10/23 and did not notice the bruise. On Wednesday 4/12/23, her right hand was swollen and black and blue, so she went to LPN 15, and she indicated to her it could have been from a lab draw. She had existing bruising to her left hand when she admitted to the facility. During an interview with LPN 23, on 4/24/23 at 2:20 p.m., she indicated they would normally document bruising when a resident was admitted or when bruising was noticed. During an interview with the DON, on 4/24/23 at 2:24 p.m., she indicated, on 4/10/23, she noticed a bruise to Resident B's right hand. She went to the shower room with the aide and asked Resident B questions and looked at her bottom. She assumed the bruising was from a lab draw that may have been drawn while she was at home. The bruise on the top of her right hand wasn't completely black and blue, but it was darker. It did get darker and darker as the week went on. Resident B did not complain of pain. Normally, they would chart bruising and she should had charted it on Monday when she noticed it. During an interview with LPN 27, on 4/24/23 at 2:45 p.m., she indicated she did not notice a bruise to the resident's right hand when she admitted to the facility. She did a thorough skin check on Resident B. When she did skin checks, she basically disrobed the resident, including checking their heels, elbows, and back. During an interview with CNA 17, on 4/24/23 at 4:23 p.m., she indicated she had noticed a bruise on the top of Resident B's right hand, and it was swollen and it didn't look fresh. She reported to the bruising to LPN 23 and she told her that she already knew about it. A family member came to pick her up on 4/13/23. The family member noticed the bruise to her right hand and was surprised. The family member asked what had happened to her hand. CNA 17 told her told her that the nurse said it was already there. The family member indicated it had not been there prior to admission. A review of a hospital history of present illness document, dated 4/14/23 at 1:31 p.m., indicated Resident B was on hospice due to terminal illness and was at a nursing home for respite care. A significant bruise was noticed over her right hand and wrist at discharge from the facility. No one seemed to know how she received the bruising. The bruise was dark brown, so it had occurred several days ago. A right wrist x-ray was performed. The impression of the x-ray indicated displaced and overriding comminuted fracture at the base of the first metacarpal (fracture dislocation of the right thumb). An undated, current, facility policy titled SKIN OBSERVATION/ASSESSMENT, provided by the DON on 4/24/23 at 3:58 p.m., indicated the following: Policy .Conditions that will be observed for include, but are not limited to, what appear to the care giver to be bruises .discoloration .Note .the care giver will notify the nurse immediately so that the nurse can perform a skin assessment and notify the physician/family as appropriate and also obtain any needed orders for treatment. Appropriate documentation and care planning will be completed as per policy This Federal tag relates to complaint IN00406798. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to develop and implement interventions to reduce the risk of falls for 1 of 3 residents reviewed for accidents, (Resident 93). This deficient practice resulted in a fall with a fracture requiring hospitalization . Findings include: During an observation, on 2/17/23 at 10:56 a.m., Resident 93's room included pressure alarms to his bed and recliner, and a floor mat beside his bed. The resident's clinical record was reviewed on 2/15/23 at 1:04 p.m. Diagnoses included, but were not limited to, non-displaced fracture of proximal phalanx of right ring finger, repeated falls and dementia. Current physician orders included the following: a. 2/4/23, non-weight bearing to right hand, elevate as tolerated. b. 2/4/23, monitor surgical incision to right hand 4th digit. c. 2/4/23, bed/chair alarm to be used at all times. d. 2/4/23, cleanse right elbow medial area open skin tear/surgical incision with wound wash, cover open area with thin layer of bacitracin, cover with non-adherent pad and wrap with gauze and secure with self-adhering wrap. e. 2/4/23, cleanse right elbow lateral area, open skin tear/surgical incision with wound wash, cover open area with thin layer of bacitracin (antibiotic), cover with non-adherent pad, wrap with gauze and secure with self-adhering wrap. f. 2/15/23, remove sutures at this time to right arm. g. 2/14/23, cleanse skin tears to the top of back of head area with wound wash then apply thin layer of bacitracin. A 1/28/23 discharge/return anticipated MDS (Minimum Data Set) assessment indicated an unplanned discharge to an acute hospital. He required extensive assistance with bed mobility, transfers, to walk in room, with dressing, toilet use and personal hygiene. Since the prior MDS assessment, he had one fall with injury, except major injury and one fall with major injury. A progress note, dated 1/19/23 at 5:00 a.m., indicated he had an unwitnessed fall in his room. His roommate alerted staff of the fall. He was found sitting on the floor, with his back to the bathroom. A head to toe assessment had been completed, with skin tears notes to his right arm and a hematoma to his left forehead. An IDT (Interdisciplinary Team) progress note, dated 1/19/23 at 1:47 p.m., indicated maintenance had inspected floor alarm with loose wiring noted, and the floor alarm was replaced. An alarm was to remain in place and be utilized during hours of sleep for impaired safety during night time hours. A current fall risk care plan, initiated on 12/16/20 and revised on 1/20/23, indicated he was at risk for falls due to his condition and risk factors, arthritis, assistive device for mobility, confusion/forgetfulness, and he refused to use call light during the night to ask for assistance. Most falls occurred during hours of sleep, he had a slow shuffling gait, and forgot to use assistive device for walking. Interventions included, but were not limited to, alarm floor mat to be used at all times during hours of sleep and check functioning every shift (3/11/22) and floor alarm replaced (1/19/23). The fall risk care plan did not indicate new interventions/precautions had been developed or implemented after his fall on 1/19/23. A progress note, dated 1/24/23 at 3:39 a.m., indicated he had woken up at about 1:30 a.m. to got to the bathroom, setting off the alarm. He was assisted back to bed by staff, 15 minutes later he had once again set off the alarm by getting up and taking himself to the bathroom, then every 10-15 minutes for two hours he got up to go to the bathroom, setting off the alarm each time. His roommate complained of getting very little sleep. Other residents on the same hall also complained of getting woke up numerous times during the night. A progress note, dated 1/25/23 at 5:21 a.m., indicated the resident had been up and down, setting the alarm off several times, and waking his roommate. Other residents had also complained about getting woken up. He was assisted to the bathroom and brought to the lounge to watch television for a short time, then he demanded to go back to bed. He was up again a short time later, taking himself to the bathroom, and setting off the alarm. Staff attempted to educate him on dangers of getting up by himself, but he was unable to understand. A progress note, dated 1/26/23 at 2:10 a.m., indicated he had been up and down since 12:30 a.m., going to the bathroom repeatedly due to not remembering he had just been there. He became short and verbally abusive to staff, and the floor alarm was upsetting other residents. A progress note, dated 1/26/23 at 9:56 a.m., indicated the doctor had been updated about resident getting up throughout the night, sounding the alarm, and causing distress to other residents. Staff had encouraged activities throughout the day. A progress note, dated 1/27/23 at 3:41 a.m., indicated he had ben up numerous times to the bathroom, setting off the alarm and waking others. The resident declined suggestions to go to television lounge with another resident. A progress note, dated 1/27/23 at 11:46 a.m., indicated a new order to start melatonin (supplement sleep-aid) at bedtime and to monitor for effectiveness and any side effects. A progress note, dated 1/28/23 at 3:00 a.m., indicated staff responded to the alarm sounding, and assisted him to the bathroom. A progress note, dated 1/28/23 at 9:55 p.m., indicated staff responded to alarm sounding. Resident 93 was found sitting on the floor. Obvious injuries had immediately been noted to his right forehead and right elbow. He was assisted up per three staff and seated on side of his bed. His right hand, fourth digit was grossly deformed with what appeared as white bone protruding from back of his finger. An order received to send to the emergency room for evaluation and treatment. An IDT progress note, dated 2/4/23 at 12:15 p.m., indicated Resident 93 returned to the facility on [DATE] from the hospital with three surgical incisions, two to his right elbow and one to his right hand fourth digit, which was a distal inter-phalangeal joint dislocation. He had also been diagnosed with pneumonia during his hospital stay. A current care plan, created on 2/4/23 and revised on 2/14/23, indicated he was at risk for complications of healing of his surgical site to right arm and finger. Interventions included, but were not limited to, administer treatment as ordered and assess incision daily during treatment for signs or symptoms of infection (increased redness or warmth), pain, drainage or dehiscence. During an interview on 2/17/23 at 10:51 a.m., CNA 5 indicated the resident used to have a floor alarm, but now had a bed and chair pressure alarm. During an interview, on 2/17/23 at 10:58 a.m., LPN 7 indicated the resident had frequent falls and needed more assistance with care since he returned from the hospital. Review of an undated, current facility policy, titled INCIDENTS/ACCIDENTS/FALLS, provided by the Director of Nursing on 2/20/23 at 11:26 a.m., indicated the following: .11 .Each fall needs a new intervention rolled out 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure dietary employees were competently trained to ensure proper food storage, understanding of safe food temperatures, and the completion of assigned dietary duties. This deficient practice had the potential of impacting 40 of 40 residents receiving meals from the facility kitchen. Findings include: During a kitchen observation, on 2/2/23 at 10:52 a.m., the hand washing sink located in the food preparation and service area was not accessible. The sink basin was blocked by a large industrial sized box of plastic wrap. During an interview, at the time of the observation, Cook 1 indicated the plastic wrap was stored in the sink do to limited space. An individual could hand wash in the bathroom, which was located at the back of the kitchen and down a short hallway, or in the three compartment dishwashing sink. During an observation, on 2/2/23 at 10:54 a.m., the thermometer located inside the reach-in refrigerator located to the right of the kitchen entrance registered 50 degrees Fahrenheit (50 F). During an interview, at the time of the observation, Cook 1 indicated 50 degrees F was an acceptable temperature for food refrigeration, but it should be a little lower. Inside the reach-in fridge by the door, there were three uncovered double handled drink glasses with fluid in each one. The cups did not have lids and were open to air. There was one uncovered, undated bowl of peaches, and one undated grilled chicken salad. Cook 1 indicated Cook 2 should have put lids or covers on the drink cups. She, herself, had put the peaches in the refrigerator uncovered and forgot to label the grilled chicken salad. During an observation, on 2/2/23 at 11:14 a.m., the reach-in refrigeration in the dry storage room had an external thermometer which registered 49 degrees F. During an interview at the time of the observation, Cook 2 confirmed it registered 49 degrees F. She indicated the external thermometer was how the facility monitored the refrigerator temperature. She would need to ask Cook 1 if the temperature was acceptable. Cook 1 confirmed to her it was indeed an acceptable temperature for food refrigeration. Inside the dry storage room refrigerator were five large cans of food. The cans were opened and covered with plastic wrap. The cans contained as follows: 1. A large, opened, restaurant sized can of chocolate pudding, covered with plastic wrap and labeled opened 1/30/23, no containers. 2. A large, opened, restaurant sized can of lemon pudding, covered with plastic wrap and labeled opened 1/27/23 and no containers. 3. A large, opened, restaurant sized can of apple sauce, with the lid still attached by a small piece of metal, was covered with plastic wrap and labeled opened 1/31/23, no containers. 4. A large, opened, restaurant sized can of extra thick tomato ketchup, covered with plastic wrap. There was no open date indicated. 5. A large, opened, restaurant sized can of grape jelly, with the lid still attached by a small piece of metal, was covered by plastic wrap. There was no open date indicated. During an interview, on 2/2/23 at 10:52 a.m., Cook 1 indicated the facility did not currently have a Dietary Manager. The previous manger had left a couple months ago. The Administrator was offering the leadership for the department until the new Dietary Manager arrived. During a 2/2/23 at 11:28 a.m. interview, the Administrator indicated the facility did not have a current Dietary Manager. She was acting as dietary leadership until the newly hired Dietary Manger started her position. During an observation and interview of lunch meal service, on 2/2/23 at 11:41 a.m., Cook 1 indicated she did not know how to ensure the correct food types and portion sizes were served for each diet type. She used the Lunch Production Sheet and if a diet wasn't listed on the production sheet, the resident just got the regular diet. No menus or recipes were followed because everything was ready to eat. She had put the canned potatoes in a pan in the oven with spices and browned them. During an interview, on 2/2/23 at 12:16 p.m., the Administrator indicated the facility did not have any verification of Cook 1 or Cook 2 having specific orientation to their job tasks or duties as a cook. Review of a facility provided document titled Dietary Employees, provided by the Administrator in 2/2/23 at 12:16 p.m. indicated the following: a. The facility currently employed five (5) dietary employees. b. Three of the Five dietary employees had been employed for less than five months. c. Cook 1 began her position as cook/dietary aide on 10/6/22. d. Cook 2 began her position as cook/dietary aide on 4/28/22. Review of a 2017 document from the facility dietary policy and procedure manual, which was provided by the Administrator on 2/2/23 at 1:14 p.m., indicated the following: .Dining Services Orientation Checklist: . Refrigerator/Freezer,Can opener .Spreadsheets/modified diets, recipes, .Food Storage: Dry/Refrigerated?Frozen .Training Documentation: Guidelines: All training and orientation functions of Dietary Services employees shall be documented .a To ensure that employees are well informed and equipped to do their best .c. To ensure that employees are acquainted with guidelines and procedures of the facility Dining Services Department A hand written facility document titled Hire and End Date, provided by the Administrator on 2/2/23 at 1:14 p.m., indicated the last Dietary Manager was employed from 10/13/22 to 1/14/23. This resulted in no dietary leadership for a 19 day period. The newly hired Dietary Manager was to begin her position 2/8/23. An undated facility document, titled Job Description, provided by the Administrator on 2/2/23 at 1:07 p.m., indicated the following: .Position Title: Cook .Position Summary: The Cook is responsible for preparing food in accordance with current applicable federal, state and local standards, guidelines and regulations .A. Roles and Responsibilities-Job Knowledge/Duties: .Review menus prior to preparation of food .3. Ensure that menus are maintained and filed in accordance with established policies and procedures 4. Prepare meals in accordance with planned menus 5. Prepare food for therapeutic diets in accordance with planned menus .12. Prepare food in accordance with standardized recipes and special diet orders .23. Must understand how to read and execute the diet spreadsheet A current, 4/2017, facility policy titled, Storage of Dry Food/Supplies, provided by the Administrator on 2/2/23 at 11:58 a.m., indicated the following: .Opened products will be labeled and stored in tightly covered containers A current, 4/2017, facility policy titled Dating & Labeling, provided by the Administrator on 2/2/28 at 11:58 a.m., indicated the following: .foods will be stored, dated and labeled in the refrigerator held at 41 F [degrees Fahrenheit] for a maximum of 7 days,,,All items which are not in their original container will be labeled A current, 4/2017, facility policy titled, Storage of Refrigerated/Frozen Foods, provided by the Administrator on 2/2/28 at 11:58 a.m., indicated the following: .food will be maintained at or below 41 F .Monitoring of food temperatures and functioning of the refrigerator/freezer units will be in place .food in the refrigerator will be covered, labeled and dated This Federal Tag relates to Complaint IN00397976. 3.1-20(h)

Based on observation, interview, and record review, the facility failed to ensure menus were approved by a Registered Dietitian with guidance for diet types. This deficient practice had the potential to impact 40 of 40 residents who received their meals from the kitchen. Findings include: During an interview, at the time of an observation of lunch meal service, on 2/2/23 at 11:41 a.m., Cook 1 indicated she did not know what a spreadsheet to portion sized guide was. She used the Lunch Production Sheet to determine portion size and correct food type for each diet type served to residents. If a diet wasn't listed on the production sheet, the resident was just served the regular diet. No menus were followed because everything was ready to eat. She had put the canned potatoes in a pan in the oven with spices and browned them. Review of a current, 2/2/23, facility document titled Order Listing Report, provided by the Administrator on 2/2/23 at 12:16 p.m., indicated the residents had the following fifteen different diet types ordered: a. One resident had an order for a Low Concentrated Sweets Diet. b. 13 residents had an order for a Regular Diet. c. One resident had an order for a Regular with Ground Meat Diet. d. One resident had an order for No Added Salt and No Concentrated Sweets Diet. e. One resident had an order for a No Added Salt Diet. f. One resident had an order for a Mechanical Soft Diet with Pureed Meat. g. One resident had an order for a Mechanical Soft Diet. h. One resident had an order for a Mechanical Soft Carb Controlled Diet. i. One resident had an order for a No Added Salt Diet. j. Seven residents had an order for a General Diet. k. Two residents had an order for a Carb Controlled Diet. l. Three residents had an order for a Pureed Diet (may have oatmeal). m. One resident had an order for a Pureed Diet. n. One resident had an order for a 2 gm Sodium Diet. o. Two residents had an order for a No Concentrated Sweets Diet. Review of the Lunch Production Sheet used by Cook 1 to serve the 2/2/23 lunch, provided by the Administrator on 2/2/23 at 12:16 p.m., indicated only four diet types listed on the document as follows: Puree, Renal, 3-4 gram Sodium, and 3 gram Sodium. Only 2 of the 4 included diet type orders were ordered for the residents in the facility. Thirteen of the facility's 15 diet types were not listed any where on the production sheet. The layout and columns on the form appeared to be designed to assist the dietary department in having enough food on hand to prepare/produce each meal. The form did not address portion sizes or offer instruction as to what food type, texture, and portion should be served for each individualized diet type. A current, 2017 facility document from the facility Dietary Policy and Procedure Manual, provided by the Administrator on 2/2/23 at 1:14 p.m., indicated the following: .Diet orders not found on the modified diet spreadsheet will either be added to the spreadsheet, or have posted instructions the serving area and/or tray card .A copy of all menus shall be kept on file for a minimum of 30 days . Standardized Diets: General/ Regular, Mechanical Soft, Pureed, No Added Salt, Low Concentrated Sweets, Renal (dialysis) diet During an interview, on 2/2/23 at 1:13 p.m., the Administrator indicated the facility did not have current menus approved by a dietitian, nor could she find diet and portion spreadsheets. This Federal Tag relates to Complaint IN00397976. 3.1-20(h)(1)

Based on observation, interview, and record review, the facility failed to ensure food was prepared, stored, and served under safe and sanitary conditions. This deficient practice had the potential to impact 40 of 40 residents who received their meals from the facility kitchen. Findings include: During kitchen observations beginning on 2/2/23 at 10:51 a.m., the following concerns regarding safe sanitary food preparation, storage and service were noted: a. The hand washing sink located in the food preparation and service area was not accessible. The sink was blocked by a large industrial sized box of plastic wrap. There was only one designated hand washing sink located in the kitchen. During an interview, at the time of the observation, Cook 1 indicated the plastic wrap was stored in the sink do to limited space. An individual could hand wash in the bathroom, which was located at the back of the kitchen down a short hallway or in the three compartment dish sink. During an interview, on 2/2/23 at 11:42 a.m. Cook 1 indicated a person could also wash their hands in the food preparation sink located at the end of the food preparation counter. b. The thermometer located inside the reach-in refrigerator, located to the right of the kitchen entrance, registered 50 degrees Fahrenheit (50 F). During an interview, at the time of the observation, Cook 1 indicated 50 F was an acceptable temperature for food refrigeration, but it should be a little lower. Food temperatures for all freezers and refrigerators were recorded in a log. During an interview, on 2/2/23 at 11:42 a.m., the Maintenance Supervisor, who was adjusting the thermostat on the refrigerators asked what temperatures refrigerators needed to be to keep food safe. c. Inside the reach-in fridge by the door, there were three uncovered double handled drink glasses, with fluid in each one. The cups did not have lids and were open to air. There was one uncovered, undated bowl of peaches, and one undated grilled chicken salad. During an interview, on 2/2/23 at 10:54 a.m., Cook 1 indicated Cook 2 should have put lids or covers on the drink cups. She, herself, had put the peaches in the refrigerator uncovered and forgot to label the grilled chicken salad. d. The side of the convection oven located beside the stove was soiled with splashed baked on black and brown food particles. e. The milk cooler top was covered with food items, paper goods, and what appeared to be items to be thrown away. f. The ice machine had a heavy lime build up over the exterior surface of the machine. g. The exterior surface of the dishwasher was covered with a heavy white lime build up. h. The door located by the dishwasher was blocked by a number of empty cardboard boxes and a trash can lid. i. There was a white cleaning cloth laying on the floor by the dishwasher. The cloth remained there for every kitchen observation on 2/2/23. j. In the dry storage room, there was a bucket overflowing with soiled cleaning cloths, located on the floor in front of a reach-in refrigerator. k. The reach-in refrigerator in the dry storage room, had an external thermometer which registered 49 F. During an interview, at the time of the observation, Cook 2 looked at the external thermometer and indicated it registered 49 F. The external thermometer was how the facility monitored the refrigerator temperature. She would have to ask Cook 1 if this was an acceptable food storage temperature. Cook 1 then looked at the dry storage refrigerator and confirmed the temperature was 49 F, which was an acceptable temperature for food refrigeration. L. Five large cans were observed in the refrigerator as follows: 1. A large, opened, restaurant sized can of chocolate pudding, covered with plastic wrap and labeled opened 1/30/23, no containers. 2. A large, opened, restaurant sized can of lemon pudding, covered with plastic wrap and labeled opened 1/27/23 and no containers. 3. A large, opened, restaurant sized can of apple sauce, with the lid still attached by a small piece of metal, was covered with plastic wrap and labeled opened 1/31/23, no containers. 4. A large, opened, restaurant sized can of extra thick tomato ketchup, covered with plastic wrap. There was no open date indicated. 5. A large, opened, restaurant sized can of grape jelly, with the lid still attached by a small piece of metal, was covered by plastic wrap. There was no open date indicated. m. The large industrial can-opener, mounted on the table in the dry storage area, had a dried, sticky, grayish substance on the mount, surface of the table around the mount, and cutting blade. During an interview, on 2/2/23 at 10:52 a.m., Cook 1 indicated the facility did not currently have a Dietary Manager. The previous manger had left a couple months ago. The Administrator was offering the leadership for the department until the new Dietary Manager arrived. During a 2/2/23 at 11:28 a.m. interview, the Administrator indicated the facility did not have a current Dietary Manager. She was acting as dietary leadership until the newly hired Dietary Manger started her position. None of the dietary employees had told her they needed food containers for the storage of canned items after they were opened. If a dietary employee had told her, she would have ensured containers were provided for the storage of canned foods after opening. Review of the facility Refrigerator/Freezer Temperature Log, provided by the Administrator on 2/2/23 at 11:25 a.m., indicated the facility following: a. Refrigerator temperature should be 41 F or less. b. The facility had not documented any refrigerator temperature since 1/25/22. c. During the 25 days of January with recorded refrigerator temperatures seven (7) entries of temperature greater than 41 F was recorded, 1/2/23 morning 45 F, 1/5/23 evening 42 F, 1/9/23 morning 45 F, 1/10/23 morning 42 F and 44 F (two separate refrigerators), 1/10/23 evening 47 F, 1/11/23 morning 45 F, 1/21/23 morning 43 F. d. The log did not offering instructions for actions to take if the temperature was greater than 41 F. The facility was made aware of ongoing kitchen sanitation concerns, as indicated by the Registered Dietitian report dated 1/19/23. A 1/19/23, Kitchen Sanitation Checklist which was completed by the Registered Dietitian was provided by the Administrator on 2/2/23 at 12:16 p.m., indicated the following: .Floor dirty . Boxes stacked on floor . Logs not used regularly . Blanket on floor, Dish machine build up . Grease on side of steamer by cooktop . Boxes stacked for garbage by door The facility was aware of ongoing menu, spreadsheet, and meal service concerns as indicated by the Registered Dietitian on 1/19/23. A 1/19/23, Tray Line & Menu Compliance Audit, completed by the Registered Dietitian was provided by the Administrator on 2/2/23 at 12:16 p.m., and indicated the following: .Staff unsure which scoop size to use .No spreadsheets A current, 4/2017, facility policy titled, Storage of Dry Food/Supplies, provided by the Administrator on 2/2/23 at 11:58 a.m., indicated the following: .Opened products will be labeled and stored in tightly covered containers A current, 4/2017, facility policy titled, Dating & Labeling, provided by the Administrator on 2/2/28 at 11:58 a.m., indicated the following: .foods will be stored, dated and labeled in the refrigerator held at 41 F [degrees Fahrenheit] for a maximum of 7 days .All items which are not in their original container will be labeled A current, 4/2017, facility policy titled, Storage of Refrigerated/Frozen Foods, provided by the Administrator on 2/2/28 at 11:58 a.m., indicated the following: .food will be maintained at or below 41 F .Monitoring of food temperatures and functioning of the refrigerator/freezer units will be in place .food in the refrigerator will be covered, labeled and dated This Federal Tag relates to Complaint IN00397976. 3.1-21(i)(3)

Based on observation and interview, the facility failed to keep a reclining shower chair in hygienic and good condition for 1 of 4 shower chairs observed (shower chair on 200 hall). Findings include: During an observation of the 200 hall shower room, on 2/14/22 at 11:32 a.m., a reclining shower chair was in the shower stall. The seat of the chair was in the shape of a toilet seat, on the left side of the seat was two strips of black velcro, the approximately size of a dollar bill, on the right side of the seat was patches of brownish black adhesive. A nickel size amount brown substance was observed on the outer edge of the seat on the frame of the reclining chair. On 2/17/22 at 1:20 p.m., CNA 36 indicated they used the shower chair for Resident 18 only, they used Quat disinfectant to clean it, they spray it on, leave it for 5 minutes then rinse it off. She was unsure what the velcro was for and they used either a towel or a chux under Resident 18 when they gave him a shower to make it more comfortable. She thought the shower chair had probably been that way since she had started working at the facility. The nickel sized brown substance, she thought looked like BM (bowel movement). The employee files indicated CNA 36's date of hire was 9/14/21. On 2/17/22 at 2:26 p.m., the DON indicated there used to be a cushion that velcroed on the seat of the shower chair and at some point it came off, she didn't realize it looked like that and ordered a new one. A current policy titled, Nursing Equipment, and provided by the DON on 2/18/22 at 12:06 p.m., indicated the following: .A. Procedure 1. Monthly .f. Geri Chairs, Shower Chairs, Walkers, Potty Chairs, and Wheelchairs .(3). Check all seats and backs for rips/loose 3.1-9(a)(4)

Based on interview and record review the facility failed to provide supervision for a cognitively impaired resident who required extensive assist with 2 person physical assist with transfers related to leaving the resident in the bathroom unattended which resulted in a fall causing bilateral femur fractures. This deficient practice effected 1 of 3 residents reviewed for falls. (Resident D) Findings include: The clinical record for Resident D was reviewed on 10/5/15 at 10:11 a.m. [DIAGNOSES REDACTED]. The most recent significant change Minimum Data Set (MDS) assessment, dated 8/5/15, was reviewed on 10/5/15 at 11:00 a.m. The MDS indicated Resident D was severely cognitively impaired with a BIMS (Brief Interview for Mental Status Score) of 4. Resident D received the following Activities of Daily Living (ADL) assistance; transfer-extensive assist with 2 person physical assist, dressing bathing and hygiene- extensive assist with 2 person physical assist, eating- extensive assistance with one person assist and extensive assist with two person physical assist for toilet use. Resident D was always continent of bowel and frequently incontinent of bladder. Resident D had no impairments to range of motion in all extremities. Review of a current care plan dated 7/26/11 indicated the following: Focus Fall Risk characterized by risk factors as listed on the fall risk assessment. Confusion/dementia, use of diuretic, poor vision/blindness, use of assistive devices, walks with walker and head down consistency (sic), psychotropic medication, history of falls. Goal Risk factors will be reduced in an attempt to avoid significant injury related to falls. Interventions included, but were not limited to, Call light within reach. Notify MD of changes in condition. Resident will have at least 2 staff present when transferring. Resident will have gait belt on at all times during transfers. An intervention to remain in the bathroom with the resident while toileting was added 8/31/15 after the fall. Review of a current care plan dated 10/29/11 indicated the following: Focus Cognition: Resident has cognitive impairments R/T Dementia. Goal Resident will accept redirection and reality orientation without incident. Interventions included, but were not limited to, Observe and report changes in cognitive status. Notify physician as needed. Review of a nursing note dated 9/3/15 at 4:54 p.m. ( a late entry from 8/30/15 at 1:00 p.m.), written by RN #2 indicated the following: Resident very drowsy, confused and having difficulty locating her silverware and food at lunch. Residents daughter and writter (sic) both present at this time. Resident acting almost drunk-like. Resident instructed to grab her silverware and resident would reach across the table at something that wasn't (sic) there. Daughter and writter (sic) concerned that the scheduled pain medication may be reason for resident's behavior. Resident almost drunk like. Review of subsequent nursing notes lacked any documentation the physician had been notified of the resident's behavior. The clinical record lacked any documentation of any follow up regarding the nurse and family concern related to the pain medication. Review of the physician orders [REDACTED]. Review of the Nursing-Occurrence Initial Assessment indicated the resident fell on [DATE] at 5:45 a.m. CNA (Certified Nursing Assistant) assisted resident to bathroom with the help of other CNA. They placed resident on toilet and stepped out of bathroom to make resident's bed. CNA heard thump and she turned around, resident was on the floor directly in front of the toilet on her knees with legs tangled up behind her at toilet area resident's back was resting straight up against toilet seat. Head to toe assessment provided by writer. No visible signs of injury. No swelling or obvious deformities noted. No inward or outward rotation of extremities. No shortening of limbs. Writer asked resident if she was hurting and resident stated Yes, all over. Resident could not pinpoint exact location for pain but writer observed resident rubbing left knee. Routine pain medication given. Resident has history of chronic pain to knees. Blood sugar obtained and was 127 no s/s (signs and symptoms) of hypo/hyperglycemia. Further comments indicated Resident assisted to wheelchair by three staff members, resident did not bear weight during transfer. CNA reports that she placed residents foot on foot pedals resident immediately removed right foot from pedal as per usual, resident did leave left foot in place on pedal. A fall risk assessment dated [DATE], included in the Nursing-Supp (Supplement)/Combo was reviewed on 10/5/15 at 11:00 a.m. The fall risk assessment indicated Resident D was assessed as a low risk for falls. Review of the nursing note dated 8/31/15 at 7:07 a.m., indicted Resident was found on bathroom floor beside toilet by CNA. Head to toe assessment provided. No visible injuries noted, but resident was observed rubbing her left knee. Neuros started. Physician made aware. POA, daughter, (name of daughter) will be notified later this morning by day shift nurse. Resident was given routine Tramadol after fall. Review of the next nursing note dated 8/31/15 at 3:49 p.m., indicated Received new order for STAT x-ray of bilateral knees d/t (due to) c/o (complaint of) pain, non weight bearing of resident's part, and s/p (status [REDACTED]. Review of a nursing note dated 8/31/15 at 6:15 p.m. indicated Bilateral knee x-rays obtained at this time per (name of imaging company). Results pending. Review of nursing note dated 8/31/15 at 9:28 p.m. indicated Report received from (name of imaging company) that is positive for bilateral femur fractures. Order received to send to (name of hospital) ER, per family request, for eval (evaluate) and treat. Resident left facility at 2000 (8:00 p.m.) and report called to (name of ER nurse). During an interview on 10/5/15 at 12:56 p.m., CNA (Certified Nursing Assistant) #1 indicated the following: She was in the rest room, I was in her room making her bed. (Name of other CNA) and I we went in to get her up and dressed for the morning. She was a 2 assist, she doesn't bear weight very well. We used the gait belt and lifted her on to the toilet. I dressed her while she was on the toilet and washed her face. I pulled her pants like to her knees and put her socks and shoes on. I shut the bathroom door and went to make her bed and I heard a loud crash and I went back into the bathroom and found her on the floor in front of the toilet. Her legs were kind of twisted under her. She wasn't screaming out in pain. She wouldn't give you much of an answer when I asked her if she was ok. She did a lot of moaning and groaning like she did, on a usual bases. We never completely leave the room when she is in the bathroom because we don't trust her. She had a tendency to lean forward and rest her elbows on her knees. We always shut the door (to the bathroom) to give her privacy. I stepped out to find the nurse and (name of other CNA). I knew we would need more help to get her off the floor. The nurse asked her what happened and she didn't get any real answer out of her either. She took her vitals and assessed her. (Name of other CNA) and I got her up while the nurse pulled her clothes up. We put her on the toilet to take a break because she wasn't bearing any weight. Before the fall she would give us minimal help with turning and pivoting but this time she was no help. We put her in the wheelchair and took her out of the bathroom. I put her feet on the pedals and she removed her right foot like normal. She usually took both of her feet off the pedals as soon as you put them on there. But she didn't move the left one at all. At this point the nurse was checking her out more and I left to go take care of another resident. I was a bit concerned after she wouldn't help with getting off the floor at all, but the nurses were there doing their assessments. CNA #1 also indicated the staff didn't trust Resident D because she tried to stand up at times without assist. CNA #1 also indicated it was normal for staff to shut the door while Resident D was in the bathroom. CNA #1 indicated she did tell the nurse her concerns related to Resident D's non weight bearing. During an interview on 10/5/15 at 1:35 p.m., RN #2 indicated the following: I was there after she fell . It happened on third shift before I got there. When I got there she was in her wheelchair, I continued to do her neuros and they were fine. She was complaining of knee pain which was not uncommon for her. It happened early so I tried calling her daughter. The third shift nurse had started neuros and did her assessment so she did not call the family but she updated the doctor. She told me she updated the doctor. At that point we did not have orders for x-rays. There was no sign of injury. She only complained of knee pain when I touched her knees. I wanted to talk to (name of daughter) to see what she wanted me to do. She had Tramadol from the third shift nurse at 6:00 a.m. (Name of daughter) came in right after breakfast. I talked to her and we both agreed we should get some x-rays so that 's when I faxed the doctor and asked for an order for [REDACTED]. The only time she would complain of pain is if I touched her knees or tried to stand her up to transfer her. So at that point is when I talked to (name of daughter) and agreed we needed x-rays. (Name of daughter) was in the day before and we had discussed her sleeping the day before. (Name of daughter) never mentioned anything to me about her Mom not acting right or anything. I assessed her again when (name of daughter) was in there and we asked to move her feet and she wiggled her toes and moved her feet and she was fine. The only time she complained of pain is when I touched her knees or we transferred her. When (name of daughter) saw how she reacted when I touched her knees she said yeah we should get the x-rays. I told her she got her at 6:00 a.m. Tramadol and then the Tylenol and her 12:00 p.m. Tramadol, she said she wanted to stick with that until we got the x-rays. I did not hear back from the doctor before I left. The second shift nurse followed up on it. During an interview on 10/5/15 at 2:47 p.m., the Director of Nursing (DON) indicated the following: There should have been a note when the doctor was notified and the nurse should have followed up on it (physician response) before the end of her shift. The DON indicated the reasons the nurses faxed the physician instead of calling him was because there was no obvious sign of injury. This Federal tag relates to Complaint IN 615. 3.1-45(a)(2)