Every finding on record at Autumn Ridge Rehabilitation Centre

Based on observation and interview, the facility failed to ensure required State Agency and Ombudsman contact information was prominently displayed in a location and manner accessible to residents, specifically those utilizing wheelchairs. This deficient practice affected 3 of 3 residents reviewed for resident rights and had the potential to affect 21 residents residing on the 3rd floor of the facility. (Residents 5, 7, and 10)Findings include:During a Resident Council group interview, on 3/25/26 at 2:00 p.m., Residents 5, 7, and 10 each indicated they did not know where to find information for the local Ombudsman or where to find information about how to contact the State Agency with concerns. Resident 5 indicated he could ask the Activities Director (AD) for the information. The residents who lived on the third floor were prohibited from accessing the first floor without staff supervision. During an observation of the third floor, on 3/26/26 at 2:59 p.m., (the floor where Residents 5, 7, and 10 resided), there were no visible postings of State Agency or Ombudsman information. During an observation of the first floor on 3/26/26 at 3:34 p.m., the required State Agency information was posted on the wall next to the elevators. The posting did not include the Ombudsman's contact information. During an interview with the Director of Nursing (DON), on 3/31/26 at 10:53 a.m., she indicated residents residing on the third floor were not given the code to the elevator because there were other residents on the third floor who were elopement risks. All residents must be accompanied by a staff member when going downstairs.During an interview and observation with the AD on 3/31/26 at 11:18 a.m., the required State Agency informational poster was measured at four feet and ten inches, or 58 inches, from the ground. The AD indicated it would be difficult for a person sitting in a wheelchair to see the information at that height. A current facility policy, titled Resident Rights, provided by the Administrator on 3/31/26 at 10:12 a.m., indicated the following: .(The) facility must ensure that information is provided to each resident in a form and manner the resident can access and understand.Each facility must post the names, addresses and telephone numbers of all pertinent State client advocacy groups, including the State survey and certification agency, the State licensure office, the State ombudsman program, the protection and advocacy network, the area agency on aging, the local mental health center and the Medicaid fraud control unit.410 IAC (Indiana Administrative Code) 16.23.1-4(j)(3)

Based on observation, interview, and record review, the facility failed to protect residents' rights to choose to move within the facility and to spend time outdoors as able for 3 of 3 residents of 21 residents residing on the third floor reviewed for residents' rights. (Residents 5, 7, and 10)Findings include:During a Resident Council group interview, on 3/25/26 at 2:00 p.m., Residents 5, 7, and 10 each indicated the facility placed significant restrictions on their mobility and autonomy. The residents who lived on the third floor were prohibited from accessing the first floor or the outdoor patio without staff supervision. Key barriers included an elevator that required a keypad code, which had not been shared with the residents, and a locked exterior door leading to the patio. These restrictions prevented residents from visiting common areas such as the first-floor aquarium or the outdoor seating area at will. Resident 7 indicated she was prevented from going to the lobby to collect cups for coffee the previous evening. Residents 5, 7, and 10 each expressed a desire for independent access to both the facility's amenities and the outdoors. Resident 5 indicated they just wanted to go outside for some fresh air or to enjoy the sunshine. Resident 5 indicated the facility felt like a prison and both Residents 7 and 10 indicated they felt the same way. Resident 7's clinical record was reviewed on 3/27/26 at 1:44 p.m. Diagnoses included anxiety, depression, and vitamin D deficiency. An annual Minimum Data Set (MDS) assessment, dated 1/27/26, indicated Resident 7 was cognitively intact, had moderate depression and did not exhibit hallucinations, delusions, or behaviors. It was very important for Resident 7 to go outside for fresh air when weather permitted. A current care plan for activities, revised on 2/22/26, indicated Resident 7 enjoyed shopping, watching television, playing games, entertainment, and socializing with others. She was care-planned to participate in two to three activities per week, was to receive assistance to go to activities as needed and was to receive verbal reminders about activities of interest. Resident 10's clinical record was reviewed on 3/27/26 at 2:22 p.m. Diagnoses included anxiety, Vitamin D deficiency, and psoriatic arthritis. A comprehensive MDS assessment, dated 8/18/25, indicated Resident 10 was cognitively intact, exhibited no hallucinations, delusions, or behaviors, and was able to transfer independently in her wheelchair. It was very important for Resident 10 to go outside for fresh air when weather permitted. A current care plan for activities, revised on 2/2/26, indicated Resident 10 enjoyed reading the newspaper, reading the Bible and spending time with family. She enjoyed going outside when the weather was nice. She was care-planned to participate in activities of her choice and receive reminders about activities. Resident 5's clinical record was reviewed on 3/27/26 at 2:29 p.m. Diagnoses included type 2 diabetes, insomnia, heart failure, chronic pain, and Parkinson's disease. An annual MDS assessment, dated 3/17/26, indicated Resident 5 was cognitively intact, exhibited no hallucinations, delusions, or behaviors, and was able to transfer independently in his wheelchair. It was very important for Resident 5 to go outside for fresh air when the weather permitted. A current care plan for activities, revised 3/18/26, indicated Resident 5 enjoyed playing bingo and other card and board games. He enjoyed going outside when the weather was good. He was able to make his own choices for activities. He was care-planned to receive assistance to activities as needed as well as reminders about activities. During an interview on 3/27/26 at 3:38 p.m., the Activities Director (AD) indicated outside activities were provided when the weather permitted. If a resident wanted to go outside and a staff member was available to accompany them, then residents could go outside. The reason residents must be supervised was because corporate wanted it that way. There were residents in the facility who would be fine to go outside unsupervised. During an interview with the Director of Nursing (DON), on 3/31/26 at 10:53 a.m., she indicated residents residing on the third floor were not given the code to the elevator because there were other residents on the third floor who were elopement risks. Most activities took place on the first floor. All residents must be accompanied by a staff member when going downstairs. The outside-access door to the patio was locked because of a previous resident elopement. She did not remember when that incident took place, but it had been several years. The aides did not have time to take the residents downstairs and/or outside. The aides were supposed to contact the AD, who would then accompany the residents downstairs and/or outside. The elevator was intended to be a barrier to get to the first floor. During an interview with the Administrator, on 3/31/26 at 1:15 p.m., he indicated there was no facility policy for keeping the third floor secured. The elevator required a code, and residents were not allowed to have the code. The residents could move through the facility freely with supervision. Supervision was always provided for the residents. Technically, if a resident lived on one end of the third floor and propelled themselves to the other end of the unit, then they had freedom of movement. Residents who wanted to go outside had to be supervised. If a resident asked to go outside, they should be allowed to go, provided there was supervision available to accompany them. It was a less-than-ideal set-up, but at least it was safe. Supervision could be provided by the receptionist or other staff in the lobby area.The third floor March 2026 activities calendar, provided by the AD on 3/27/26 at 3:38 p.m., lacked scheduled outdoor activities for the month.A current facility policy, titled Resident Rights, provided by the Administrator on 3/31/26 at 10:12 a.m., indicated the following: .(The) facility must ensure that the resident can exercise his or her rights without interference coercion, discrimination, or reprisal from the facility.On 3/30/26 at 12:09 p.m., the Administrator indicated the facility did not have a policy for residents going outside. 410 IAC (Indiana Administrative Code) 16.2 - 3.1-3(a)(1)

Based on observation, interview and record review, the facility failed to ensure residents received bathing assistance according to their assessed needs and preferences for 1 of 1 resident reviewed for activities of daily living (ADLs). (Resident 7) Findings include:On 3/24/26 at 12:45 p.m., during the lunch meal, Resident 7 was observed seated at a dining table. Resident 7's hair was greasy and disheveled.During the Resident Council group interview, on 3/25/26 at 2:04 p.m., Resident 7 indicated she had not received a shower for over a week. Her hair was still greasy and stringy, and she was wearing the same clothes from the day before. Saturdays and Tuesdays were her scheduled shower days, but she did not receive a shower on either scheduled day. Resident 7 was willing to take a shower at any time of day and although Tuesdays and Saturdays were her assigned days, she was willing to change days if it would help staff. She had never refused a shower.Resident 7's clinical record was reviewed on 3/27/26 at 1:44 p.m. Diagnoses included anxiety, depression, and Vitamin D deficiency.An annual Minimum Data Set (MDS) assessment, dated 1/27/26, indicated Resident 7 was cognitively intact. It was very important for Resident 7 to choose between a shower, bed bath, or sponge bath. She was frequently incontinent of both bladder and bowel. She required partial to moderate assistance for bathing/showering.Facility shower sheets for the month of March 2026 through the survey dates, provided by the DON on 3/25/26 at 3:46 p.m., indicated the following:On Saturday, 3/7/26, the shower sheet indicated Resident 7 received a shower.On Tuesday, 3/10/26, the shower sheet indicated Resident 7 received a complete bed bath and her hair was washed.On Tuesday, 3/17/26, the shower sheet was blank except for the resident's name and date.On Saturday, 3/21/26, the shower sheet indicated the resident refused a shower.On Tuesday, 3/24/26, the shower sheet was blank except for the resident's name and date.A review of Resident 7's March 2026 Point of Care History for bathing indicated the following:3/1/26 at 12:23 a.m. - Partial Bed Bath (PBB) 8:51 a.m. - Shower 8:03 a.m. - PBB3/2/26 at 12:00 a.m. - PBB 10:48 a.m. - PBB 8:00 a.m. - PBB 11:51 a.m. - PBB3/3/26 at 10:58 a.m. - PBB 3:49 p.m. - PBB3/4/26 at 12:42 a.m. - PBB 9:50 a.m. - activity did not occur 5:29 p.m. - PBB 11:33 p.m. - PBB3/5/26 at 7:11 a.m. - PBB 8:24 p.m. - PBB 11:34 p.m. - PBB3/6/26 at 10:14 a.m. - activity did not occur 7:57 p.m. - PBB3/7/26 at 12:26 a.m. - PBB 1:11 p.m. - Shower 7:42 p.m. - PBB3/8/26 at 12:24 a.m. - PBB 12:43 p.m. - activity did not occur 8:44 p.m. - PBB3/9/26 at 12:49 a.m. - PBB 8:58 a.m. - PBB 5:11 p.m. - PBB3/10/26 at 12:00 a.m. - PBB 10:29 a.m. - PBB 9:16 p.m. - PBB 11:12 p.m. - PBB3/11/26 at 4:42 p.m. - PBB3/12/26 at 2:42 a.m. - PBB 11:19 a.m. - PBB 7:38 p.m. - PBB3/13/26 at 1:54 a.m. - activity did not occur 3:55 p.m. - PBB 11:29 p.m. - PBB3/14/26 at 10:33 a.m. - PBB 7:41 p.m. - PBB 11:29 p.m. - PBB3/15/26 at 9:41 a.m. - PBB 3:14 p.m. - PBB 11:46 p.m. - PBB3/16/26 at 11:06 a.m. - PBB 8:55 p.m. - PBB3/17/26 at 3:58 a.m. - activity did not occur 10:06 a.m. - PBB 4:10 p.m. - PBB3/18/26 at 12:38 a.m. - PBB 9:00 a.m. - activity did not occur 3:18 p.m. - PBB3/19/26 at 8:11 a.m. - activity did not occur 7:06 p.m. - PBB 11:22 p.m. - PBB3/20/26 at 1:59 p.m. - activity did not occur 9:23 p.m. - PBB3/21/26 at 12:13 a.m. - PBB 1:36 p.m. - activity did not occur 3:31 p.m. - PBB3/22/26 at 12:36 a.m. - PBB 1:16 p.m. - activity did not occur 3:49 p.m. - PBB3/23/26 at 2:42 a.m. - activity did not occur 9:50 a.m. - PBB 7:00 p.m. - PBB3/24/26 at 12:12 a.m. - PBB 1:31 p.m. - PBB 7:46 p.m. - PBB 11:54 p.m. - PBB3/25/26 at 10:48 a.m. - activity did not occur 6:58 p.m. - PBBDuring an interview with CNA 10 on 3/25/26 at 3:37 p.m., she indicated the sheets at the front of the shower sheet binder were filled out with the residents' names and dates. CNAs would pull the blank sheets each day and provide showers for the residents on their assigned shower days. A blank shower sheet could mean different things. The resident could have refused, or the CNA possibly forgot to fill out the sheet. A shower sheet without a signature would indicate the shower was missed or ignored.During an interview with the Director of Nursing (DON), on 3/25/26 at 3:46 p.m., she indicated a blank shower sheet meant no shower had occurred. If there was only a signature, she would ask the residents if they got their shower. During an interview, on 3/26/26 at 9:51 a.m., CNA 7 indicated she provided showers whenever it worked best for the resident, and that some residents preferred to wait until the afternoon. She added that she tried to get all showers done before lunch and on her assigned weekends, and staff did a lot of extra showers. If a shower sheet contained only a signature and nothing more, it might be staff forgot to fill out the details. She was not sure if staff documented peri-care as a partial bed bath. During an interview on 3/31/26 at 12:55 p.m., CNA 8 indicated a partial bed bath consisted of taking the residents to the bathroom, allowing them to use the restroom, and then bringing in a wash basin with two cloths-one with soapy water and one with rinse water. She indicated she began with the face, armpits, then front and back of the peri-area. She preferred to allow the residents to wash their own hands, face, and armpits when possible. Any time she performed peri-care, she documented that as a partial bed bath.During an interview with CNA 9 on 3/31/26 at 1:00 p.m., she indicated a partial bed bath included washing the resident's peri-area and legs, and sometimes their backs. The only option in the electronic health record was to mark peri-care as a partial bed bath. A partial bed bath could mean just peri-care or an actual partial bed bath. If a resident had four partial bed baths documented on any given day, there was no way to know if it was just peri-care or an actual partial bed bath.On 3/30/26 at 2:46 p.m., the Administrator indicated there was no facility policy regarding showering/bathing.A current facility policy, titled Resident Rights, provided by the Administrator on 3/30/26 at 2:46 p.m., indicated the following: .All staff members recognize the rights of residents at all times and residents assume their responsibilities to enable personal dignity, well-being, and proper delivery of care. 410 IAC (Indiana Administrative Code) 16.2 - 3.1-38(a)(3)

Based on observation and interview, the facility failed to ensure a resident with complaints of mouth pain was assessed and provided interventions to provide comfort for 1 of 3 residents reviewed for pain. (Resident 22). Findings include:A breakfast observation, in the 3rd floor dining room on 3/25/26, indicated the following:At 8:29 a.m., Resident 22 openly communicated out loud she had a bad toothache. Resident 22 was guarding her right lower jaw and stated, it really hurts. RN 3 walked near Resident 22. Resident 22 looked toward RN 3 and indicated she had a bad toothache. RN 3 continued walking past Resident 22 without acknowledging Resident 22's toothache complaints. RN 3 sat down at a table directly behind Resident 22 to assist another resident with eating. Resident 22 continued stating, it hurts, it hurts a lot, while indicating she had a dental appointment that morning. Resident 22 declined eating breakfast.At 8:39 a.m., Resident 22 was grimacing and stating her tooth hurt. RN 3 continued to assist another resident with meal service at a table directly behind Resident 22. Two CNA were walking in and out of the dining room delivering hall trays to residents. When the two CNA's entered the dining room, they were approximately ten feet away from Resident 22.At 8:44 a.m.- CNA 7 asked RN 3 when Resident 22's dental appointment was. RN 3 shrugged her shoulders and stated, I am not looking while RN 3 continued to assist another resident. Resident 22 continued to indicate she had a dental appointment and needed to go there now.At 8:50 a.m., Resident 22 was crying out in pain, stating it hurts so bad, please. RN 3 asked CNA 7 to get the DON to assist Resident 22. Resident 22's crying out intensified as she indicated she needed to see the dentist right away as it hurt badly.At 8:51 a.m., the DON entered the 3rd floor dining room and walked over to Resident 22. The DON notified Resident 22 that her dental appointment was not today, and staff would get her some Orajel (oral numbing anesthetic).At 8:52 a.m., CNA 7 took over assisting the other resident for RN 3. RN 3 walked down the hallway toward the nurse's station while the DON propelled Resident 22 behind RN 3. As Resident 22 was propelled toward the nurses' station, Resident 22 stated she was in horrible pain.8:53 a.m., RN 3 administered Orajel to Resident 22 on a disposable mouth sponge. Resident 22 applied the sponge to her gums. The DON indicated Resident 22 was edentulous (no natural teeth) and RN 3 would check if Resident 22 could have any pain medication. The DON propelled Resident 22 down the hallway to her room while RN 3 checked to see if Resident 22 could have any pain medication.At 8:57 a.m., RN 3 administered some acetaminophen (Tylenol, for pain or fever) to Resident 22.During an interview, on 3/25/26 at 8:59 a.m., RN 3 indicated she was unaware she could leave the dining room to administer pain medication to Resident 22. She thought she had to remain in the dining room, in case of an emergency. RN 3 could not recall shrugging her shoulders and stating she would not look when Resident 22's dental appointment was.During an interview, on 3/25/26 at 10:22 a.m., Resident 22 indicated staff did not give her any pain medication that morning and she had to suffer with mouth pain. She was going to the dentist later today.Resident 22's clinical record was reviewed on 3/27/26 at 1:38 p.m. Diagnoses included Parkinson's disease, dementia, seizures, anxiety, chronic pain and pain disorder related to psychological factors.Current orders included acetaminophen 500 milligram (mg) every six hours, give with Tramadol (prescription pain reliever) 50 mg, Orajel (over the counter oral numbing gel) toothache-gum, one application on mucus membrane every six hours as needed and acetaminophen 650 mg every four hours as needed. A 3/11/26, quarterly, Minimum Data Set (MDS) assessment indicated Resident 22 was moderately cognitively impaired. She received scheduled and as needed pain medications, she was frequently in pain, and pain interfered with sleep and daily activities frequently. Resident 22's verbal description of pain was severe.A current care plan, dated 1/11/24 and reviewed on 3/27/26, indicated Resident 22 called out for staff at times when cold, wet, mouth pain, or needed assistance. Interventions included offer hot tea (3/27/26) and meet resident needs/wants (1/11/24).A current care plan, dated 2/13/18 and reviewed 3/31/26, indicated Resident 22 was at risk for pain related to decreased mobility, osteoarthritis in bilateral knees, muscle weakness, diabetes, COPD (chronic obstructive pulmonary disease), other abnormalities of gait and mobility, dementia, chronic pain, general discomfort. Interventions included administering pain medication as ordered (2/13/18), assist with positioning to comfort (2/13/18), document effectiveness of as needed medications (2/13/18), notify physician if pain is unrelieved and/or worsening (2/13/18), and offer nonpharmacological interventions such as quiet environment, rest, shower, back rub, or reposition (2/13/18).A behavior note, dated 3/26/26 at 6:23 a.m., indicated Resident 22 complained of discomfort to her mouth, and then changed her complaint to discomfort of her ear after staff administered medication for mouth pain. Orajel was administered per order, warm tea was accepted, and a movie was playing on the television.A progress note, dated 3/27/26 at 10:23 a.m., indicated Resident 22 was seen by the Nurse Practitioner (NP) for increased complaints of pain to her gums. A new order was received for gabapentin (prescription nerve pain reliever) 100 mg twice a day.A progress note, dated 3/27/26 at 11:37 a.m., indicated staff followed up with Resident 22 regarding her behavioral expression. Resident 22 has had some mouth pain which had switched to ear pain. No signs or symptoms of psycho-social distress were noted and she would be monitored.During an interview, on 3/30/36 at 2:47 p.m., LPN 4 indicated she usually tried to look right away to see if a resident experiencing pain can receive any medication. If they were unable to have medication, she would try to offer other ways to elevate the pain such as repositioning the resident. For Resident 22, they could offer Orajel or sometimes hot tea. Resident 22 did receive scheduled pain medications. Resident 22 did complain of pain a couple times a day. During an interview, on 3/30/26 at 2:59 p.m., LPN 5 indicated she would assess any resident complaining of mouth or jaw pain. If there are any abnormalities, she would notify the physician for orders. She would check to see if any pain medication was able to be administered. If it was too soon to administer pain medication, she would try a warm or cold compress to the area.During an interview, on 3/30/26 at 3:17 p.m., RN 3 indicated she should have acted quicker when Resident 22 was complaining of dental pain. She should have assessed her, but Resident 22 had been to the dentist previously and had received her scheduled pain medications that morning.During an interview, on 3/31/26 at 10:50 a.m., the DON indicated RN 3 should have assessed Resident 22 when she first started to complain of mouth pain. It is not uncommon for Resident 22 to complain of mouth pain. She had seen the dentist previously. Resident 22 did have some attention seeking behaviors, but pain isn't something you normally go to when attention seeking. Staff should address the pain complaint first, as pain is subjective.A current facility policy, dated 1/2003 and titled Pain Management Policy, provided by the Administrator, on 3/31/25 at 11:51 a.m., indicated the following: . Policy: It is the policy of American Senior Communities to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing, including pain management. 3. Interviewable residents- pain medications will be prescribed and given upon based upon the intensity of the pain as follows using the verbal descriptive, numerical scale (1-10) or Wong-Baker FACES scale. 410 Indiana Administrative Code (IAC) 16.2-3.1-37(a)

A. Based on observation and interview, the facility failed to utilize infection prevention and control practices related to hand hygiene during laundry delivery. This deficiency had the potential to affect 38 of 41 residents who received facility laundry services. B. Based on observation, interview, and record review, the facility failed to utilize infection prevention and control practices related to enhanced barrier precautions (EBP) during care for residents at a higher risk for infection for 1 of 3 residents reviewed for infection control. (Resident 32) Findings include: A1. During an observation on 3/25/25 at 10:53 a.m., Laundry Aide 11 pushed a mesh covered laundry cart down the 300 hall. She reached into an opening of the flap of the mesh curtain on the laundry cart and removed clothing on hangers from the clothing rack. She entered room [ROOM NUMBER], delivered the items and exited the room with empty hangers. She reached through the opening of the mesh flap of the laundry cart and hung them on the clothing rack. She pushed the laundry cart to room [ROOM NUMBER]. She used both hands and reached into the opening of the mesh covering and removed clothing on hangers from the rack and entered room [ROOM NUMBER]. She opened the closet and placed the clothing in the closet. She gathered the empty hangers and closed the closet door and exited room [ROOM NUMBER]. She reached into the mesh covering and hung the empty hangers on the rack. She pushed the laundry cart to room [ROOM NUMBER]. She reached into the mesh covering and removed some items that were on hangers. She entered room [ROOM NUMBER]. She used her hands and opened the closet door. She hung the laundry in the closet. She touched and sorted through previously hung clothing in the closet and gathered empty hangers. She used her hands to shut the closet door. She exited the room and reached into the mesh covering of the laundry cart and hung the empty hangers on the clothing rack. Hand hygiene was not performed at any time during the observation. During a continuous observation on 3/27/25 from 10:5. to 10:55 a.m., Laundry Aide 11 pushed a laundry cart that was enclosed with a mesh covering down the 300 hall and stopped at room [ROOM NUMBER]. She reached into the opening of the flap of the mesh curtain on the laundry cart and removed clothing on hangers from the clothing rack. She entered room [ROOM NUMBER]. She opened the closet with her bare hands and hung up the clothing on hangers in the closet. She gathered the empty hangers and brought them out to the laundry cart. She reached into the flap of the mesh covering and hung them on the clothing rack. She reached down and grabbed clothing items from a small bin located on the bottom rack of the laundry cart. She re-entered room [ROOM NUMBER] and using her hands she opened a drawer and placed items into the drawer. She used her hands to close the drawer and exited the room. She pushed the laundry cart to room [ROOM NUMBER]. She reached into the opening of the mesh flap and removed clothing on hangers. She entered room [ROOM NUMBER] and shut the door. She exited room [ROOM NUMBER]. She pushed the laundry cart to room [ROOM NUMBER]. She reached into the opening of the mesh covering of the cart and retrieved clothing on hangers as well as clothing items from the bins located on the bottom rack of cart. She placed the hangers in her left hand and using her right hand placed the items from the bins into the crook of her left elbow, holding them against her scrub top. She entered room [ROOM NUMBER] and hung the items in the closet and placed the other items in drawers. She exited room [ROOM NUMBER] and shut the door. She then pushed the laundry cart to room [ROOM NUMBER]. She reached through the mesh opening and removed the clothing on hangers from the clothing rack and entered room [ROOM NUMBER]. She opened the closet doors and hung-up items. She sorted through the closet and retrieved empty hangers. She closed the closet doors and exited the room. She reached into the mesh covering and placed the empty hangers on the clothing rack. She pushed the laundry cart to room [ROOM NUMBER]. She reached into the opening of the mesh covering and retrieved the clothing on hangers and placed it into her left hand. She leaned over and retrieved socks and cloth pads from bins on the lower rack of the laundry cart. She placed the socks and a cloth pads in the crook of her left elbow and held them up against her scrub top. She knocked on the door of room [ROOM NUMBER], introduced self, and took items into the room. After hanging items in the closet and putting away the socks and cloth pads, she exited the room and shut the door. She pushed the laundry cart to room [ROOM NUMBER]. She reached into the opening of the mesh covering and retrieved clothing on hangers. She knocked on room [ROOM NUMBER] door and entered. She opened the closet and hung the items up, closed the closet doors, and exited the room. She pushed the laundry cart to room [ROOM NUMBER]. She reached into the opening of mesh covering and removed items on hangers from the cart and took them into room [ROOM NUMBER]. She opened the closet door, hung up the items, and shut the closet door. She exited and shut the door. Hand hygiene was not performed at any time during the continuous observation. During an interview, on 3/27/25 at 10:58 a.m., Laundry Aide 11 indicated hand hygiene was to be performed when she exited resident rooms. Hands are contaminated after touching knobs and dressers. During an observation, on 3/28/25 at 10:51 a.m., Laundry Aide 11 pushed a laundry cart that was enclosed with a mesh covering down the 300 hall to room [ROOM NUMBER]. She reached into the opening on the mesh covering and retrieved items on hangers. She entered room [ROOM NUMBER]. She opened the closet door and hung the items in the closet. She closed the closet door and exited the resident's room. She pushed the laundry cart to room [ROOM NUMBER]. She reached into the mesh covering and retrieved items on hangers and took them into room [ROOM NUMBER]. No hand hygiene was observed when room [ROOM NUMBER] was entered and exited and no hand hygiene performed when room [ROOM NUMBER] was entered. During an interview on 03/31/25 at 11:19 a.m., the Assistant Housekeeping and Laundry Supervisor indicated laundry staff passed out residents' clean laundry and hand hygiene was to be performed each time a laundry staff member entered and exited resident rooms due to hand contamination when closets and drawers were touched. During an interview on 3/31/25 at 3:44 p.m., the Maintenance and Laundry Supervisor indicated 38 of the 41 residents received laundry services from the facility. B1. During an observation on 3/25/25 at 2:59 p.m., Resident 32 had a personal protective equipment (PPE) cart against the wall at the foot of her bed. Resident 32's clinical record was reviewed on 3/31/25 at 10:40 a.m., Diagnoses included surgical aftercare following surgery on the digestive system, rectal abscess, malignant neoplasm of cervix uteri, and Enterococcus as the cause of diseases classified elsewhere-blood culture and port. A physician's order, dated 3/22/25, included Heparin (an anticoagulant) lock flush, pre-filled syringe 10 units/milliliters (mL), administer 2.5 mL intravenously every 6 hours. Special instructions: Flush central line following normal saline per saline, administer, saline, heparin (SASH) to maintain patency. A physician's order, dated 3/22/25, included Pre-Filled Normal Saline (sodium chloride 0.9 %) syringe, administer 10 mL every 6 hours. Flush central line before and after antibiotic administration to maintain patency. The clinical record lacked an order for EBP. A quarterly Minimum Data Set (MDS) assessment, dated 3/4/25, indicated the resident was cognitively intact. She received central line IV medications. A current care plan, dated 3/14/25, indicated the resident had a central line IV access to the left upper chest and was at risk for infection and complications. Interventions included flush as ordered (1/6/25) and observe insertion site for signs of infiltration, redness, swelling, tenderness, coolness, and non-functioning access (1/6/25). The clinical record lacked a care plan or interventions for EBP. During an observation of central line flushing, on 3/31/25 at 10:52 a.m., LPN 3 placed items needed for central line flush on resident's bedside table. She performed hand hygiene and applied gloves. She indicated she had forgotten the alcohol prep pads. She removed her gloves, threw them in the trash, and exited the room. She returned at 10:55 a.m. She performed hand hygiene and applied gloves. She removed one of the double lumen line caps. She cleansed the IV tip with an alcohol prep pad. She flushed the line with a 10 mL prefilled syringe of normal saline, followed with the Heparin prefilled syringe. She applied a new cap to the IV line. She then removed the cap from the second lumen and cleansed the IV tip with an alcohol prep pad. She flushed line with a 10 mL syringe of normal saline, followed with the Heparin prefilled syringe. She applied a new cap to the IV line. She discarded trash, removed her gloves, and performed hand hygiene. LPN 3 did not don additional PPE during the central line access. During an interview, on 3/31/25 at 11:01 a.m., LPN 3 indicated staff was made aware of residents' on EBP through the resident profile and face sheet located in residents' electronic chart. All residents on contact, droplet, standard isolation, and those on EBP precautions all require the same PPE. Staff should use additional PPE when caring for Resident 32. During an interview, on 3/31/25 at 11:22 a.m., LPN 3 indicated EBP signs were posted beside the PPE carts. She did not put on the required PPE when she flushed Resident 32's central line. During an interview, on 3/31/25 at 11:28 a.m., the DON and Corporate Nurse indicated that staff were made aware of residents on EBP because it was on their care sheets and in their profile. EBP signage was on the wall in the resident's room. If sharing a room, the signage and EBP cart would be on the resident's side that needed the EBP. EBPs were required for indwelling catheters, wounds, feeding tubes, tracheostomies, certain MDROs, peritoneal dialysis, and anything invasive. During an interview, on 3/31/25 at 2:07 p.m., CNA 14 indicated EBP signs were posted on the resident's door or by the PPE cart in the residents' room. Residents that needed EBP were those who had COVID-19, flu, and anyone that had an illness that could be transmitted through airborne or touch. During an interview, on 3/31/25 at 2:49 p.m., the DON indicated if a resident had a central line or a foley catheter, staff was to wear EBP when they were doing hands-on care. EBP consisted of a gown and gloves. EBP signs were posted in resident rooms on the side of room that the resident resided on. A current facility policy, last revised 12/2021, titled, Laundry/Linen, provided by the Assistant Housekeeping and Laundry Supervisor on 3/31/25 at 11:33 a.m., included the following: .Purpose of Policy: To ensure the proper care and handling of linen and laundry to prevent the spread of infection. Policy: The laundry and nursing staff shall handle, store, process, and transport linen appropriately to prevent the spread of infection, in resident-care areas and in the laundry facility. Procedure .2. Resident care areas: clean linen: a. Clean linen must be protected from soiling or contamination .i. Clean linen should be carried away from body to prevent contamination .,4. Laundry area: . e. Before removing or touching clean laundry - perform hand hygiene A current facility policy, last revised September 2023, titled, Standard and Transmission-Based Precautions (Isolation) Policy provided by the Administrator on 3/31/25 at 9:46 a.m., indicated the following: .ENHANCED BARRIER PRECAUTIONS: .expands the use of PPE beyond situations in which exposure to blood and body fluids is anticipated, it refers to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . Resident Placement: Post Enhanced Barrier Precautions sign on the resident door or on wall above room identifier . Use of Personal Protective Equipment - Gown and Gloves: During high-contact resident care activities .device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator An undated corporate document, provided by the DON on 3/31/25 at 3:05 p.m., indicated providers and staff must wear gloves and a gown for the following high-contact resident care activities: . Device Care or Use:central line, urinary catheter, feeding tube, tracheostomy 3.1-18(l) 3.1-18(b)(2)

Based on observation and interview, the facility failed to protect a resident's dignity by failing to respond to a resident's request to provide needed assistance with bed mobility for toileting needs for 1 of 41 residents reviewed for dignity. (Resident 194) Findings include: During a random observation, on 3/25/25 at 10:50 a.m., Resident 194 was resting in bed on his back. The head of bed (HOB) was slightly elevated. At that time, the resident was trying to use his urinal. His left foot dangled off the side of the bed. Resident 194 asked CNA 9 to reposition him in bed. CNA 9 walked toward his door and replied, give me a second. CNA 9 had not returned to the resident's room as of 11:04 a.m. the resident had managed to get a small amount of urine into his urinal. The urinal was still positioned between his legs. At 11:05 a.m., CNA 10 entered his room. He asked CNA 10 to reposition him in bed. CNA 10 helped reposition the resident in bed before exiting his room. During an interview, on 3/25/25 at 11:08 a.m., CNA 10 indicated she was covering both halls, as the other CNA was on break. CNA 9 had not informed her that Resident 194 requested to be adjusted in bed. During an interview, on 3/25/25 at 11:10 a.m., CNA 9 indicated Resident 194 was messing with his privates and she wanted to give him privacy. The DON asked if she could help another resident, and she forgot to go back and reposition Resident 194. Resident 194's clinical record was reviewed on 3/28/25 at 9:20 a.m. Diagnoses included chronic obstructive pulmonary disease (difficulty breathing), heart failure, acute respiratory failure with hypoxia (lack of oxygen), hypertension (high blood pressure) and type 2 diabetes mellitus. Resident 194's comprehensive care plan, dated 3/20/25, indicated he required assistance with activities of daily living (ADLs) including bed mobility, transfers, eating and toileting. Interventions included to assist with bed mobility as needed. During an interview, on 3/25/25 at 2:59 p.m., Resident 32 indicated she had to wait an hour before someone assisted her. Staff would come in, turn off her call light, and leave. It would take a while before staff returned to assist her. During an interview, on 3/26/25 at 9:34 a.m., Resident 20 indicated call lights took a while to be answered. Staff would turn off the call light and leave without providing any assistance. The staff members would return, it could take a long time. During an interview, on 3/28/25 at 11:16 a.m., the DON indicated she expected staff to reposition residents when they requested. They should reposition the resident before leaving the room. It was not acceptable for residents to wait 20 or more minutes to have their call lights answered. During an interview, on 3/28/25 at 2:50 p.m., CNA 8 indicated a resident should not have to wait more than 15 minutes for their call light to be answered. If a resident asked to be repositioned, he would reposition that resident before exiting their room. During an interview, on 3/31/25 at 9:46 a.m., the administrator indicated he did not have a policy regarding answering call lights in a timely manner. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to provide daily grooming assistance for nail care for 1 of 3 residents reviewed for Activities of Daily Living (ADLs). (Resident 37) Findings include: During a random observation, on 3/25/25 at 11:39 a.m., Resident 37 was sitting in a recliner in front of his television. Resident 37 indicated no one has offered to cut his fingernails since his admission on 2/14/25. His nails were varying lengths between 1/16th and 1/8th inches long. Resident 37's clinical record was reviewed on 3/26/25 at 2:27 p.m. Diagnoses included fracture of the left femur, muscle weakness, anxiety, depression, essential hypertension (high blood pressure), and unspecified mood disorder. An admission Minimum Data Set (MDS) assessment, dated 2/21/25, indicated Resident 37 was cognitively intact. No behaviors were identified during the assessment period. He required set up or cleanup assistance for personal hygiene and had upper extremity impairment on one side of his body. Rejection of care was not documented during this assessment period. During a random observation, on 3/27/25 at 11:24 a.m., Resident 37 was sitting in his recliner in front of his television. Resident 37 indicated he had asked a staff member about cutting his nails. That staff member was going to notify the nurse about trimming his fingernails. His nails were long and jagged. His right thumb nail came to a point. His right index finger and middle finger were 1/16th inches long. His left thumb nail was 1/8th inch long and jagged. His left ring finger was very sharp and jagged. During an interview, on 3/27/25 at 12:28 p.m., CNA 6 indicated the CNAs would cut residents' fingernails whenever there was a need. During an interview, on 3/28/25 at 10:42 a.m., CNA 7 indicated residents' fingernails were cut whenever they needed to be cut or whenever the resident would request their nails be cut. During a random observation, on 3/28/25 at 10:46 a.m., Resident 37 indicated he had asked a staff member the night before to cut his fingernails. His nails were still between 1/16th and 1/8th inches long. Seven out of his ten fingernails were sharp, jagged, or chipped. His left thumb nail being the longest. During an interview, on 3/28/25 at 11:16 a.m., the DON indicated a non-diabetic resident's fingernails are cut by either the CNA or activities. Generally, nail care was provided on shower days. Staff looked at resident fingernails routinely. Any resident who declined nailed care would have a note on the resident's shower sheet. During an interview, on 3/28/25 at 2:33 p.m., CNA 8 indicated the CNA was responsible for cutting a non-diabetic resident's nails. He cuts residents' fingernails during their PM care. If a resident declined nail care, he was unsure where that would be documented. During an interview, on 3/31/25 at 9:46 a.m., Resident 37 indicated CNA 8 had cut his thumb nails while the resident was able to cut his other fingernails. CNA 8 had left the fingernail clippers on Resident 37's bedside table for future use. He indicated it was a struggle for him to cut his fingernails. During an interview, on 3/31/25 at 2:15 p.m., the Administrator indicated he did not have a policy on nail care/ grooming nails. 3.1-38(3)(E)

Based on observation and interview, the facility failed to offer and/or provide bedtime snacks to 6 of 6 residents reviewed for frequency of meals. (Residents 5, 6, 7, 33, 36, 37) Findings include: During a resident council meeting, on 3/26/25 at 1:27 p.m., four members were present (Residents 5, 6, 7, and 33) and each indicated bedtime snacks were offered approximately half the time. 1. Resident 37's clinical record was reviewed on 3/26/25 at 2:27 p.m. Diagnoses included fracture of the left femur, muscle weakness, anxiety, depression, hypertension (high blood pressure), and unspecified mood disorder. Current physician's orders included offering a bedtime snack. An admission MDS assessment, dated 2/21/25, indicated Resident 37 was cognitively intact. He required set up or clean-up assistance with eating. He required substantial/maximal assistance with sit to lying, lying to sitting, sit to stand, and chair/bed to chair transfer. During an interview, on 3/28/25 at 12:11 p.m., Resident 37 indicated snacks were offered at times. 2. Resident 36's clinical record was reviewed on 3/27/25 at 2:30 p.m. Diagnoses included myocardial infarction (heart attack), heart failure, right side hemiplegia (paralysis), generalized anxiety disorder, cerebral infarction (a stroke), and acute respiratory failure. Current physician's orders included offering a bedtime snack. An admission MDS assessment, dated 2/22/25, indicated Resident 36 was mildly cognitively impaired. He required substantial/maximal assistance with rolling to the left and right, sit to lying, lying to sitting, sit to stand, and chair/bed to chair transfer. During an interview, on 3/28/25 at 3:17 p.m., Resident 36 indicated he had never received or had been offered a bedtime snack. He took medications at bedtime and would like a snack. 3. Resident 7's clinical record was reviewed on 3/28/25 at 11:38 a.m. Diagnoses included chronic obstructive pulmonary disease, morbid obesity, type 2 diabetes mellitus, seizures, major depressive disorder, schizophrenia, heart failure and hypertension (high blood pressure). Current physician's orders included offering a bedtime snack A quarterly MDS assessment, dated 2/25/25, indicated Resident 7 was cognitively intact. He required setup or clean- up assistance with eating. 4. Resident 5's clinical record was reviewed on 3/31/25 at 9:59 a.m. Diagnoses included cerebral infarction (stroke), malignant neoplasm of breast (breast cancer), hypertension (high blood pressure), chronic kidney disease, type 2 diabetes mellitus, and heart failure. Current physician's orders included offering a bedtime snack. A quarterly Minimum Data Set (MDS) assessment, dated 2/3/25, indicated Resident 5 was cognitively intact. She required substantial/maximal assistance with rolling to the left and right, sit to lying, and lying to sitting. She required partial/ moderate assistance with sit to stand and chair/bed to chair transfers. During an interview, on 3/28/25 at 2:23 p.m., Resident 5 indicated she received her bedtime snacks occasionally, when the facility had snacks available. 5. Resident 33's clinical record was reviewed on 3/31/25 at 3:30 p.m. Diagnoses included atrial fibrillation (irregular heartbeat), chronic kidney disease, type 2 diabetes mellitus, muscle weakness, difficulty walking, fatigue, abnormal weight loss, and Alzheimer's disease. Current physician's orders included offering a bedtime snack. An admission MDS assessment, dated 12/26/24, indicated Resident 33 was cognitively intact. He required setup or clean- up assistance with eating. He required supervision or touching assistance with sitting to stand, and chair/bed to chair transfer. 6. Resident 6's clinical record was reviewed on 3/31/25 at 3:35 p.m. Diagnoses included chronic obstructive pulmonary disease (difficulty breathing), heart failure, hypertension (high blood pressure), anxiety, type 2 diabetes mellitus, and muscle weakness. Current physician's orders included offering a bedtime snack. A quarterly MDS assessment, dated 2/12/25, indicated Resident 6 was cognitively intact. She required setup or clean-up assistance with eating. She required substantial/ maximal assistance with sitting to stand, and chair/bed to chair transfers. During an interview, on 3/28/25 at 11:41 a.m., Resident 6 indicated she asked for snacks in the past, but staff indicated they were out. She was supposed to get a cookie every night. Last night was the first time in two weeks she had received her snack. During an interview, on 3/28/25 at 2:50 p.m., CNA 8 indicated bedtime snacks were offered when residents were placed into bed for the night. They have run out of snacks on the third floor in the past. There was a locked pantry to the right of the elevators where resident snacks were kept. At the same time as the interview, an observation of the pantry included the following: five bottles of Gatorade in the refrigerator and eight single serve fig cookie bars were inside a small plastic storage container. During an interview, on 3/28/25 at 4:00 p.m., the Dietary Manager indicated dietary staff delivered bedtime snacks every evening. Bedtime snack options included peanut butter crackers, cottage cheese, cheese and cracks, and yogurt. The third floor dietary aide delivered the bedtime snacks when they stocked the overflow room off the lounge. The dietary aide left the bedtime snacks at the nurses station or the coffee bar in the lounge. During an interview, on 3/28/25 at 4:23 p.m., the DON indicated the pantry was where bedtime snacks were kept. The small room off the lounge was where dining overflow was kept. The dietary aide would bring up the resident's bedtime snacks and place them in the locked pantry. A current facility policy, dated 2/02, titled Snacks, provided by the Administrator, on 3/31/25 at 9:46 a.m., indicated the following: .Snacks will be available between meals and HS snack will be offered to all residents consistent with their current diet order 3.1-21 (4)(e)

Based on observation, interview, and record review, the facility failed to ensure qualified staff assisted residents with eating for 1 of 3 mealtime observations. Finding includes: During an interview, on 6/12/24 at 9:42 p.m., the Administrator indicated the facility did not have paid feeding assistants. During an observation on 6/14/24 at 12:21 p.m., Activity Assistant 10 sat down beside Resident 16 and assisted her with eating by filling the spoon with bites of food and placing it into the resident's mouth. During an interview, on 6/14/24 at 2:18 p.m., the DON indicated only licensed and certified personnel were permitted to assist residents with eating. The activity assistants had been certified recently as CNAs. She would locate Activity Assistant 10's certification. During an interview, on 6/14/24 at 2:23 p.m., the DON indicated Activity Assistant 10 had passed her skills test, but not her written test, for the CNA certification. Review of a CNA Skills Test document, provided by the DON on 6/14/24 at 2:23 p.m., indicated Activity Assistant 10 had passed her skills test on 1/9/24. During an interview, on 6/18/24 at 10:32 a.m., the DON indicated she was uncertain of how long Activity Assistant 10 was able to assist the residents with eating after taking her class without passing the certification. The DON was not generally on the secured unit during mealtimes and was uncertain how often Activity Assistant 10 actually assisted the residents with eating. During an interview, on 6/18/24 at 12:50 p.m., CNA 8 indicated the nurses and CNAs assisted the residents with eating. The Dementia Care Director was not permitted to assist the residents with eating. Activity Assistant 10 assisted the residents with eating because she was certified. A current facility policy, dated 10/2023, provided by the Administrator on 6/18/24 at 4:08 p.m., titled Nurse Aide In-Training Program Policies and Procedures, indicated the following: .after an individual has received a certificate of completion for passing a Nurse Aide Training Program, they have twenty-four months from the date disclosed on the Certificate of Completion to pass their state exam. In the meantime, they may be employed as a Nurse Aide for up to 120 days. After 120 days, if the individual has not completed and passed the State exam, they must be transferred into a non-certificate required role 3.1-53(c)(6)

Based on interview and record review, the facility failed to provide notification of Medicare non-coverage for 2 of 3 residents reviewed for beneficiary protection notifications. (Resident 24 and 138) Findings include: On 6/12/24 at 10:45 a.m., the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review Forms were reviewed, and indicated the following: 1. Resident 24 had been admitted to the facility on [DATE] under the Medicare Part A Skilled Services. The last covered day of Part A services was 5/24/24. The resident remained in the facility. The clinical record lacked Skilled Nursing Facility Advance Beneficiary Notice of Non- Coverage (SNF ABN). 2. Resident 138 had been admitted to the facility on [DATE] under the Medicare Part A Skilled Services. The last covered day of Part A Services was 1/16/24. The resident remained in the facility. The clinical record lacked Skilled Nursing Facility Advanced Beneficiary Notice of Non- Coverage (SNF ABN). During an interview, on 6/17/14 at 11:20 a.m., the Administrator indicated she would check to see if there was any documentation stating the form was mailed to the resident representatives for Resident 24 and Resident 138. During an interview, on 6/17/24 at 11:36 a.m., the Administrator indicated she was unable to find any documentation showing the SNF ABN form was completed and mailed to their representatives. During an interview, on 6/18/24 at 10:12 a.m., the Social Services Director indicated she received a notice from therapy when resident's skilled services were to end. She tried to notify the resident representative on the same day. She filled out the NOMNC confirmation of notice by phone document and discussed the benefit options with them and how they could file an appeal. She was unaware she needed to fill out the SNFABN form. She mailed the forms to the representative and had them mail back the SNFABN form with their decision. She was unable to provide documentation showing discussion of the SNFABN form nor provide tracking information showing she mailed the forms. During an interview, on 6/17/24 at 2:09 p.m., the Administrator indicated the facility did not have a specific policy regarding the Beneficiary Protection Notification and agreed the SNF ABN form was not completed. 3.1-4(f)(2) 3.1-4(f)(3)

Based on observation, interview, and record review, the facility failed to provide grooming and dressing assistance (Resident 1) and failed to perform timely showers (Resident 26) for 2 of 3 residents reviewed for activities of daily living (ADLs). Findings include: 1. During an observation, on 6/12/24 at 10:47 a.m., Resident 1 propelled herself in a wheelchair to the activity/dining area. She had brown facial hair the length of the diameter of a triple A battery to her upper lip. During an observation, on 6/12/24 at 3:46 p.m., the resident was seated in front of the nurse's station. The ADON talked to the resident briefly. The resident had a hole in her blue pants the size of a half dollar, in the left lower section of her abdomen, showing a white undergarment. During an observation, on 6/13/24 at 10:07 a.m., the resident sat in a wheelchair in the activity/dining area at a table eating a snack. She wore the same blue pants with a hole as mentioned above. The facial hair to her upper lip remained. During an observation, on 6/14/24 at 10:21 a.m., the resident asked the staff to help her back to her room from the nurse's station. The facial hair to her upper lip remained. Her shirt was pulled up on the left side and pants were down sitting low on her waist on the left side which left an area of her skin on her side exposed approximately the size of a half lengthwise standard sheet of notebook paper. LPN 4 assisted the resident back to her room. During an observation, on 6/14/24 at 10:33 a.m., the ADON asked the resident to go sit at the activity/dining room table, and she would get her a snack. The resident's shirt and pants were positioned as described above and continued to expose her skin on her abdomen and side. During an observation, on 6/14/24 at 11:48 a.m., the resident propelled herself in a wheelchair down the hall. Her shirt and pants remain positioned as described above. During an observation, on 6/17/24 at 11:17 a.m., the resident propelled herself in a wheelchair in the hall. She had small bits of brown particles smeared on her shirt. The facial hair to her upper lip remained. During an observation, on 6/18/24 at 10:25 a.m., the resident sat in a wheelchair at a table in the dining/activity area. The facial hair to her upper lip remained. The resident's clinical record was reviewed on 6/17/24 at 9:51 a.m. Her diagnoses included unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety disorder, bipolar disorder, current episode hypomanic, major depressive disorder, anemia, and muscle weakness. The quarterly Minimum Data Set (MDS) assessment on 5/21/24 indicated the resident was moderately cognitively impaired. No behaviors were indicated. She required supervision or touching assistance with upper body dressing. She required partial/moderate assistance with lower body dressing, toileting hygiene, personal hygiene, transfers to bed, chair, and toilet, and moving from sitting to standing position. A current care plan for potential for tiredness, weakness, and abnormal labs due to anemia (10/1/21) included an intervention to assist with care as needed (10/1/21). The care plan was reviewed/revised on 6/4/24. A current care plan for ADLs functional status (6/18/21) indicated the resident required assistance with ADLs. The interventions included assist with dressing/grooming/hygiene as needed. Encourage the resident to do as much for self as possible (6/18/21). The care plan was reviewed/revised on 6/4/24. A current care plan (6/18/21) indicated the resident required assistance and/or monitoring with AM/PM care, nutrition, hydration, and elimination. The interventions included AM cares including bathing, dressing, hair combing and oral care (6/18/21) and PM Cares including bathing, dressing, hair combing and oral care. The care plan was reviewed/revised on 6/4/24. The progress notes and point of care documentation from 5/19/24 to 6/17/24 lacked resident refusals of grooming or dressing. During an interview, on 6/17/24 at 1:54 p.m., CNA 5 indicated when a resident refused showers, AM care, or PM care it is recorded under the POC (point of care) charting. During an interview, on 6/17/24 at 2:14 p.m., CNA 7 indicated if the resident refused AM or PM care she told the nurse. During an interview, on 6/17/24 at 2:18 p.m., CNA 7 indicated she put out clean clothes, underwear, washcloths and a towel for Resident 1 for PM care. The resident washed herself. During an interview, on 6/18/24 at 10:47 a.m., CNA 8 indicated Resident 1 was independent. CNA 8 had very recently started working day shift and was uncertain how the resident was about removing facial hair. She was typically pretty good with showers. If the resident refused showers, AM care, or PM care it would be put on the electronic record. The nurse would also be informed of the refusal. During an interview, on 6/18/24 at 12:30 p.m., the DON indicated Resident 1 did a lot for herself and sometimes refused help. The DON would expect the staff to offer to change the resident's clothing if there were holes in them. She would expect the staff to offer to shave a resident as needed. She was unable to find refusals of dressing, changing clothes, or shaving in the resident's clinical record. The resident did not have refusals of facial hair removal or refusal to change clothing care planned. During an interview, on 6/18/24 at 12:38 p.m., the DON indicated she would expect the staff to offer to adjust a resident's clothing as needed. During an interview, on 6/18/24 at 12:50 p.m., CNA 8 indicated when a resident's clothes were not adjusted to cover their body, she would offer to adjust them. During an interview, on 6/18/23 at 3:32 p.m., Resident 1 indicated she did not need any help to get dressed or groomed. She did it herself. A current facility document, review date 4/2012, provided by the Administrator on 6/18/24 at 2:30 p.m., titled A.M. Care, indicated the procedure steps for A.M. care included .Shave the resident, is [sic] needed .Assist resident with dressing 2. During an observation, on 6/12/24 at 3:57 p.m., CNA 7 assisted Resident 26 out of her room in a wheelchair. The resident indicated loudly she did not have her eyes repeatedly as her wheelchair was being pushed. CNA 7 continued to push the resident's wheelchair down the hall. The Dementia Care Director stopped CNA 7 and indicated the resident needed her glasses. The resident's hair was greasy and [NAME]. During an observation, on 6/13/24 at 10:02 a.m., the resident sat in a wheelchair at a table in the dining/activity area with her glasses on listening to recorded bagpipe music. Her hair was greasy. During an observation, on 6/17/24 at 11:15 a.m., the resident sat in a wheelchair at a table in the dining/activity area. Her hair was greasy. The resident's clinical record was reviewed on 6/14/24 at 1:45 p.m. Her diagnoses included dementia without behavioral disturbance, psychotic disturbance, mood, disturbance, and anxiety, depression, other fatigue, and muscle weakness. An annual MDS assessment on 4/24/24 indicated the resident was severely cognitively impaired. No behaviors were indicated. She required substantial/maximal assistance with showering/bathing and personal hygiene. A current care plan for ADLs functional status (7/9/22) indicated the resident required assistance with ADLs. The interventions included the following: Assist with bathing as needed per resident preference. Offer showers two times a per week, partial bath in between (7/9/22). The care plan was reviewed/revised on 4/25/24. The clinical record lacked a care plan for refusal of showers. The Point of Care notes indicated showers were given 5/16/24, 5/20/24, 5/27/24, 6/3/24, 6/6/24, 6/10/24, and 6/13/24. The notes indicated partial bed baths were given between 5/20/24 and 5/27/24 and between 5/27/24 and 6/3/24. No showers or full bed baths were given during the aforementioned time frames. The Point of Care notes lacked refusals of showers during the time frame from 5/20/24 through 6/3/24. The progress notes lacked refusal of showers between 5/20/24 and 6/3/24. During an interview, on 6/13/24 at 12:28 p.m., Resident 26's representative indicated the resident's hair often looked greasy and had never looked that way before in her life. She questioned if the resident was getting her showers and hair washed two times a week as scheduled. During an interview, on 6/17/24 at 1:54 p.m., CNA 5 indicated the residents could get as many showers a week as they wanted. They should get at least two a week. Their hair was washed with the showers. If the resident refused the shower, then it was documented in the electronic medical record. During an interview, on 6/17/24 at 2:14 p.m., CNA 7 indicated if the resident refused a shower, then it was documented on the shower sheet and in the computer. The residents had their hair washed with showers. During an interview, on 6/18/24 at 10:44 a.m., CNA 8 indicated the showers were marked on a paper and would mark on it if the resident refused. The refusal would also be documented in the electronic medical record. She washed the residents' hair each time showered. During an interview, on 6/18/24 at 12:24 p.m., the DON indicated the refusal of a shower should show up as a full bed bath as this would be what would be given if refused. She had not known the resident to usually have a problem with showers. She reviewed the resident's clinical record and was unable to locate refusal of shower or a full bed bath was given from 5/20/24 to 5/27/24 and 5/27/24 to 6/3/24. She asked the ADON to get her the resident's facility shower sheets between 5/23/24 and 6/3/24. During an interview, on 6/18/24 at 12:33 p.m., the DON indicated the facility had shower sheets that were to be filled out with showers. She reviewed the resident's shower sheets between 5/23/24 and 6/10/24. There were no shower sheets for the times between 5/20/24 and 5/27/24 and 5/27/24 and 6/3/24. She indicated there was one shower given in a week span during the above-mentioned time periods. A current facility document, reviewed on 4/2012, provided by the Administrator on 6/18/24 at 2:30 p.m., titled Shower, indicated the following: .Help resident shampoo and rinse hair 3.1-38(a)(2)(A) 3.1-38(a)(3)(D) 3.1-38(a)(3)(B) 3.1-38(b)(2) 3.1-38(b)(3)

Based on record review and interview, the facility failed to ensure an incident of resident to resident verbal abuse was reported immediately to the Executive Director and submitted to the State Agency in the required timeframe for 1 of 5 resident incidents reviewed (Resident F and C). Findings include: The resident to resident abuse investigation regarding Resident F and Resident C was reviewed on 8/18/22 at 1:00 p.m. A typed statement, dated 7/21/22 at 10:45 a.m. indicated Cottage Activity Assistant 7 informed the Executive Director sometime in the previous week, Resident F wheeled by the table and called Resident C stupid and other names, but Resident C didn't hear him. During an interview with the Executive Director, on 8/18/22 at 1:32 p.m., she indicated as soon as it was reported to her, on 7/21/22, she reported it to IDOH. A current facility policy titled, Abuse Prohibition, Reporting, and Investigation, provided by the Nurse Consultant, on 8/18/22 at 2:30 p.m., indicated the following: .Investigation: Resident to Resident Abuse .3. The individual who witnessed the abuse will report the situation immediately to his/her supervisor and Executive Director This Federal Tag This Federal tag relates to complaint IN 966. 3.1-27(b)

Based on observation and interview, the facility failed to ensure staff were knowledgeable on how to test the temperature and sanitizer of the dishwasher during a follow up visit to the kitchen. Findings include: During a follow up visit to the kitchen on 6/2/22 at 10:36 a.m., Culinary Aide 31 indicated the dishwasher was a high temperature washer, she was unable to determine how to test the water temperature or how to test the sanitizer. The Dietary Manager stepped in and indicated to Culinary Aide 31 where and how to read the dishwasher thermometer and the temperature and the temperature should be between 120 and 140 degrees and ran the dishwasher through a cycle. Culinary Aide 31 indicated the temperature read 58. The Dietary Manager indicated the thermometer read 130 and she needed to look under the lip of the thermometer to read it. The Dietary Manager ran the dishwasher through a cycle and tested with the sanitizer strip, she saturated the test strip in the water overflow of the dish machine and a stripe appeared between the saturated portion of the test strip and the dry portion of the test strip, the part of the test strip that was dipped into the overflow of the dishwasher did not change colors. She tried it again and the saturated part of the strip read between 25 ppm (parts per million) and 50 ppm and should read between 50 and 100 ppms. The Dietary Manager indicated Culinary Aide 31 had worked at the facility for a couple months. Culinary Aide 31 indicated she just was testing and reading the thermometer wrong, she had been trained on it when she started at the facility. The low temp dishwasher temperature/sanitizer log indicated lunch and supper for June 1, 2022 was not completed and breakfast was completed on June 1 and 2, 2022 by Culinary Aide 31. On 6/2/22 at 2:10 p.m. the Administrator indicated the dishwasher servicing company had came into the facility and serviced the dishwasher. Review of a copy of the test strip container instructions, provided by the Administrator on 6/2/22 at 3:08 p.m., it indicated the following: Dip and Remove quickly. Blot immediately with paper towel. Compare to Color Chart at Once. During an interview with the Dietary Manager, on 6/2/22 at 3:55 p.m., she indicated the dishwasher service company had found that the tubing in the middle tube [NAME] was worn and was not turning and Culinary Aide 31 had tested the dishwasher this morning. Review of the service report, provided by the Administrator, on 6/3/22 at 8:10 a.m., indicated the drain solenoid was not working properly and was replaced and the squeeze tubes were worn and were replaced. A current facility policy titled, Recording Dish Machine Temperature/Sanitizer, provided by the Administrator, on 6/2/22 at 2:25 p.m., indicated the following: .4. The Dietary Services Manger will spot check these logs to assure the temperatures/sanitizer concentrations are appropriate, and staff are monitoring dish machine temperatures 3.1-21(i)(2)

Based on observation, record review and interview, the facility failed to ensure incontinent products were stored in a manner to maintain a resident's dignity, for 1 of 2 residents reviewed for dignity (Resident 10). Findings include: During an observation on 5/31/22 at 2:09 p.m., Resident 10 was lying in bed, two bags of incontinent products at the foot of the bed were visible from the hallway. During an observation on 6/1/22 at 10:41 a.m., a bag of incontinent products was at the foot of his bed and visible from the hallway. During an observation, on 6/2/22 at 9:22 a.m., a bag of incontinent products was at the foot of his bed and visible from the hallway. The resident's clinical record was reviewed on 6/1/22 at 8:59 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 3/8/22 quarterly MDS (Minimum Data Set) assessment indicated he was cognitively intact. He required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. He had an indwelling urinary catheter and was always incontinent of bowel. A current care plan, dated 9/13/21, indicated he was incontinent of bowel movements due to no apparent awareness of being soiled. The interventions included, but was not limited to, assist with incontinent care as needed. During an interview, on 6/2/22 at 10:43 a.m., the resident did not know why the incontinent products were at the foot of bed. During an interview, on 6/6/22 at 9:29 a.m., LPN 7 indicated the incontinent products should not be stored at the foot of the bed. Review of a current facility policy, titled Resident Rights, with a revised date of 11/16 and provided by the Nurse Consultant on 6/6/22 at 11:41 a.m., indicated .All staff members recognize the rights of residents at all times and residents assume their responsibilities to enable personal dignity, well being, and proper delivery of care 3.1-3(a)

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent abuse by a resident (Resident 28) toward other residents for 2 of 4 residents reviewed for abuse (Resident 38 and Resident 36). Findings include: 1. On 6/1/22 at 2:12 p.m. Resident 38 sat in a facility chair in dining room with activities and eating snacks. On 6/2/22 at 9:24 a.m., she was walking to activities to the dining room from her room. On 6/2/22 at 1:01 p.m., she was ambulating to room. On 6/3/22 at 9:00 a.m. she sat on the sofa in the dining room. On 6/6/22 at 9:22 a.m., she was in bed in her room. Resident 38's clinical record was reviewed on 6/1/22 at 2:01 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] and other specified anxiety disorders. An 4/6/22 annual MDS indicated she was severely cognitively impaired. She required limited assistance of one staff member for transfers, walking in her room and corridor, locomotion on and the off unit. She had a 5/12/22 revised behavioral symptoms care plan that indicated she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included, but were not limited to, keep resident separated from Resident 28 (4/5/22) and encourage and assist to utilize the cordless phone and a private area to utilize the cordless phone (4/6/22). A nurses note, dated 4/4/22 at 2:24 p.m., indicated she stood at the nurses station talking on the phone when Resident 28 came up to her and grabbed hold of her sweater sleeve and was shook it. The CNA and QMA intervened and separated the residents. Skin assessment done and no injuries were noted. 2. On 6/1/22 at 1:39 p.m. Resident 36 sat in a facility chair just outside the dining room, an activity aide asked if he would like to participate in an activity. On 6/2/22 at 8:45 a.m. he was working with therapy in the dining room. On 6/2/22 at 1:05 p.m. he was working with therapy in the dining room. On 6/3/22 at 8:56 a.m. he was ambulating independently in the hallway. On 6/6/22 at 9:21 a.m. he was working with therapy in the sun room. Resident 36's clinical record was reviewed on 6/1/22 at 1:35 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An 4/12/22 admission MDS indicated he was severely cognitively impaired. He required limited assistance of one staff member for transfers. He required supervision to walk in his room and corridor and locomotion on and off the unit. He had a 5/5/22 revised communication care plan that indicated he was to be separated from Resident 28 and to redirect to a separate activities of choice. A nurse note dated 5/5/22 at 10:05 a.m. indicated he was seated at table in dining area of the secured unit. He reported to staff that Resident 28 made contact with his left ear. It was not witnessed by staff. Residents were immediately separated, assessment completed with no injuries. He was assisted to a different area of unit and began conversing with other resident with no signs or symptoms of psychosocial distress. 15 minute monitoring was initiated. Review of the investigation provided by the Administrator, on 6/2/22 at 2:25 p.m., indicated an interview with CNA dated 5/5/22, she heard Resident 38 call out ouch and reported Resident 28 made contact with his left ear. 3. On 6/1/22 at 8:35 a.m., Resident 28 was observed in the dining room at a table with a male resident sitting to his right and a female resident sat across from him. On 6/2/22 at 10:08 a.m., he sat at a table in the dining room eating breakfast. On 6/2/22 at 1:27 p.m., staff assisted him to his room from the table in the dining room. On 6/3/22 at 9:01 a.m., he sat in dining room eating breakfast. On 6/6/22 at 9:28 a.m., he was ambulating independently in hall with napkin in his left hand and mumbling to himself. Resident 28's clinical record was reviewed on 6/1/22 at 8:23 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His medications included, but were not limited to, [MEDICATION(S)] (antipsychotic) tablet 25 mg (milligram) twice daily. A quarterly, MDS (Minimum Data Set) dated 3/28/22, indicated he was severely cognitively impaired, He had delusions and hallucinations. He wandered daily. He required extensive assistance with two staff members for bed mobility. He required supervision with transfers, walking in his room and the corridor, locomotion on and off the unit. He used a wander/elopement alarm daily. He had a 5/26/22, revised behavioral symptoms care plan that indicated he had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . and he utilized an antipsychotic medication (5/26/22). Interventions included,1. Ensure resident sees and hears staff prior to approach and provide care so as not to startle. 2. Redirect to activity of interest, listening to music, sports, etc . 3. Validate residents feelings when appropriate. 4. Redirect resident to a safe, calming environment to complete activity of choice to deter overstimulation. 5. 15 minute safety checks or one on one staff supervision as needed. 6: Allow resident to throw his trash away, put his dirty dishes in proper spot so that they can be washed with staff assistance as resident accepts (2/18/22). 7. Resident to have two staff members present while completing all personal cares, assuring staff members safety as well as resident's (5/9/22). He had a 5/25/22, revised behavioral symptoms care plan that indicated he had a potential for contact with another resident due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Offer him a snack and fluids upon arising and wandering throughout the secured unit (9/30/21). 2. He was to receive toileting assist when awake at night. 3. Increase supervision as appropriate (9/30/21). 4. Separate residents immediately and notify supervisor (9/30/21). 5. Offer an activity of his choice prior/during to shift change. Offer a cup of coffee and quiet area. He had labs and urinalysis to rule out a current medical issue. Provide him with a busy box to carry around and collect items of his choice (4/6/22). 6. Keep resident separated from Resident 38 (4/5/22). 7. Keep him separated from [another resident name] (5/2/22). 8. Keep him separated from Resident 36 (5/5/22). 9. Offer an a.m. snack between breakfast and lunch meals. Offer and encourage resident to use bathroom prior too and following meals as resident accepted (5/6/22). His nurses notes and IDT notes indicated, but was not limited to the following: On 4/4/22 at 2:21 p.m., he was by the nurses station while Resident 38 was on the phone, he went up to Resident 38 and grabbed hold of her sweater sleeve. CNA and QMA intervened and separated the residents. No injuries were noted. He was given a snack and sat down at table in the dining room. An IDT (Interdisplinary Team) note, dated 4/5/22 at 10:28 a.m., indicated he stood at the nurses station while Resident 38 used the phone and he grabbed hold of her arm. They were immediately separated and a head to toe assessment was completed and they were offered a separate activity of their choice. The root cause of his behavior was psychosocial factors, he was completing an activity as he only participated in activities of his choice, he was attempting to collect items for his personal collections in which he enjoys and attempted to get the phone from Resident 38 for his personal collection of items. The preventative intervention related to the root cause was he was to be offered a activity of his choice prior/during to shift change and to be offered a cup of coffee and quiet area. He was to have labs and urinalysis to rule out a current medical issue and provide him with busy box for him to carry around and collect items of his choice. On 4/5/22 at 2:47 p.m., the psychiatric nurse practitioner evaluated Resident 28 due to the resident to resident event. She awaited lab results and discontinued the 15 minute checks. On 5/5/22 at 10:05 a.m., Resident 28 was ambulating in the unit, Resident 38 reported that Resident 28 made contact with his ear. They were immediately separated. The contact was not witnessed by staff. Assessment of resident revealed no injury. Resident 28 was assisted with toileting then seated at table with snack. 15 minute monitoring was initiated. An IDT note, dated 5/6/22 at 1:02 p.m., indicated Resident 28 was in the unit dining room. Resident 38 stated that Resident 28 made contact with his left ear. Immediate interventions were that they were separated, assessments were completed by the nurse, Resident 28 was toileted, coffee and snack was provided. The potential root cause was Resident 28 needed to use the bathroom, prior to him eating breakfast, he rested in bed and denied the use of the bathroom. He was toileted and offered a snack and was calm. The preventative intervention was to offer and encourage activity of choice separate from Resident 38. Offer an a.m. snack between breakfast and lunch meals. Offer and encourage him to use bathroom prior to and following meals as he accepted. On 5/6/22 at 3:02 p.m., staff were in the shower room providing care to Resident 28, upon staff attempting to pull up pants, he punched staff in nose. Another staff member attempted to pull up his pants when he attempted to swing. They were able to pull up his pants and provided space to him, he was offered coffee and accepted. One on one observation was initiated On 5/6/22 at 3:22 p.m., a referral was made to a psychiatric hospital and awaited a call back with acceptance. On 5/6/22 at 5:34 p.m., he continued on one on one staff supervision. He was accepted to the psychiatric hospital, however, they did not have any available beds. He would remain one on one throughout weekend. An IDT note, dated 5/9/22 at 1:31 p.m., indicated Resident 28 was physically aggressive with staff when completing cares. Immediately ceased interaction from staff member that was hit in the nose, other staff member finished care. The nurse completed a head to toe assessment of resident, placed on one on one staff supervision, snack and fluids offered and accepted, and a referral was made to inpatient psychiatric hospital. The potential root cause was his cognitive level. Two CNAs were completing care task when he hit one of the CNAs as the other CNA was helping resident pull his pants up and hit the CNA in nose, making her nose bleed with an abrasion to the bridge of her nose. He was startled while cares were being completed as he seen one aide walk away and did not see the other aide, he was given simple instruction and he accepted, when task was being complete he reacted and hit the CNA in nose. The preventative intervention was he was to have two staff members present while completing all personal cares, assuring staff members safety as well as his. A referral was made for an inpatient psychiatric stay. He would have one on one staff supervision until he was accepted to inpatient psychiatric stay. On 5/9/22 at 5:45 p.m. he was discharged to psychiatric hospital. On 5/25/22 at 12:40 p.m., he returned from the psychiatric hospital. During an interview with the MCSS (Memory Care Social Service), on 6/2/22 at 2:14 p.m., she indicated Resident 28 had a physical decline and was not dressing or toileting himself anymore. he was in Vietnam and hallucination were more vivid. He was on a new medication and had not noticed him having those hallucinations as before. He was pleasant with assistance now. He was having normal conversations with peers now and not about war. He would go up to residents to get their attention, not sure if that's what he is doing with Resident 38. He lived in a war. He had been sweet since he came back. The incident with the staff member, they were done with his care and he punched the staff member and broke her nose. During an interview with LPN 33, on 6/3/22 at 9:13 a.m., he indicated he had been more peaceful since he has been back for the psychiatric hospital stay. He was difficult and resisting care. They would reapproach and let him calm down. If you get him coffee and snacks it preoccupied him. He occasionally ambulated by himself, he was incontinent of bowel and bladder. They try to have him go to the bathroom every hour or two, cognitively he did not understand when the staff cued him. During an interview with CNA 37, on 6/3/22 at 2:08 p.m., she indicated her and another CNA assisted him with his shower and he was fine. The other CNA walked away but was still in the same room. She was standing on his left side and was pulling up his pants and he came around with his right hand and hit her in the nose and broke it. The staff had been telling the nurses that he was becoming more combative with care. He was not normally aggressive towards residents, it was mostly during cares. During an interview with Activity Assistant 39, on 6/6/22 at 9:34 a.m., she indicated the resident was in Vietnam, if you come at him a certain way he would freak out. Sometimes he had his moments being aggressive he wound pound on table, pick up chairs and push them. She had never seen him be aggressive to other residents. When he was like that she tried not to get too close to him. She would talk to him, do one on ones with him, play ball, offer him a snack and coffee. A current policy, titled Abuse Prohibition, Reporting, and Investigation, provided in the survey binder, by the Administrator, at entrance to the facility on [DATE], indicated the following: .Policy: It is the policy of American Senior Communities to provide each resident with an environment that is free from abuse .This includes but is not limited to .physical abuse. American Senior Communities will not permit residents to be subjected to abuse by anyone, including .other residents 3.1-27(a)

Based on observation, interview, and record review, the facility failed to ensure a referral appointment to a retinal specialist was scheduled for 1 of 1 residents reviewed for vision services (Resident 40). Findings include: During an interview, on 5/31/22 at 1:16 p.m., Resident 40 indicated he had seen the eye doctor in the facility a few months prior and was supposed to be referred to a retinal specialist, but he had not yet been seen by one. He liked to read, but the low vision in his left eye prevented him from doing so. Resident 40's clinical record was reviewed on 5/31/22 at 2:00 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 3/4/22, quarterly, Minimum Data Set assessment indicated he was cognitively intact. Review of a 3/24/22 optometry note indicated he had a complaint of blurred vision for two months. He was diagnosed with a retinal detachment of the left eye and mild cataract of both eyes. An ophthalmology consult was ordered and he was to see a retinal specialist. A 3/25/22 Event note indicated an ophthalmology consult had been ordered with a retinal specialist for retinal detachment. The event note was closed without an appointment being documented. A 3/25/22 progress note indicated he was to be seen by an ophthalmologist and received a new order for ophthalmology consult and retinal specialist for retinal detachment. The resident and his family were made aware. Review of a 5/24/22 activity assessment indicated he enjoyed doing activities of own choice such as watching outdoors shows and news channels. He enjoyed doing word puzzles and playing cards. During an interview, on 6/3/22 at 9:20 a.m., LPN 71 indicated the nursing department scheduled appointments for the residents. A calendar was kept at the desk and the appointments were also entered in the clinical record as an order, so the system would alert staff of the appointment. During an interview, on 6/3/22 at 11:08 a.m., the DON indicated the referral appointment had not been made until the morning of 6/3/22. The resident was scheduled to see the ophthalmologist on June 14, 2022. 3.1-39(a)

Based on observation, record review and interview, the facility failed to ensure syringes and medicated ointments were securely stored for 1 of 1 random observations (3rd floor treatment cart). Findings include: During a random observation, on 6/2/22 at 10:36 a.m., the treatment cart on the 3rd floor was unlocked and unattended. A review of the contents of the treatment cart, on 6/2/22 at 10:38 a.m. accompanied by the DON, indicated the cart contained, but was not limited to the following, [MEDICATION(S)] syringes, [MEDICATION(S)] ointment, antifungal creams, and Santyl ointment. Review of a current facility policy, titled Medication Pass Procedure, with a revised date of 12/2016 and provided by the Nurse Consultant on 6/6/21 at 11:41 a.m., indicated .26. Med room and med/tx carts locked when unattended 3.1-25(m)

Based on observation, interview, and record review, the facility failed to ensure infection control practices and mask use were maintained according to professional standards during medication administration and random observations of mask use (Third Floor Nursing Unit). Findings include: 1. During a medication administration observation, on 6/2/22 at 8:20 a.m. with LPN 73, the following was observed: LPN 73 donned gloves, prepped an insulin pen for Resident 16 and indicated she would need to obtain another pen in order to administer the correct dosage. She did not perform hand hygiene. She administered the injection to the resident, returned to the medication cart, disposed of the needle, and doffed her gloves. She did not perform hand hygiene. She placed the used insulin pen onto the top of the cart and reviewed the orders in the computer. She then went to the medication room, entered the room, and then exited the room with an insulin pen. She returned to the cart, opened it, obtained an alcohol swab and needle, donned gloves, and prepped the new insulin pen. She did not perform hand hygiene prior to donning the gloves or prepping the insulin pen. She administered the remainder of the dosage to the resident, doffed her gloves, and then performed hand hygiene. During the medication administration observation, an insulin pen was observed in the top drawer of the cart, on top of a large pile of loose lancets. LPN 73 indicated it was an empty insulin pen for Resident 34 and she had placed the discarded pen in the top drawer to remind her to pull another insulin pen for the resident. She indicated she should have completed hand hygiene during the medication administration. During an interview, on 6/6/22 at 10:46 a.m., the Infection Preventionist indicated hand hygiene should be completed before prepping insulin and after administering it. 2. During a medication administration observation, on 6/2/22 at 8:43 a.m., LPN 14 was preparing to administer insulin to a resident, her face mask was below her nose. She entered the resident's room and administered the insulin, her face mask remained below her nose. She returned to the cart to prepare that resident's other insulin dose. On 6/2/22 at 9:03 a.m., she had administered the second dose of insulin, her face mask had remained below her nose. During an interview on 6/6/22 at 10:46 a.m., the Infection Prevention Nurse indicated the face mask should be worn above the nose and below the lower lip. Review of a current facility policy, titled Insulin Pen Administration, dated 10/2019 and provided by the Nurse Consultant on 6/6/22 at 11:41 a.m., indicated the following: .3. Gather needed supplies. 4. Perform hand hygiene .21. Removed gloves and perform hand hygiene Review of a current facility policy, titled Infection Prevention and Control Program, with a revised date of 3/2022 and provided upon entrance, indicated POLICY: The facility shall establish and maintain infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections 3.1-18(l)

Based on interviews and record review, the facility failed to properly prevent and/or contain COVID-19 by failing to ensure employees were tested according to the Indiana Department of Health (IDOH) and the Centers for Disease Control and Prevention (CDC) guidance for COVID-19 for 2 of 5 employees reviewed for COVID testing (Laundry Aide 9 and QMA 10). Findings include: 1. Employee COVID-19 test results, provided by the Administrator on 1/24/22 at 11:55 a.m., were reviewed, on 1/25/22 at 10:33 a.m., and indicated Laundry Aide 9 was tested for COVID-19 on 1/06/22, 1/13/22 and 1/17/22. According to the current employee vaccination status list provided by the Administrator, on 1/24/22 at 11:48 a.m., Laundry Aide 9 was not vaccinated for COVID-19. During an interview, on 1/25/21 at 12:41 p.m., the Administrator indicated Laundry Aide 9 tested negative for COVID-19 today (1/25/22). She indicated the COVID-19 testing paperwork and spreadsheet was rechecked. She spoke with Laundry Aide 9. She indicated no additional COVID-19 testing was completed. She indicated Laundry Aide 9 worked during the period from 1/06/22 to 1/25/22. 2. Employee COVID-19 test results, provided by the Administrator on 1/24/22 at 11:55 a.m., were reviewed, on 1/25/22 at 10:33 a.m., and indicated QMA 10 was tested for COVID-19 on 1/06/22 and 1/13/22. According to the current employee vaccination status list provided by the Administrator, on 1/24/22 at 11:48 a.m., QMA 10 was not vaccinated for COVID-19. During an interview, on 1/25/21 at 12:41 p.m., the Administrator indicated she rechecked the COVID-19 testing paperwork and spreadsheet. She indicated she was unable to locate additional COVID-19 testing documentation for QMA 10. She indicated QMA 10 worked during the period from 1/13/22 to 1/23/22. During an interview, on 1/25/21 at 1:11 p.m., the Administrator indicated the Payroll Coordinator performed COVID-19 testing of staff on Tuesdays and Fridays. She indicated no process was currently in place for following up on employees who failed to test as required. Review of a current facility policy titled COVID Testing Requirements for Staff and Residents revised on 11/29/21 and provided by the Administrator on 1/24/22 at 11:48 a.m., indicated the following: . Routine testing of unvaccinated staff should be based on community transmission . Facilities should use their community transmission level reported in the past week, found on the CDC website, as a trigger for staff testing frequency . Table 2: Routine Testing Intervals by County COVID-19 Level of Community Transmission in the current policy indicated minimum testing frequency of unvaccinated staff for a county transmission level of high (red) was twice a week. Review of the CDC COVID Data tracker website (https://covid.cdc.gov/covid-data-tracker/#datatracker-home), on 1/25/21 at 1:25 p.m., indicated level of community transmission for Wabash County was high (red) from 12/27/21 through 1/25/22. Review of an Indiana Department of Health resource document, retrieved from the IDOH Long Term Care newsletter dated 11/24/21, titled LTC COVID-19 SOP Guidance, Clinical Guidance, last updated 11/22/21 indicated, .The facility should test all unvaccinated staff at the frequency prescribed in the Routine Testing table based on the level of community transmission reported in the past week . The Routine Testing table indicated the minimum testing of unvaccinated staff is twice a week when the level of COVID-19 community transmission is high (red). 3.1-18(b)

Based on observation, interview and record review, the facility failed to prevent staff to resident abuse for 1 of 1 resident's reviewed for staff to resident abuse (Resident B). Findings include: A review of an incident report, dated 10/19/21, indicated at 12:35 p.m., while staff was assisting the Resident B to bed, the resident made a negative statement to the MCS (Memory Care Support) and the MSC responded in a negative way to the resident. Resident B was monitored by social services for 72 hours for signs and symptoms of psycho-social discord. An internal investigation was initiated. MCS was suspended pending the investigation. Resident B's record was reviewed on 10/25/21 at 3:00 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS, dated [DATE], indicated the resident was moderately cognitively impaired. He required extensive assistance of two staff members for bed mobility, transfers and toileting. Her required extensive assistance of one staff member for locomotion on and off the unit, dressing and personal hygiene. He required a wheelchair. The investigation was provided by the DON, on 10/25/21 at 10:33 a.m., staff and resident were interviewed related to the MCS and abuse. Inservice for staff on abuse was initiated covering abuse definition, examples and policy and procedure. Investigation was concluded on 10/21/21. Upon careful review of all information this allegation was unsubstantiated. The MCS returned to work on 10/22/21. During an interview with the MCS, on 10/25/21 at 9:24 a.m., she indicated Resident F was having behaviors, the nurse called her into the room to assist. Resident F had already punched a CNA twice in face. As they transferred him to the bed with the stand up lift, he was hitting, scratching and punching at them. She held onto his bottom as they transferred him to the bed because she felt that he was going to fall. He had bitten her on the forearm, scratched the nurse on the forearm. She indicated to him We do not act like a five year old by punching, hitting and kicking. She received abuse training and education after the incident. She was suspended from noon on Tuesday and came back to work Friday morning. This had never happened before and she felt it was just in the heat of the moment. He had behaviors all day and had thrown water on everyone. During an interview, on 10/25/21 at 2:15 p.m., CNA 17 indicated on 10/19/21, Resident B was in the dining room at lunch and throwing things. He was removed to his room for safety towards other residents and was going to assist him to bed. They used the stand lift to put him to bed as they went to stand him, he (Resident B) refused. He had hit her in the jaw a couple times. LPN 44 went to go get the MCS, all of them assisted him on the bed and the MCS swung his legs into bed. He said to the MCS your being a b***h and she turned around and said your being a [MEDICATION(S)]. No one said anything else and left the room. She did not hear her say to him to stop acting like a five year old. During a telephone interview, on 10/25/21 at 3:13 p.m., LPN 44 indicated Resident B had a lot of behaviors, cussing and touching the girls. That day Resident B was cussing and throwing water in the dining room. He was given ice cream and punched a CNA in the face. The MCS came in a diffused the situation and was polite with the resident the whole time. She assisted with the stand lift for him to get to bed. On the way out of the room the MCS indicated quietly to LPN 44 why does Resident B have to be a [MEDICATION(S)]. LPN 44 did not think the resident could hear her say it and the television was on. It was an inappropriate comment but not towards Resident B, it was as they were walking out of his room. Resident B had no reaction to it. He did not remember her saying that he was acting like a 5 year old. It was kind of a jungle in his room, his bed was wet, he was cussing and swinging and was pretty nuts in there. If she said it to the resident that would be abuse. A current facility policy, titled ABUSE PROHIBITION, REPORTING, AND INVESTIGATION, located on the conference table on 10/26/21 at 1:15 p.m., indicated the following: It is the policy of American Senior Communities to protect resident from abuse including physical abuse, sexual abuse, verbal abuse, mental abuse .POLICY/PROCEDURE: American Senior Communities will not permit residents to be subjected to abuse by anyone, including employees, other residents . This Federal Tag relates to Complaint IN 315. 3.1-27(a)(1) 3.1-27(b)

Based on record review and interview the facility failed to ensure a resident with dysphagia and at risk for choking received supervision while eating for 1 of 4 residents at risk for choking. This deficient practice resulted in the resident choking, coded and the emergency services being called and the resident hospitalized . The resident later died on [DATE]. (Resident B). The immediate jeopardy began on [DATE] when a Dietary Aide served Resident B a tray of food and left the resident with no assistance or supervision. The Administrator and Nurse Consultant were notified of the immediate jeopardy at 1:11 p.m. on [DATE]. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of isolated, 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 [DATE] at 9:58 a.m. Diagnoses included, but were not limited to, unspecified intellectual disabilities, other intellectual disabilities, unspecified dementia without behavioral disturbance, age-related cognitive decline, [CONDITION(S)], gastro-[CONDITION(S)] reflux disease without esophagitis, dysphagia, unspecified note: [CONDITION(S)] and dysphagia, oropharyngeal phase. Her orders included, but were not limited to, consistent carbohydrate, mechanical soft, ground meat, special instructions: Kennedy cups (a spill proof cup with lid) and divided plate with meals started on [DATE] and speech therapist to treat three times week for eight weeks for oropharyngeal dysphagia treatment will include restorative exercise, compensatory strategy training, and staff/caregiver as indicated started on [DATE]. A 5-day admission Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was moderately cognitively impaired. She required extensive assistance of one staff member for eating. She required a therapeutic diet and she had no swallowing disorders. She had no natural teeth or tooth fragment(s) (edentulous). A physician evaluation and management report for a swallow study performed on [DATE] indicated the resident was seen due to problems with eating and drinking. The diet recommendations were to give pills, one at a time in puree carrier. The following actions were recommended regarding the patient's feeding: small bites/sips, alternate bites/sips, precautions during mouth feeding: speech language therapist and trained staff only, small bites/sips, cueing for strategies: allow extra time, aspiration precautions: monitor for pulmonary status, reflux precautions: head of bed no lower than 45 degrees all other times, upright at 90 degrees during by mouth and 45 minutes after meals, monitor patient for adequate nutrition and hydration. A [DATE] reviewed/revised care plan indicated the resident was at risk for aspiration related to diagnosis of dysphagia. Her goal was that she would be free from symptoms of aspiration. Interventions included, but not limited to, diet as ordered and observe for symptoms of aspiration, which included choking, frequent cough that occurs before/during or after swallowing, runny nose while eating. A diet order and communication form from Speech Therapist 17, dated [DATE], indicated there was a diet change, mechanical soft with thin liquids and needed divided plates and a Kennedy cup. A [DATE] reviewed/revised care plan for the resident required assistance with Activity of Daily Living(ADLs) including eating. Interventions included, but were not limited to, may use divided plates and Kennedy cups with meals, assist with eating and drinking as needed, assist with oral care at least two times daily, upper and lower dentures. A diet order and communication form from Speech Therapist 17, dated [DATE], indicated a diet order for controlled carbohydrates, a mechanical soft diet and she needed a divided plate and a two handled spout cup. A Speech Therapist progress note, dated [DATE], indicated Impact on Burden of Care/Daily Life: the patient continued to require set up assist prior to and supervision during intake. Patient required set up assist for bolus size modifications, large food items to be cut to bite-size due to decreased safety awareness, decreased safety judgement, and poor ability to bite due to edentulous status. Due to impulsivity and poor safety judgement, she required verbal cues to slow rate of intake, finish one bolus prior to initiating another. She continued to require modified diet of mechanical soft secondary to poor ability to masticate, poor oral control, poor lingual coordination and Base of Tongue (BOT) strength, poor pharyngeal [MEDICATION(S)]. She continued to require adaptive equipment i.e. spout cup or Provale cup to facilitate rate of liquid intake. She continued to require handled cup and divided plate to facilitate self-feeding. She continued to require reflux precautions secondary to [CONDITION(S)] reflux and retention. Precautions: Supervise by mouth intake, soft diet, cut foods to bite-size, poor safety awareness, poor recall, high fall risk, weight bearing as tolerated for her left lower extremity. A nurse's note, dated [DATE] at 1:45 p.m., indicated the resident was in the dining room eating when a CNA noted the resident choking, the [MEDICATION(S)] was performed at that time, a finger sweep was performed three times and was unsuccessful. The resident was moved to her room at that time Cardiopulmonary Resuscitation (CPR) was initiated and 911 was called. On [DATE] at 1:58 p.m., the local fire department was at the facility and CPR continued. On [DATE] at 2:17 p.m., the local fire department (Emergency Management Team) EMTs continued with CPR, pulse and respiration was revived. Resident was transported to a local hospital's emergency room . During an interview with Dietary Cook 15, on [DATE] at 11:14 a.m., she indicated on [DATE] someone had called down to the kitchen and requested a peanut butter and jelly sandwich because the resident didn't like what she had on her tray. She prepared the peanut butter and jelly sandwich, a banana, an oatmeal creme pie and a chocolate milk and took the tray upstairs, Activity Aide 21 was in the dining room with another CNA and indicated she thought the resident had already ate, Dietary Cook 15 indicated to Activity Aide 21 that the resident didn't like what was on her tray and she placed the tray in front of the resident. During an interview, on [DATE] at 11:28 a.m., QMA 12 indicated she was passing medication and one of the CNAs said the resident was choking, QMA 12 went to the dining room and did the [MEDICATION(S)] maneuver on her while she was in her wheelchair and told the CNA to get the nurse and the DON came to the dining room. The DON did an assessment on the resident and took her to her room, then QMA 12 grabbed some oxygen supplies and other supplies the DON needed. She was unaware if anyone was in the lounge with the resident when she started choking because she was passing down the hall where the DON's office. One of kitchen staff brought the peanut butter and jelly sandwich up to the resident because she didn't care for the food they had that day. During an interview, on [DATE] at 11:35 a.m., CNA 29 indicated the CNAs were in and out of the dining room doing weights because Resident B was done eating. She didn't know who called down to the kitchen and asked for the sandwich. Therapy worked with her, the resident could feed herself, they would set her up, get her started and she would do it herself. During an interview, on [DATE] at 12:00 p.m., Speech Therapist 17, indicated the resident was on her caseload, she was working with her on rate of intake because she liked to eat quickly and not finish the bite in her mouth before she took another bite. She needed verbal and tactile cues, she followed verbal cues well. She was also working on taking smaller bites and smaller drinks, she was not cognitively aware of safety and her fine motor skills were not great. She had not worked with her on the day she choked. She had recommended supervision in the resident's progress notes and the swallow study recommended supervision also. She did verbal education with the nursing staff and reviewed the recommendations from the swallow study a couple months ago but there had been a lot of new staff since then and didn't know if it got carried over. She worked with peanut butter and jelly with the resident and would cut it up for her and would cue her, she didn't feel it was safe for her to eat unsupervised. During an interview, on [DATE] at 2:01 p.m., Physical Therapist 34, indicated he completed an evaluation at a table in the dining room on third floor around the same area as Resident B had choked. He had glanced over and noticed Resident B started to choke and the CNAs were standing in the hallway behind the resident. He ran to the nurse who was standing at the medication cart and told her the patient was choking and she started doing the [MEDICATION(S)] maneuver on the resident. She was not purple, she was starting to choke. A review of the hospital notes on [DATE] at 9:30 a.m. indicated the following: History of Present Illness (HPI) dated [DATE] from the local hospital emergency room (ER) indicated the resident presented emergency department status post respiratory and subsequent [CONDITION(S)]. She had multiple medical problems. She was found unresponsive. First responder found her pulseless and started CPR. She had full Advanced Cardiovascular Life Support (ACLS) protocol. She was apparently found in asystole. She had a few rounds of [MEDICATION(S)] and about 20 minutes of chest compressions. She was intubated. She apparently had a large amount of peanut butter sandwich removed from her airway. She regained pulses and transported to the ER. There was no trauma. Medical Decision Making (MDM) dated [DATE] from the local hospital ER indicated the resident was hydrated and maintained on a ventilator. Antibiotics were initiated for possible pneumonia and urinary tract infection. She required sedation and had a satisfactory blood pressure and heart rate at that time. She would be transferred to a larger hospital and remained generally unchanged during the emergency department course. A Communication with Primary Treatment Team from the larger hospital, dated [DATE], indicated the resident's family was at bedside and poor prognosis, completed hypothermia, Electroencephalogram(EEG) with no epileptic waveform with goals and process of compassionate extubation was discussed. Family planned for compassionate extubation sometime that day. A progress note dated [DATE], at 4:17 p.m. indicated the resident was extubated to room air. A hospital progress note, dated [DATE] at 6:54 p.m., indicated the resident's respirations had ceased. A hospital progress note, dated [DATE] at 8:25 p.m., indicated the event that lead to death was the patient choked on a peanut butter sandwich and then [CONDITION(S)]. Diagnosis was [CONDITION(S)]. Date and time of death was [DATE] at 6:54 p.m. During an interview with the Administrator and the Nurse Consultant, on [DATE] at 2:34 p.m., the Administrator indicated a housekeeper had called down to the kitchen to order the resident's food. A current facility policy, revised on ,d+[DATE], titled Deliver and Documentation of Meal Service and Between Meal Nourishments, provided by the Nurse Consultant on [DATE] at 3:00 p.m. indicated the following: .PROCEDURE, Delivery, The Nursing Department with the assistance of the Dietary Department will be responsible for the delivery of meals and nourishments and ensuring that all efforts are made to assist residents during meal and nourishment times. The Licensed Nurse is responsible for the supervision and coordination of CNAs during these daily activities .Specific mealtime responsibilities are: Provide assistance needed for meal set up (i.e. buttering bread, opening condiment packages, opening removing covers on foods and beverages). Assist residents in eating as needed .Review tray identification card .Substitutes for Food Refusals .Substitutes should be offered which are within the parameters of any therapeutic diet order .In the event that a resident consistently will accept only substitutes which are outside the parameters of the diet order, the Dietary Manger or Registered Dietitian will offer diet instruction and the benefits of the special diet to the resident's overall health. This will be documented in the medical record The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility educated staff regarding supervision during meals including ordering meals for residents, Speech Therapy screened all residents who were coded as total dependent, extensive assist, limited assist and supervision during meals, but the noncompliance remained at no actual harm, but potential for minimal harm because all care plans and profiles had not been updated and education and monitoring had not been completed. This Federal tag relates to complaint IN 093. 3.,d+[DATE](2)

Based on record review and interview the facility failed to ensure a resident with dysphagia and at risk for choking received a diet in the correct form for 1 of 4 residents reviewed for a risk of choking. This deficient practice resulted in the resident choking, coding and the emergency services being called and resident hospitalized . The resident later died on [DATE]. (Resident B). The immediate jeopardy began on [DATE] when a Dietary Aide served Resident B a tray of food that was not in the correct form and left the resident to eat. The Administrator and Nurse Consultant were notified of the immediate jeopardy at 1:11 p.m. on [DATE]. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of isolated, 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 [DATE] at 9:58 a.m. Diagnoses included, but were not limited to, unspecified intellectual disabilities, other intellectual disabilities, unspecified dementia without behavioral disturbance, age-related cognitive decline, [CONDITION(S)], gastro-[CONDITION(S)] reflux disease without esophagitis, dysphagia, [CONDITION(S)] and dysphagia, oropharyngeal phase. Her orders included, but were not limited to, consistent carbohydrate, mechanical soft, ground meat, special instructions included to use Kennedy cups (a spill proof cup with lid) and divided plate with meals started on [DATE] and the speech therapist was to treat three times week for eight weeks for oropharyngeal dysphagia (the inability to initiate swallowing). The treatment would include restorative exercise, compensatory strategy training, and staff/caregiver as indicated started on [DATE]. A 5-day admission Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was moderately cognitively impaired. She required extensive assistance of one staff member for eating. She required a therapeutic diet and she had no swallowing disorders. She had no natural teeth or tooth fragment(s) (edentulous). A physician evaluation and management report for a swallow study performed on [DATE] indicated the resident was seen due to problems with eating and drinking. The diet recommendations were to give pills, one at a time in puree carrier. Meat diet was to be mechanical soft (all solids ground) and thin liquids. The following actions were recommended regarding the patient's feeding: a. small bites/sips b. alternate bites/sips Precautions during mouth feeding included: a. speech language therapist and trained staff only b. small bites/sips Cueing strategies included: a. allow extra time A diet order and communication form from the Speech Therapist (ST) 17, dated [DATE], indicated there was a diet change, the resident was to have a mechanical soft diet with thin liquids and needed divided plates and a Kennedy cup. A diet order and communication form from Speech Therapist 17, dated [DATE], indicated a diet order for controlled carbohydrates, a mechanical soft diet and she needed a divided plate and a two handled spout cup. A nurse's note, dated [DATE] at 12:56 a.m., indicated the resident had behaviors that shift and yelled out profanities throughout the shift. Resident had been given two cookies, fresh ice water, a strawberry ensure, and potato chips. An ST progress note, dated [DATE], indicated Impact on Burden of Care/Daily Life: the patient continued to require set up assist prior to and supervision during intake. Patient required set up assistance for bolus size modifications, large food items to be cut to bite-size due to decreased safety awareness, decreased safety judgement, and poor ability to bite due to edentulous status. Due to impulsivity and poor safety judgement, she required verbal cues to slow rate of intake, finish one bolus prior to initiating another. She continued to require modified diet of mechanical soft secondary to poor ability to masticate, poor oral control, poor lingual coordination and Base of Tongue (BOT) strength, poor pharyngeal [MEDICATION(S)]. She continued to require adaptive equipment i.e. spout cup or Provale cup to facilitate rate of liquid intake. She continued to require handled cup and divided plate to facilitate self-feeding. She continued to require reflux precautions secondary to [CONDITION(S)] reflux and retention. Precautions: Supervise by mouth intake, soft diet, cut foods to bite-size, poor safety awareness, poor recall, high fall risk, weight bearing as tolerated for her left lower extremity. A nurse's note, dated [DATE] at 1:45 p.m., indicated the resident was in the dining room eating when a CNA noted the resident choking, the [MEDICATION(S)] was performed at that time, a finger sweep was performed three times and was unsuccessful. The resident was moved to her room at that time CPR was initiated and 911 was called. On [DATE] at 1:58 p.m., the local fire department was at the facility and CPR continued. On [DATE] at 2:17 p.m., the local fire department Emergency Medical Technicians (EMTs) continued with CPR, pulse and respiration was revived. Resident was transported to a local hospital emergency room . A [DATE] reviewed/revised care plan for the resident indicated she utilized a full set of dentures and was at risk for mouth pain/problems due to use of dentures and needed assistance in caring for dentures. Her goal was that she would have clean, properly fitting dentures/bridge or partial, assure that device was fitting properly and assure that device was present before meals. Observe for any chewing. During an interview, on [DATE] at 11:10 a.m., the Dietary Manager, indicated the mechanical soft diets were anything that pertained to the meat and vegetables, like salisbury steak would be served with gravy and peas would be pureed due to the pods, the peanut butter and jelly sandwich would probably not be mechanical soft. On [DATE] a staff member, not the therapist, called the kitchen and asked for the sandwich. The kitchen staff had taken the sandwich to the third floor. The kitchen staff should have looked at the diet order first before taking to the third floor. During an interview with Dietary Cook 15, on [DATE] at 11:14 a.m., she indicated on [DATE] the menu was ham and bean soup for lunch and someone had called down to the kitchen and requested a peanut butter and jelly sandwich because the resident didn't like what she had on her tray. She prepared the peanut butter and jelly sandwich, a banana, an oatmeal creme pie and a chocolate milk and took the tray upstairs, Activity Aide 21 was in the dining room with another CNA and indicated she thought the resident had already eaten, Dietary Cook 15 indicated to Activity Aide 21 that the resident didn't like what was on her tray and she placed the tray in front of the resident. Dietary Cook 15 indicated the food was soft and appropriate for the resident's mechanical soft diet. On her ticket it indicated the resident had a mechanical soft diet and a divided plate because she doesn't like her food touching, it did not indicate to cut up her food. It was not uncommon for the staff to call the kitchen and ask for a sandwich and she would deliver what they requested to the resident. During an interview, on [DATE] at 11:28 a.m., QMA 12 indicated she was passing medication and one of the CNAs said the resident was choking, QMA 12 went to the dining room and did the [MEDICATION(S)] maneuver on her while she was in her wheelchair and told the CNA to get the nurse and the DON came to the dining room. The DON did an assessment on the resident and took her to her room, then QMA 12 grabbed some oxygen supplies and other supplies the DON needed. She was unaware if anyone was in the lounge with the resident when she started choking because she was passing medication down the hall where the DON's office was located. One of kitchen staff brought the peanut butter and jelly sandwich up to the resident because she didn't care for the food they had that day. She had seen the dentures in the resident's room before and she thought the resident needed set up assistance for eating. During an interview on [DATE] at 11:35 a.m., CNA 29 indicated that on the day Resident B choked, the nurse instructed them to weigh the residents and that they needed to make a few beds. They weighed the residents in a closet in the dining room. CNA 22 and herself were taking turns weighing the residents. Lunch was over, they assisted the residents that needed assistance with eating and picked up all the trays in the dining room and down the halls including Resident B's meal tray. Dietary Cook 15 took the sandwich to Resident B's room and another CNA was making Resident B's roommates' bed and indicated to Dietary Cook 15 that Resident B was in the dining room and she had just finished lunch and that was why everyone was confused because she had already eaten. CNAs were in and out of the dining room doing weights because Resident B was done eating. She didn't know who called down to the kitchen asking for the sandwich. The resident wore dentures and refused them often and she was offered dentures in the morning. CNA 22 did put her dentures in that morning because when she went in to collect linens after CNA 22 performed morning care, CNA 22 was cleaning the dentures and had put them in her mouth. After the incident she thought they found the residents denture in her room in the denture cup. Therapy worked with her, the resident could feed herself, they would set her up, get her started and she would do it herself. During an interview on [DATE] at 12:00 p.m., The Speech Therapist 17, indicated the resident was on her caseload, she was working with her on rate of intake because she liked to eat quickly and not finish the bite in her mouth before she took another bite. She needed verbal and tactile cues, she followed verbal cues well. She was also working on taking smaller bites and smaller drinks, she was not cognitively aware of safety and her fine motor skills were not great. She had not worked with her on the day she choked. She had only known the resident to wear her dentures one time and that was when she first did her evaluation and she had worked with the resident five days a week for the last two months. The resident did not like her denture and they didn't fit due to weight loss. She offered the resident her dentures and she refused and said she didn't like to have them in. She had recommended supervision in the resident's progress notes and the swallow study recommended supervision also. She did verbal education with the nursing staff and reviewed the recommendations from the swallow study a couple months ago but there had been a lot of new staff since then and didn't know if it got carried over. She worked with peanut butter and jelly with the resident and would cut it up for her and cued her, she didn't feel it was safe for her to eat unsupervised. During a telephone interview with the resident's nurse at the hospital, on [DATE] at 1:22 p.m., she indicated the resident was being terminally weaned from the ventilator at 3:00 p.m. During an interview on [DATE] at 2:01 p.m., Physical Therapist 34, indicated he completed an evaluation at a table in the dining room on third floor around the same area as Resident B had choked. He had glanced over and noticed Resident B started to choke and the CNAs were standing in the hallway behind the resident. He ran to the nurse who was standing at the medication cart and told her the patient was choking and she started doing the [MEDICATION(S)] maneuver on the resident. A review of the hospital notes on [DATE] at 9:30 a.m. indicated the following: a. History of Present Illness (HPI), dated [DATE] from the local hospital ER indicated the resident presented emergency department status post respiratory and subsequent [CONDITION(S)]. She had multiple medical problems. She was found unresponsive. First responder found her pulseless and started CPR. She had full ACLS protocol. She was apparently found in asystole. She had a few rounds of [MEDICATION(S)] and about 20 minutes of chest compressions. She was intubated. She apparently had a large amount of peanut butter sandwich removed from her airway. She regained pulses and was transported to the ER. b. Medical Decision Making (MDM), dated [DATE] from the local hospital ER indicated the resident was hydrated and maintained on a ventilator. Antibiotics were initiated for possible pneumonia and urinary tract infection. She required sedation and had a satisfactory blood pressure and heart rate at that time. She would be transferred to a larger hospital and remained generally unchanged during the emergency department course. c. An assessment from the larger hospital, dated [DATE], indicated the resident was orally intubated with oral gastric tube and her pupils were pinpoint, deviated upward. She was slightly coarse in her bilateral upper lung fields. She was having facial twitching, noted of mouth around eyes, no response to verbal stimuli. d. A Communication with Primary Treatment Team from the larger hospital, dated [DATE], indicated the resident's family was at bedside and poor prognosis, completed hypothermia, EEG with no epileptic waveform with goals and process of compassionate extubation was discussed. Family plans for compassionate extubation sometime that day. e. A palliative care assessment completed on [DATE], indicated the resident's palliative performance scale determined she was moribund-fatal processes progressing rapidly. She was intubated, her pupils were not reactive. She had decreased breath sounds and rhonci was present with no wheezing. Bowel sounds were decreased, and she had a urinary foley catheter. She was unresponsive, intubated with no spontaneous or purposeful movement. f. A progress note, dated [DATE] at 4:17 p.m. indicated the resident was extubated to room air. g. A hospital progress note, dated [DATE] at 6:54 p.m., indicated the resident's respirations had ceased. h. A hospital progress note, dated [DATE] at 8:25 p.m., indicated the event that led to death was the patient choked on a peanut butter sandwich and then [CONDITION(S)]. Diagnosis was [CONDITION(S)]. Date and time of death was [DATE] at 6:54 p.m. During an interview with CNA 23, on [DATE] at 12:03 p.m., she indicated Resident B was on soften mechanical diet. They did not normally feed the resident peanut butter and jelly, therapy would give it to her, cut it up and watch her. The resident did not normally didn't eat alone. Sometimes the kitchen staff would deliver the food directly to the resident. The day the resident choked, she did not order any food and the other two CNAs that were working said they didn't order it, either. CNA 23 was observed during the interview on the kiosk, she indicated to find the diets for the residents, it would be on their profile and on the meal tickets. She clicked on a resident to find the diet and was unable to locate the diet. Then she tried to look up another resident and with much searching she found his diet. Then went back to the other resident to locate her diet. Someone would order food for a resident and kitchen staff would take it directly to the residents. There were normally two or three staff members in the dining room, they were in and out of the dining room weighing residents that day and the therapist was in there but she was not aware the resident had a second tray and was eating. A current facility policy, dated [DATE], titled PROTOCOL FOR ALTERED DIET CONSISTENCY/THICKENED LIQUIDS, provided by the Administrator on [DATE] at 1:17 p.m. indicated the following: Speech therapist determine an altered diet consistency and/or thickened liquids are necessary: 1. Speech Therapist to meet with resident and/or responsible party to discuss the recommendations to include: Reasons for the altered diet consistency and/or thickened liquids order i.e. chewing/swallowing difficulties, risk for aspiration. Risks associated with not following the recommendation for the altered diet consistency and/or thickened liquids. 2. Speech Therapy to complete Altered Diet Consistency Acknowledgement in Matrix .An altered consistency diet is any diet consistency that is not a regular consistency - Mech Soft, Ground or Chopped Meat, Puree, etc A current facility policy, revised on ,d+[DATE], titled Deliver and Documentation of Meal Service and Between Meal Nourishments, provided by the Nurse Consultant on [DATE] at 3:00 p.m. indicated the following: .PROCEDURE Delivery The Nursing Department with the assistance of the Dietary Department will be responsible for the delivery of meals and nourishments and ensuring that all efforts are made to assist residents during meal and nourishment times. The Licensed Nurse is responsible for the supervision and coordination of CNAs during these daily activities .Specific mealtime responsibilities are: Provide assistance needed for meal set up (i.e. buttering bread, opening condiment packages, opening removing covers on foods and beverages). Assist residents in eating as needed .Review tray identification card .Substitutes for Food Refusals .Substitutes should be offered which are within the parameters of any therapeutic diet order .In the event that a resident consistently will accept only substitutes which are outside the parameters of the diet order, the Dietary Manger or Registered Dietitian will offer diet instruction and the benefits of the special diet to the resident's overall health. This will be documented in the medical record An undated paper titled, Mechanical or Dental Soft Diet, provided by the Administrator on [DATE] at 9:34 p.m. from the Indiana Diet Manual, indicated the following: Use: The mechanical soft or dental soft diet is for individual who have difficulty chewing regular textured foods, perhaps due to ill fitting dentures or worn teeth. The SLP (Speech Language Pathologist) may evaluate the individual to determine if the diet is appropriate. This diet may not be appropriate for individuals being treated for dysphagia .Food allowed: Bread/grains: easy to chew breads, toast crackers, graham crackers, cooked pasta or rice, hot cereal, dry cereal moistened with milk .Foods not allowed: dry tough meats, whole pieces of meat, bacon slices, peanut butter or cheese by itself, hot dogs The Administrator indicated at that time the peanut butter was not allowed but the soft bread was on the allowed list. A document, titled National Dysphagia Diet Mechanically Altered, provided by the Nurse Consultant on [DATE] at 2:34 p.m. and indicated they were following, the document indicated the following: Definition: This diet consists of foods that are mechanically altered by blending, chopping, grinding, or mashing so that they are easy to chew and swallow. Meat pieces are ground or minced and no larger that ¼-inch pieces. Foods are moist and soft textured to easily form a bolus. Foods in large chunks or foods that are too hard to be chewed thoroughly should be avoided. Indications: This diet is appropriate for individuals with dysphagia or chewing/swallowing issues as assessed by a speech-language pathologist. The chart indicated the foods that were recommended were soft pancakes, breads, sweet rolls, Danish pastries, French toasts well mositened, blended, chopped or ground to less than ,d+[DATE]-inch thick with syrup or sauce .Smooth nut and seed [NAME], such as peanut butter, almond butter, and sunflower seed butter as tolerated, and ok if used in tolerated recipes. All seasonings and sweetners, inclluding honey, jams, jellies and perserves The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility educated staff regarding serving the appropriate meal/proper form per order as well as ordering food for residents, an audit of all resident's diet orders and proper form and resident's that identified with any altered diet was screened by the Speech Therapy to ensure proper form was being served/ordered, but the noncompliance remained at at no actual harm, but potential for minimal harm because all care plans and profiles were not updated and education and monitoring had not been completed. This Federal tag relates to complaint IN 093. 3.,d+[DATE](a)(3)

Based on observation, interview and record review, the facility failed to ensure a resident, who was at risk for elopement, received the supervision to prevent elopement from the facility for 1 of 4 residents reviewed for elopement. This failure resulted in the resident being without supervision, climbing a wall/fence and crossing a busy road. (Resident C) The immediate jeopardy began on 10/10/19 when the resident left the third floor, coded the elevator to go to the first floor, went through the activity room door, which was unlocked, through the sunroom door, which was unlocked, through a screen door to a courtyard where he climbed the wall and left the property. The resident was unaccounted for approximately 15 minutes. The Executive Director was notified of the immediate jeopardy on 10/24/19 at 12:04 p.m. The Immediate Jeopardy was removed on 10/24/19, but non compliance remained at a pattern of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: The Indiana State Department of Health (ISDH) reportable, dated 10/11/19 at 2:27 p.m., indicated Resident c exited the facility without supervision at approximately 2:15 p.m. on 10/10/19. The report indicated staff pursued the resident and returned him to the facility. The resident was placed on one to one observation and a head to toe assessment was completed. The resident was found to have removed his security bracelet and a new one was reapplied. During an interview and observation, on 10/23/19 at 11:53 a.m., Resident C indicated when asked how he was doing, stated he did not remember. He thought he maybe left the facility, but could not really remember because he was incoherent. He enjoyed reading the Bible, but was having a hard time retaining what he read. He was unsure of what prompted his memory loss, but said he had a fall and hit his head, but not at the facility. He indicated he did have on a security bracelet around his ankle. The clinical record for Resident C was reviewed on 10/23/19 at 8:53 a.m. [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment, dated 9/10/19, indicated the resident was severely cognitively impaired. He required 1-person assistance for bed mobility, transfers, toileting and hygiene. A health care plan, dated 9/3/19, indicated the resident was at risk for elopement per the Elopement Risk Assessment. Interventions included, but were not limited to, place a security bracelet and to have all facility exits secured. On 10/10/19, the care plan was updated to include self removal of bracelet, exit seeking behavior, pacing near exit doors and verbalizing a desire to exit facility. A pre-admission assessment, dated 9/3/19, indicated Previous Medical History: patient left the emergency room (ER) Against Medical Advice (AMA). Review of an Elopement Risk Assessment, dated 9/3/19, indicated Resident C was at risk for elopement. The resident had a history of [REDACTED]. On 9/6/19, the resident scored 22 on the a Patient Health Questionnaire-9 PHQ-9, which indicated the resident had severe depression. On 9/6/19, a progress note indicated the resident was seen by the physician and was given a new [DIAGNOSES REDACTED]. A progress note, dated 9/8/19 at 2:08 p.m., indicated the resident told staff he was depressed while being on the locked unit because he had no one with whom to converse. A progress note on 9/9/19 at 10:10 a.m., indicated the resident continued to state he did not belong on the locked unit and had no one with whom to talk/ A progress note on 9/9/19 at 10:23 a.m., indicated Resident C was transferred to the 3rd floor, unlocked unit. He was forgetful at times, but made his needs known. He was able to ambulate with a slow and steady gait. On 9/9/19, Resident C's Power of Attorney (POA) was notified of the room change. The reason indicated the resident had transitioned to the 3rd floor from the locked unit. There was no new Elopement Risk Assessment completed prior to the unit change. A psychiatric Nurse Practitioner (NP) progress note, dated 9/10/19, indicated the resident was seen for a new patient visit. The chief complaint included concerns of anxiousness and short term memory loss. A review of symptoms included episodes of forgetting short term things, which caused anxiety. The mental status exam indicated the resident's short term memory was fair, long term memory was intact and his judgement was fair. On 9/10/19 at 3:49 p.m., a new prescription was received for [MEDICATION NAME] (anti-anxiety medicine ) 5 mg twice daily for 3 days then increase to 5 mg three times daily. A late entry behavior note completed on 10/21/19 at 9:30 a.m., indicated on 10/10/19 at 2:15 p.m., the resident was seen by a staff member and the staff member escorted the resident back to facility. The resident was put on 1:1 supervision. A new or worsening behavior form completed 10/18/19 at 7:04 p.m., indicated on 10/10/19 the resident was placed on 1:1 supervision and a new security bracelet was placed. The resident was believed to have removed the previous bracelet, but they were unable to find it. The resident wrote a note to self and hung in conspicuous area of his room to remind him not to leave facility without his brother. During an interview on 10/23/19 at 10:45 a.m., the Director of Nursing (DON) indicated the resident did exit through the activity room doors. The secure unit was more for resident safety and memory enhancement and it would have been a disservice to keep him there. During an interview on 10/24/19 at 8:06 a.m., the Administrator indicated the video was viewed on 10/10/19 and the resident was seen getting off the elevator, walking the halls a bit and then walking through the activity room door at 2:20 p.m. He indicated the video was no longer available. The resident had left the hospital AMA, but returned and was then discharged to home. The resident was a direct admit to the facility from his home. During an interview on 10/24/19 at 9:32 a.m., Housekeeping Supervisor (HS) 2 indicated she usually clocked out between 2:00 and 2:30 p.m. When she clocked out on 10/10/19, she saw the resident after she got into her car and had pulled away from the facility. She pulled over and asked Resident C where he was going. He said he was going to a convenience store. She asked if she could take him back to the facility, he said no and started walking. After the resident crossed a busy highway and intersection, she had to turn her car around because she could not cross the street at that location due to heavy traffic. She pulled into the parking lot of the convenience store and the resident then got into her car. She was not sure if he ever went into the gas station or not. She brought the resident back to the building and then left. She was asked to come back to the facility to give a statement. She indicated she did not clock back in so she filled out a missed punch card. She referred to her cell phone and indicated she had called the facility at 2:37 p.m. to let them know she was bringing him back. Review of HS 2's time card, she clocked out at 2:33 p.m. and she clocked back in at 2:35 p.m. During an interview 10/24/19 at 9:47 a.m., the DON indicated the Activity Director (AD) was in her office in the activity room when the resident exited the building, but she did not see or hear anything and they did not obtain a statement from her. The AD was currently on vacation. She indicated the resident went through the unlocked activity room door, through the unlocked door to the sunroom and then through the door to the outside courtyard. He then went over the wall surrounding the courtyard. Observation made at this time with the DON, the door to the activity room and the door to the sunroom required a key to lock, the activity office was in the activity room and to the right down a short hallway. The door to the sunroom was at the back of the room parallel to the activity office. The door to the activity room could not be seen from the office. During an interview on 10/24/19 at 11:20 a.m., Corporate Nurse 1 indicated the Indiana State Department of Health reported incident was incorrectly dated 10/11/19 and should have been dated 10/10/19 on the day of elopement. During a driving tour with HS 2 on 10/25/19 at 10:42 a.m., we exited the facility parking lot and turned left onto (name of street) then right onto (name of street) and went 0.2 miles. We then turned north onto (name of avenue). The convenience store was on the west side of the road. HS 2 indicated when she was driving, she saw someone walking and turned her head around and saw it was Resident C. She then went to make a U-turn at a hair salon and by the time she got her car turned around, he was right across the street. She asked him to go back to the facility and he said no. He continued to walk towards the gas station and because traffic was heavy, she had to wait to turn out onto the highway. She then pulled in the gas station and the resident was in the parking lot. She was not sure if he ever made it into the gas station or not. He then got into her car and she brought him back to the facility. She indicated he would have crossed the road before he got to the cross-walk. During an interview and observation of the courtyard on 10/25/19 at 10:53 a.m., the Maintenance Director indicated after the resident left the facility, he went around and checked all the door locks to make sure they were functioning. He would normally check the doors weekly and put into the computer system. The activity room door was changed to an automatic locking door approximately 1 week ago. The outside perimeter fence was 5'2 from ground to the top. Review of a current facility policy, dated 4/97 and revised 10/17, titled Elopement Prevention and Response Program, provided by the DON on 10/24//19 at 2:18 p.m., indicated the following: Policy: It is the policy of the facility that staff who have residents under their care are responsible for knowing the location of those residents, and in case of a missing resident, ensuring appropriate action is taken. Procedure: .ELOPEMENT PREVENTION PROGRAM 1. Resident identified to be at risk for elopement will be identified as follows: a. The facility will utilize .to identify residents at risk to leave the facility unattended. b. A list of residents at risk for elopement is maintained in a book with corresponding pictures c. Resident will be identified as an Elopement Risk, Wanderguard 2. Residents at risk for elopement may utilized a security bracelet POST ELOPEMENT PR[NAME]EDURE 1. Upon return .head to toe .notify the physician 2. Preventative safety measures will be put into place including relocation to a secured unit, increased supervision; etc. .5. The Executive Director or designee will conduct an investigation of the occurrence. Findings will be presented to .root cause analysis. The immediate jeopardy that began on (MONTH) 10, 2019, was removed on (MONTH) 24, 2019 when staff interviews confirmed the facility was in-servicing staff on the elopement procedure and monitoring the locking of all doors to the outside, but the non-compliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because monitoring was still on going. This Federal tag relates to Complaint IN 136. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a resident receive transportation for a scheduled surgery for [REDACTED]. This deficient practice resulted in Resident G having prolonged discomfort and pain and surgery being postponed for approximately 2 months. Findings include: The clinical record for Resident G was reviewed on 10/9/18 at 3:20 p.m. [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set assessment, dated 8/1/18, indicated the resident was cognitively intact. A health care plan, dated 1/7/18, indicated the resident was at risk for pain related arthritis and chronic pain. Interventions included, but were not limited to, document effectiveness of pain medication and to notify the physician for any signs of pain. During an interview on 10/9/18 at 2:48 p.m., the resident indicated she was scheduled to of had total hip replacement surgery on 9/24/18, but someone at the facility did not set up transportation. She was extremely upset and it was the final straw. On 10/10/18 at 10:02 a.m., the resident indicated she was to be at the appointment at 7:30 a.m. Around 7:10 a.m, she began to question why they had not yet left. She was not told, but had to ask them about it. She felt the delay in surgery has prolonged her recovery. A physician's office visit on 8/21/18, indicated the resident was seen for bilateral hip pain. The [DIAGNOSES REDACTED]. The plan included left posterior total hip arthroplasty. A nurses note, dated 8/22/18 at 3:44 p.m., indicated the facility received a call from the physician's office with a left total hip replacement surgery on 9/24/18 at 8:30 a.m. She was to have a follow up on 10/23/18 at 10:15 a.m. The note indicated the resident had been made aware and the facility was to provide transport. Review of the facility electronic appointment calendar, Resident G was scheduled for total hip surgery and the facility was to transport on 9/24/18. A nurses note, dated 9/24/18 at 10:53 a.m., indicated Transport conflict this AM. Surgery rescheduled NPO (nothing by mouth) d/c'd (discontinued) Review of the Medication Administration Record [REDACTED]. The order indicated an appointment on 9/24/18 at 8:30 a.m. and to be at the appointment at 7:00 a.m. There was also an order [REDACTED]. Resident G had an order for [REDACTED]. During an interview with the Director of Nursing (DON) on 10/10/18 at 9:52 a.m., she indicated a bus driver was not available. One was at school and one was out of town. They made several attempts to contact another transport company, but everyone was busy. She indicated they had a total of three staff who could drive the bus, but one had let his commercial driver's license expire. The physician's office would also not let them bring her in later in the day so it was rescheduled. A current undated health care policy, titled .BUS/TRANSPORTATION GUIDELINES provided by the DON on 10/10/18 at 2:10 p.m., indicated the following: Transportation will be provided by the facility bus/van for residents participating in activities outside of the facility. Transportation will be provided by the facility bus/van for residents going to and from physician appointments (local) when no other option is available. .3. Charge nurse must notify family/responsible part of the resident leaving and returning. 4. Paperwork must be sent with the driver/resident for the appointment. .12. Resident transportation needs must be addressed in the medical record and plan of care and communicated to the van drive prior to transport. 3.1-34(a)

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent falls for 4 of 5 residents reviewed for accidents (Residents 80, 45, 43, and 19) in a sample of 7. This deficient practice resulted in harm for 4 residents who required extensive assistance who are residing in the facility. Findings include: 1. During an observation, on 7/13/17 at 10:18 a.m., Resident 43 was asleep in her bed. A wheelchair with an alarm was parked at the foot of her bed. During an observation, on 7/14/17 at 12:42 p.m., she was in bed, awake. During an observation, on 7/17/17 at 7:53 a.m., she was in bed asleep. During an observation, on 7/17/17 at 8:11 a.m., she was in bed, with Activity Assistant 35 assisting her with breakfast. During an observation, on 7/17/17 at 8:27 a.m., she continued to be assisted with breakfast. She alternated with moaning loudly, which could be heard in the hallway. Review of the clinical record began on 7/13/17 at 10:54 a.m. [DIAGNOSES REDACTED]. She had been admitted to hospice services on 4/7/17 due to malnutrition. A 4/20/17, significant change, MDS (Minimum Data Set) assessment indicated she was severely cognitively impaired and required extensive assistance for mobility. She had current physician orders [REDACTED]. Review of a Fall Event document, dated 7/12/17 at 5:28 p.m., indicated she had abruptly landed onto bed. The document indicated she was standing by her bed and stumbled to the side and then back and abruptly landed back across her bed, landing diagonally across her bed on her left side. She complained to pain to her left hip/upper thigh. The note indicated she already had a bed sensor, wheelchair alarm, and a dycem to her wheelchair. A new intervention of removing her wheelchair from her room when not in use was added. A 7/13/17 IDT review of the fall indicated a slightly displaced left femoral fracture. The note indicated she had end stage dementia and received hospice services. New interventions included a scoop mattress to aid bed boundary awareness and to remove her wheelchair from her room when not in use. She had a current care plan problem of high risk for falls. On 7/17/17 at 1:40 p.m., LPN 36 indicated Resident 43 had previously been able to transfer herself into her wheelchair and propel herself around the unit. She indicated she had been very mobile and active. She indicated she was not a great eater, but had enjoyed snack foods and her favorite had been pizza. She indicated she seemed to be comfortable when she was laying still, but appeared to be in pain when she was moved, such as when she was repositioned. On 7/18/17 at 10:57 a.m. the DON indicated she was awaiting information from Resident 43's family regarding medical history that may put her at risk for such fractures. She indicated she could not answer why the facility had not asked for such information when the fracture had occurred, but she did know the resident had a vitamin D deficiency. No additional information was provided by the facility prior to exit from the facility. 2. During an observation, on 7/13/17 at 10:58 a.m., Resident 45 was ambulating with a gait belt, being assisted by family members. She became weak suddenly, causing them to get a wheelchair for her to sit in. During an observation, on 7/17/17 at 8:33 a.m., she was being assisted to ambulate to her room by CNA 31. During an observation, on 7/17/17 at 8:44 a.m., she was in bed asleep. During an observation, on 7/17/17 at 10:01 a.m. she was in bed asleep. Review of the clinical record began on 7/13/17 at 10:46 a.m. [DIAGNOSES REDACTED]. A quarterly, 7/13/17, MDS assessment indicated she was severely cognitively impaired and required extensive assistance for mobility. She had current physician's orders [REDACTED]. She had a current, 6/15/17 physician's orders [REDACTED]. On 7/17/17 at 2:53 p.m., she was laying in bed, awake. An observation, accompanied by CNA 34, indicated she was not wearing hipsters. On 7/17/17 at 2:55 p.m., LPN 33 indicated she had them on that morning, so they may have gotten wet and not been reapplied. Review of Fall Event documents and progress notes indicated the following: On 5/28/17 at 5:35 p.m., she was found on the floor in the dining room, laying against the wall. She complained of hip pain, but had no resulting injury. An interdisciplinary team (IDT) review of the fall indicated the possible root cause of the fall was fatigue. New interventions added were to monitor for fatigue, toilet, and lay down as needed. On 6/2/17 at 10:51 a.m., she tripped on a couch, landing onto her left side, but sustained no injury. The added intervention was to move the couch. On 6/12/17 at 11:44 a.m., she was found on the floor in another resident's room with a laceration to her left temple and was sent to the emergency room (ER) for evaluation. On 6/12/17 at 2:15 p.m., she returned from the ER with [DIAGNOSES REDACTED]. A 6/13/17 IDT review of the 6/12/17 fall indicated a motion sensor alarm was recommended to be placed at the threshold of the door to the room that she had fallen in. Further recommendation was made to discontinue her Remeron, as it was being used to stimulate her appetite and her previous falls had occurred near meal times. On 6/15/17 at 9:16 a.m. as a staff member was charting, they looked up and saw the resident on the floor on her back with a chair nearby. The ambulance was called, and a temporary splint was placed due to a possible fracture to her right wrist. A 6/16/17 IDT review indicated she had been dragging a chair backward, tripped, and fell . A new intervention of 1:1's were added when she was up and a bed alarm was placed in her room. On 6/23/17 at 12:40 p.m., she was standing up by the dining table, and began to take a step and tripped over the foot pedals of her wheelchair before staff caught her and lowered her to the floor. The clinical record indicated she restarted the Remeron 15 mg daily at bedtime on 6/21/17 due to a decrease in appetite over the previous week. She had a current care plan problem of risk for falls, which was last updated on 7/14/17. Interventions included, but were not limited to, 1:1 when awake, hipsters, sensor in bed, Remeron discontinued 6/13/17, motion sensor on threshold of room 208 as resident will visit uninvited, and non-skid strips in front of toilet. During an interview, on 7/17/17 at 1:33 p.m., LPN 35 indicated Resident 45 was still able to ambulate, but her ability had reduced since she had fallen, although she was getting better. During an interview, on 7/17/17 at 2:40 p.m., the DON indicated her Remeron had been discontinued because she had been becoming more active at meal times, so they thought maybe decreasing the Remeron would calm her at meal times, but it was restarted after a week. She indicated the IDT team did not consider if pain was a factor in her decreased appetite. 3. During an observation, on 7/13/17 at 10:32 a.m., Resident 80 was in his room, laying in the bed by the door, wrapped in a blanket. A blue floor mat and a bed alarm were in place to the bed by the window. The bed nearest to the door was not against the wall, nor did it have an alarm or fall mat next to it. During an observation, on 7/14/17 at 12:44 p.m., he was in the bed by the door, asleep. A blue floor mat and a bed alarm were in place to the bed by the window. During an observation, on 7/17/17 at 10:03 a.m., he was in the bed by the door, asleep. A blue floor mat and a bed alarm were in place to the bed by the window. During an observation, on 7/17/17 at 1:18 p.m., he was in the bed by the door, asleep. A blue floor mat and a bed alarm were in place to the bed by the window. During an observation, on 7/17/17 at 1:23 p.m., he was up walking to the bathroom in his stocking feet, with his slippers next to the bed nearest to the door. Review of the clinical record began on 7/13/17 at 10:56 a.m. [DIAGNOSES REDACTED]. An admission, 7/6/17, Minimum Data Set (MDS) assessment indicated he was severely cognitively impaired and required extensive assistance for mobility. He had current physician's orders [REDACTED]. Current physician's orders [REDACTED]. Review of a Fall Event document, dated 7/1/17 indicated he had been found on the floor in his room and had received a red mark to right frontal scalp/forehead. He had a current care plan problem of risk for falls. Interventions included, but were not limited to, bed against the wall, blue mat at bedside, bed sensor alarm, call light in reach, and personal items in reach. During an interview on 7/17/17 at 1:24 p.m., CNA 31 indicated he was supposed to have the bed with the alarm and the mat, but he preferred the other bed. During an interview, on 7/17/17 at 1:37 p.m., LPN 33 indicated the alarm seemed to frustrate him and staff had tried to redirect him, but it didn't always work. 4. During an observation, on 7/13/17 at 10:22 a.m., Resident 19 was seated in her chair in her room with her walker in front of her. During an observation, on 7/18/17 at 7:47 a.m., Resident 19 was seated in her chair in her room with her walker in front of her. Her dresser now had pads taped to two sides. Review of the clinical record began on 7/13/17 at 11:13 a.m. [DIAGNOSES REDACTED]. A 5/12/17, quarterly MDS assessment indicated she was severely cognitively impaired and required extensive assistance for mobility. She had current physician orders [REDACTED]. She had a current, 4/15/16, physician order [REDACTED]. Review of a Fall Event document, dated 6/1/17, indicated she had been taking a shower, stood up, and slipped, resulting in a laceration to the back of her head. The note indicated she had slipped while standing from the shower chair. Interventions included to add non-skid strips to the shower room and a stationary shower chair. A 6/2/17 IDT review of the resident fall indicated she had been incontinent of stool, which had contributed to the fall, although she had been assisted by staff. IDT was agreeable to stationary shower chair, but to discontinue non-skid strips to shower room floor due to poor adhesion to chronic wet surface. She had a current care plan problem of risk for falls. Interventions included, but were not limited to, non-skid strips in front of chair in room, stationary shower chair, call light, foot wear, personal items in reach, therapy screen. On 7/17/17 at 3:21 p.m. an observation of the Cottage shower room, accompanied by LPN 36, indicated two shower stalls, one eastern stall nearest the entrance door, with one non-skid strip and three bare pieces of adhesive where it appeared there were strips previously. The western stall, furthest from the door, had one bare strip, two non-skid strips, and two additional bare strips. There was no friction observed when rubbed with a shoe. During an interview, at 3:24 p.m., with CNA 34, who indicated they were present when Resident 19 fell on [DATE], indicated the resident had an incontinent episode of bowel and required a shower. She had placed a pair of socks on the resident and assisted her to stand at the area of the non-skid strips and turned away for a moment to the trash can, and heard the resident call out as she was falling back after having another loose stool, and struck her head on the wall dividing the shower stalls. She indicated the shower room appeared the same to her since the time of the fall. On 7/18/17 at 10:57 a.m., the DON indicated the non-skid strips used on the shower floor were clear in color, but new ones were added yesterday. Review of a policy, titled, Fall Management Program, dated 7/2016, and provided by the DON on 7/18/17 at 10:18 a.m., indicated the following: .It is the policy of American Senior Communities to ensure residents residing within the facility will maintain maximum physical functioning through the establishment of physical, environmental, and psychosocial guidelines to prevent injury related to falls 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure each resident with a [MEDICAL CONDITION] received care to prevent accumulation of thick mucus, including mucous plugging and [MEDICAL CONDITION] requiring multiple emergency room visits and hospitalization s for respiratory treatment, and failed to have suctioning equipment readily available for these residents. This deficient practice affected 2 of 3 residents with a [MEDICAL CONDITION] in the sample of 3 and 1 of 1 resident with a [MEDICAL CONDITION] in the supplemental sample of 1. (Residents B, C & D) This deficient practice resulted in an immediate jeopardy (IJ). The IJ was identified on 12/13/2010 and began on 11/04/2010. The facility Administrator, DON, and ADON were notified of the IJ on 12/13/2010. The IJ was removed on 12/14/2010, but the facility remained out of compliance at the level of isolated no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to complete staff inservices and monitoring to ensure staff provided sectioning/[MEDICAL CONDITION] care and were maintaining a patent airways for the residents who needed care. Findings include: 1. Resident B's closed record was reviewed on 12/13/2010 at 10:40 A.M. Resident B's [DIAGNOSES REDACTED]. Resident B was admitted to the facility on [DATE]. The nursing admission assessment dated [DATE] indicated Resident B had a [MEDICAL CONDITION] stoma. The stoma was not cannulated (there was no inner and/or outer cannula (tube) inside the [MEDICAL CONDITION]). The physician's transfer orders from his previous long term care facility included an order for [REDACTED]. Suction as needed." The September 2010 MAR (Medication Administration Record) indicated an order for [REDACTED]. The nurses' notes indicated: 10/7/2010 12 A.M. "...O2 sat (saturation) 94% c (with) O2 on at 2 L (liters) per trache ([MEDICAL CONDITION]) mask c (with) humidity. Has intermenttent (sic) prod (productive) cough c clear sputum. Lung sounds diminished thru (through) out...." 10/7/2010 9 A.M. "Res. noted to be SOB (short of breath) ... R (respiratory rate) 22... O2 sat 82% (normal sats are 92-100%) on 2 L (liters) c (with) humidification. Bilat (bilateral) lungs c wheezes. PRN saline administered et (and) not effective." 10/7/2010 "Res. O2 sats down to 80% after tx (treatment)." 10/7/10 9:10 A.M. "M.D. aware new order to send to ER (emergency room ) for eval (evaluation) et tx (treatment)." 10/7/10 9:15 A.M. "Res noted to be coughing up thick sputum out [MEDICAL CONDITION]. Remains to have SOB. O2 sats 84% on 2.5 L (liters) c (with) humidification. Res turned up O2 per self...." The emergency room physician's documentation indicated the resident had "increased cough, congestion and shortness of breath with [MEDICAL CONDITION]. His O2 saturation they were unable to get above 84% with oxygen.... He stated this came on the last two days with cough productive of yellow phlegm....Diagnosis: [REDACTED]. 2. Acute [MEDICAL CONDITION], resolved...." The respiratory emergency room progress notes dated 10/7/10 at 10:25 A.M. indicated "trach (had) green plugs." The nurses' notes indicated: 10/7/10 1:10 P.M. "Res arrived from ER.... Res had mucous plug removed et has pneumonia...." The nurses' notes indicated: 10/31/2010 2:10 A.M. "Res SOB, O2 Sat. 83% c (with) O2 on at 2 [MEDICAL CONDITION] c (with) humidity. Aerosol br (breathing) tx (treatment) .... O2 sat 88 % then droping (sic) to 83-84%. Pulse 123 (normal 60-80). [MEDICATION NAME] (an anti-anxiety medication) 2 mg (milligrams) admin (administered) per Dr. order." 10/31/2010 2:20 A.M. "Dr (name) on call for Dr (name) notified of res. low (indicated by an arrow pointing down) O2 sat, high (indicated by an arrow pointing up) pulse SOB, aerosol tx. admin & [MEDICATION NAME] 2 mg s (without) relief. N.O. noted to send to ER...." The emergency department record dated 10/31/2010 at 2:46 A.M. indicated the resident arrived with a respiratory rate of 42 with a mask over his trach. He was suctioned at 2:53 A.M. by the respiratory therapist and again at 2:55 A.M. with moderate amount of creamy contents. The [DIAGNOSES REDACTED]. The emergency room note written by the physician indicated: ".... Paramedics got there and found he has a large mucous plug....I wrote some orders for some steroids as well as for some [MEDICATION NAME] and breathing treatments...." The physician's note dated 10/31/2010 at 3:10 A.M. from the emergency room indicated "Venti mask at 6 liters. Suction c (with) saline Q. (every) 4 o (4 hours)." The physician's orders [REDACTED]. 10/31/2010 "..... mask at 6 liters. Suction c (with) saline q. 4 o (every 4 hours)." The October 2010 MAR indicated The entire month was blank indicating this had not be done. There was an additional order dated 10/30/10 for "Suction c (with) saline q. 4 o (hours)." There were initials at 8 A.M., 12 P.M., and 4 P.M. indicating this had been done as ordered. The November 2010 recapitulation orders had an order for [REDACTED]." There was a lack of an order for [REDACTED]. The physician's orders [REDACTED]. 11/1/2010 6 P.M. "O2 3 L/NC (nasal cannula). D/C (discontinue) Ventimask. D/C suction qid & prn...." The November 2010 MAR indicated [REDACTED] The order for the "Venti Mask @ 6 l/min (liters per minute)" had initials on the 6-2 shift indicating this had been done. The order was discontinued on 11/1/2010 at 6:00 P.M. The physician's progress note dated 11/4/2010 indicated "....The nurses are restricted by nursing home policies and are not allowed to suction his pharynx. He has a [MEDICAL CONDITION]. Unfortunately they can't directly clean it out...." The nurses' notes indicated: 11/7/10 1 P.M. "122/66, P (pulse) 100. R 28, T 98.4. Sat 91% on 3 L O2. Very SOB upon any exertion.... Wants to go to ER re (regarding) SOB.... may send to ER for eval. (evaluation)...." The physician's orders [REDACTED]. 11/7/2010 "Send to ER for eval due to SOB et unable to relax." The nurses' notes indicated: 11/7/10 10 P.M. "....was admitted to hosp (hospital)." The hospital admission note, written by the resident B's physician, indicated "....severe end stage [MEDICAL CONDITION]. He is status [REDACTED]. has a recent episode of shortness of breath on the 31st of October. He was in the emergency room and had a mucous plug blocking in his airway causing [MEDICAL CONDITION]. On Friday the 5th he had a chest x-ray done which showed a left lower lobe infiltrate.... in the emergency roiagnom on the date of admission becoming even more dyspneic and hypoxic. He was hypoxic but did respond to tracheal oxygen....Impression: acute exacerbation of [MEDICAL CONDITION]. Plan: ... Put him on antibiotics. [MEDICAL CONDITION] toilet." The hospital discharge note written by the resident's physician on 11/10/2010 indicated "....He has had a [MEDICAL CONDITIONS] of larynx in the past; occasionally needed suctioning which the nursing home is not able to provide...." The hospital discharge orders indicated an order for [REDACTED]. The nurses notes indicated: 11/10/2010 11:15 A.M. "readmitted from (name of hospital)...." There was a physician's orders [REDACTED]. DC (discontinue) stoma suctioning due to facility policy." The physician's readmission orders [REDACTED]." The November 2010 MAR indicated [REDACTED]." written on 11/12/2010. There was a lack of oxygen orders from 11/1/2010 until 11/12/2010. 11/25/2010 11:30 A.M. "Dr (name) in @ this time to assess res. Mucus plug noted to [MEDICAL CONDITION] @ this time. Res having SOB et anxiety related to mucus plug. M.D. attempted to extract mucus plug but attempt unsuccessful. M.D. gives order @ this time to send res. to ER for eval et txt (treatment) et removal of mucus plug...." There was a physician's orders [REDACTED].M. for "Send to ER for eval et tx, due to SOB - mucus plug [MEDICAL CONDITION]." The emergency room note dated 11/25/2010 indicated "....Has [MEDICAL CONDITION] has a big mucous thick plug in it that he is trying to breathe past. He can breathe a little bit through his nose. Cannot talk.... pulmonologist, (name). He accepts the patient in transfer to (name) hospital and transfer him by ambulance...." The History and Physical dated 11/25/2010 from the accepting hospital indicated Resident B was transferred with "respiratory insufficiency...." There was a care plan dated 10/18/2010 with second date of 11/10/2010 for the problem of "Resident has [MEDICAL CONDITION] stoma, potential for complications." The interventions included "Observe for congestion [MEDICAL CONDITION] site. Observe for symptoms of infection: malodorous drainage, increased secretions, redness at site, fever. Encourage resident to be out of bed daily. Observe for shortness of breath, implement interventions as needed,. Medications/oxygen as ordered. Notify M.D. for symptoms of infection or unrelieved shortness of breath or increased [MEDICAL CONDITION]. Labs/Xray as ordered. Observe for and treat symptoms of anxiety related to shortness of breath." During an interview with the DON (Director of Nurses) on 12/13/2010 at 11:00 A.M., she indicated the facility didn't have a policy to suction a [MEDICAL CONDITION] stoma. During an interview with the DON on 12/13/2010 at 12:15 A.M., she indicated the facility did not have an order to suction the resident. She further indicated the physician did not want the resident suctioned due to his history [MEDICAL CONDITION]. She then indicated the physician wanted a [MEDICAL CONDITION] had sent the resident to the ER to get one. During an interview with the DON on 12/13/2010 at 2:20 P.M., she indicated it was "too traumatic to go down an open stoma." During an interview with Resident B's physician on 12/13/2010 at 1:45 P.M., he indicated he had given the facility orders to discontinue suctioning of the resident's [MEDICAL CONDITION] stoma because he was told corporate didn't have a policy for deep suctioning and had been told by the facility they couldn't do suctioning of the [MEDICAL CONDITION]. He indicated Resident B had a poor airway and he had wanted suctioning of the resident. He also indicated the resident had thick secretions and didn't cough the secretions out of the stoma. 2. During the facility tour on 12/13/2010 at 9:30 A.M., with the DON, she identified Resident C as having a [MEDICAL CONDITION] stoma, which was not cannulated. Resident C was observed on 12/13/2010 at 12:20 P.M. lying in bed with no oxygen. There was no suction equipment in the room. Resident C's record was reviewed on 12/13/2010 at 12:28 P.M. Resident C's [DIAGNOSES REDACTED]. Review of the nurses notes indicated: 10/24/2010 4:00 P.M. "...phlegm cont. (continues) yellow/green in color productive. Res. cont. to cough up will cont. to monitor." 10/24/2010 6:15 P.M. "Resident moist, cool to touch, color pale, B/P (blood pressure) 120/90, HR 144 (normal 60-80), O2 (oxygen) sat (saturation) 88 (normal 92-100%), placed O2 @ 2 lpm (liters per minute), Sat. up to 93%-94%. Resp (respirations) 36 (normal 12-16), Crackles throughout upper lung lobes & diminished in lower lobes. T 101.1 ax (axillary)...." 10/24/2010 6:45 P.M. "....order to sent to (name) ER...." Review of the physician's orders [REDACTED]. 10/24/2010 6:45 P.M. "Send to (name) ER for evaluation & tx." 10/25/2010 12:00 MN (midnight) "Called (name) ER....Pt was transported to (name).... c (with) dx (diagnosis) septic...." The history and physical at the hospital dated 10/25/2010 indicated "....[MEDICAL CONDITION] and [MEDICAL CONDITION]. A lot of thick secretions were suctioned and the oxygen saturation improved. It was reported to be in the 80s on room air on arrival.... The nurses' notes indicated the resident returned on 10/29/2010. Review of the readmission orders The case history dated 11/02/2010 indicated the resident had ".... pulse ox 82% on room air....seem to have dry mucous membrane. Neck: patient has stoma over her neck without a [MEDICAL CONDITION] which is covered with secretions...." Resident C's November 2010 MAR indicated [REDACTED]. The discharge form dated 11/6/2010 from the hospital indicated an order for [REDACTED].!" There was a phone order written at the hospital on [DATE] at 2:25 P.M. of "discontinue oxygen if sat (greater than or equal to) 93%.... may speak c (with) pts (patient's) personal physician re: strong suctioning." The physician's orders [REDACTED].M. indicated "D/C (discontinue)[MEDICAL CONDITION]." There was a notation of "Nursing measure - Monitor O2 sat Q. shift if under 90% call M.D." The nurses' note dated 12/8/2010 indicated Resident C was breathing room air. Review of the resident's care plan indicated the lack of a care plan for [MEDICAL CONDITION] stoma care. During an interview with LPN #1 on 12/13/2010 at 1:10 P.M., she indicated she did not suction Resident C and she wouldn't suction her, except in her mouth, without an order to suction her. She indicated there was not a suction machine in the room with the resident. During an interview with Resident C's physician on 12/13/2010 at 1:45 P.M., he indicated he had not seen her lately, but they need to make sure they have the equipment there. Review of undated policies provided by the DON on 12/13/2010 at 12:10 P.M., indicated policies for "[MEDICAL CONDITION]" and "Suctioning (Aspiration) (Nasopharyngeal or Oropharyngeal Aspiration with Catheter)." The purpose was "To clear secretions of foreign material from the upper airway or pharynx...." 3. During the facility tour on 12/13/2010 at 9:30 A.M., with the DON, she identified Resident D as having a [MEDICAL CONDITION] stoma, which was not cannulated. Resident D was observed on 12/13/2010 at 12:20 P.M., she was lying in bed with no oxygen. There was no suction equipment in the room. Resident D's record was reviewed on 12/13/2010 at 12:50 P.M. Resident D's [DIAGNOSES REDACTED]. Resident D's December 2010 recapitulation orders had an order for [REDACTED]. There was a second order for "may have oral suctioning as needed to maintain patent airway" first written on 3/26/10. Resident D's record lacked a care plan for care of the [MEDICAL CONDITION] and maintaining an open airway. During an interview with LPN #1 on 12/13/2010 at 1:10 P.M., she indicated she did not suction Resident D and she wouldn't suction her without an order to suction her. She indicated there was not a suction machine in the room with the resident. An Immediate Jeopardy (IJ) was identified on 12/13/2010 at 3:02 P.M. The IJ began on 11/04/2010 when the physician's progress note indicated the facility's policies prevented the facility from meeting the suctioning needs of Resident B. The facility Administrator, DON, and ADON were notified of the IJ on 12/13/2010 at 3:05 P.M., of the IJ related to Resident B having multiple incidents of mucous plugs resulting in trips to the emergency room and admissions to the hospital with the resident returning to the facility with orders for suctioning only to have the orders discontinued. The IJ was related to an additional 2 residents in the facility who lacked suctioning equipment in their rooms. The IJ was removed on 12/14/2010, when through observation, interview, and record review, it was determined that the facility had implemented the plan of action to remove the IJ and that the steps taken removed the immediacy of the problem. The observations indicated the residents with tracheostomies had suction equipment in their rooms, the interview indicated inservices had been conducted, record review indicated order for suctioning were present. Even though the facility's corrective action removed the IJ, the facility remained out of compliance at a reduced scope and severity level of isolated no actual harm with potential for more than minimal harm that is not immediate jeopardy. This federal tag relates to complaint IN 165. 3.1-47(a)(4) 3.1-47(a)(5) 3.1-47(a)(6)