Every finding on record at Edgewater Woods

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from sexual abuse by a visitor for 1 of 3 residents reviewed for abuse. (Resident B) Using the reasonable person concept, it is likely Resident B would experience humiliation and fear related to the sexual abuse.The Immediate Jeopardy began on 7/30/26 when Resident B was sexually abused by a visitor, and staff failed to intervene. The Regional [NAME] President of Operations, Corporate Nurse Consultant, Administrator, and interim DON were notified of the Immediate Jeopardy on 8/5/26 at 3:32 p.m. The Immediate Jeopardy was removed on 8/6/26 but remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include:A facility reported incident, dated 8/1/26 at 1:49 p.m., indicated staff reported a family member being inappropriate with Resident B and the family member was removed from the facility pending an investigation. On 8/4/26 at 1:14 p.m., Resident B was observed in her room, dressed, and in her wheelchair. On 8/4/26 at 1:23 p.m., Resident B was observed in bed with her eyes closed. Resident B's clinical record was reviewed on 8/4/26 at 1:21 p.m. Diagnoses include unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Down syndrome, other specified depressive episodes, and legal blindness. A 7/13/26, quarterly, Minimum Data Set (MDS) assessment indicated she was rarely/never understood. She was dependent with toileting, personal hygiene, and upper and lower body dressing. Physician orders included to apply a brief under her while in bed but keep it unfastened. A review of her progress notes indicated the following: On 6/12/25 at 4:48 p.m., Family Member 6 showed staff a video of Resident B's left groin area. She had a small skin tear to left groin area/upper thigh. The area was assessed and Calmoseptine cream (skin protectant) was applied and left open to air. She showed no signs or symptoms of pain. The resident's guardian was notified and discussed leaving her brief open and under the resident at night. There was no other documentation in the clinical record regarding potential abuse or dignity concerns from 6/12/25 through 8/1/26. On 8/1/26 at 1:53 p.m., the Administrator was made aware of a reportable incident on 8/1/26 at approximately 12:00 pm. The legal guardian and the nurse practitioner were notified of the pending investigation. On 8/1/26 at 1:58 p.m., a head-to-toe assessment was completed by two nurses. A red area was noted to the resident's left labia and a (pre-existing) pressure area to her coccyx. There were no signs or symptoms of pain or infection. On 8/1/26 at 4:07 p.m., she was transferred to a local hospital via EMS (emergency medical services) for further assessment. On 8/1/26 at 9:01 p.m., she returned to the facility by ambulance on a stretcher with no new orders. There were no signs or symptoms of pain or distress at this time. A local police case report, dated 8/1/26 at 2:24 p.m., indicated the Administrator indicated that CNA 2 had reported seeing Family Member 6 on 7/30/26 having his hand down Resident B's pants, and on 7/31/26 seeing Family Member 6 having his hand up her shirt. The Administrator further indicated that CNA 2 told her that she did not initially report it on 7/30/26 due to another nurse telling her that Family Member 6 might be checking Resident B's brief to see if she was wet (incontinent) or not. Resident B had been diagnosed with Down Syndrome, along with not being able to speak or walk. The Administrator indicated that it was reported on 8/1/26 due to her being notified by CNA 2 that day and that she later made contact with Family Member 6 and advised him of the allegations and that he was not to come back to the facility and he would not be let inside in the future. Family Member 6 indicated that he had never touched her breast and the only reason he would touch down there was to tuck in her shirt. When the police officer notified Resident B's guardian, she did not seem surprised to learn of the allegations made against Family Member 6 and stated that this is just the first time he was caught, implying that Family Member 6 may have done this before to Resident B. The officer advised the Administrator of the further investigation needed including a sexual assault exam (SANE) kit at a local hospital. Consent was received from Resident B's guardian to complete a SANE kit at the hospital with the stipulation that a nurse or trusted adult from the nursing home would also go with Resident B. The Administrator and the police officer escorted Resident B to the hospital. The SANE exam was performed, and the nurse from the hospital indicated that they did not notice anything abnormal or any injuries and there were pending DNA results. The touch DNA was expected from Family Member 6 if he had performed any kind of care and redness to Resident B's genitalia area was also expected due to her requiring to wear incontinence briefs. An 8/2/26 care plan for psychosocial well-being related to her guardian reports a history of sexual abuse/unwelcome touching, verbalized possibly from the uncle or stepdad. She was non-verbal but made vocalizations at times, she might swat at caregivers hands/arms during care, express discomfort using facial expressions or gestures. She was at risk for experiencing re-traumatization, feeling unsafe/untrusting, and/or distressed. She was assessed by psychiatric provider on 8/3/26 with no triggers identified. Interventions included behavioral health services including psychiatric nurse practitioner for medication and behavior evaluation (8/2/26), encourage peer support and socialization (8/2/26), encourage resident and resident representative's input in developing/reviewing the plan of care (8/2/26), ensure resident has a sense of environment and physical safety (preferences for environment, caregivers, etc.) (8/2/26), and establish and encourage open communication between resident and staff (8/2/26). The clinical record lacked a care plan prior to 8/2/26 regarding a history of sexual abuse or unwelcome touching, possibly by the resident's uncle or stepdad. During an interview, on 8/5/25 at 11:47 a.m., Resident C indicated she was previously Resident B's roommate, and Resident C had concerns with Family Member 6. She observed him marking Resident B's incontinence brief and he put his hand down her pants. She reported to the Social Services Director that she did not trust Family Member 6 and wanted to move to a different room. Staff did not ask what made her uncomfortable, they just made arrangements for her to move out of the room. Family Member 6 did not do anything to her personally or say anything inappropriate to her, but he just made her nervous. She did not report that she observed Family Member 6's hand was in Resident B's pants. During an interview, on 8/5/26 at 12:05 p.m., the ADON indicated Family Member 6 and Family Member 8 were very attentive to Resident B. Family Member 6 pushed her up and down the hallway and assisted her with eating. The ADON had not seen anything inappropriate and nothing inappropriate had been reported to her regarding their interactions. Staff were asked about concerns every morning. It was not appropriate for Resident B's private area to be video recorded, as no one should be taking pictures of someone's private areas. While this was inappropriate, it was difficult to answer if it would be considered sexual abuse. Any abuse of any kind should be reported to the administrator as soon as the resident's safety was ensured. She did not remember reporting Family Member 6 video recording Resident B's private area and did not recall the details of the situation. During an interview, on 8/5/26 at 8:04 a.m. Resident B's guardian indicated she was notified on 8/1/26 at 11:59 a.m. of allegations that Family Member 6 had placed his hand on Resident B's breast and his hand in her pants. This was not the first time the facility had notified her of him behaving inappropriately. She was uncertain of the date, but approximately one year ago, someone from the facility contacted her to report Family Member 6 had reached around with his hand from behind the wheelchair and kissed Resident B on the lips. Resident B's guardian indicated there had not been known abusive trauma to Resident B prior to her admission to the facility, just intuition. During an interview, on 8/5/26 at 10:13 a.m., the Corporate Nurse Consultant indicated she reviewed care plan meetings to see if there were any concerns brought to the facility's attention by Resident B's guardian regarding Family Member 6, nothing was found, and she was not aware of any previous visitor restrictions related to Family Member 6 and Resident B or other residents regarding inappropriate conduct. During an interview, on 8/6/26 at 3:00 p.m., the Administrator indicated, within their admission agreement, they asked family members not to video or photograph in the facility. It was the facility policy for staff not to take videos or photographs in the facility. Under her watch, she wanted that reported to her immediately. She indicated photos taken by a family member should certainly be addressed. For abuse or suspected abuse, if they see something that did not look right or feel right, then staff were to contact the Administrator immediately. They were required to ensure the resident was safe and protected, then immediately report it to her. Confidential interviews were conducted during the survey and indicated the following: The door to Resident B's room was slightly open and she saw Family Member 6 with his right hand down inside the front of Resident B's brief. She went to the nurse's station and asked LPN 24 and CNA 9 about him placing his hands in the resident's pants. CNA 9 indicated that he typically did that to check to see if she was dry and LPN 24 agreed. No one else was notified, as it seemed the behavior was normal. On 7/30/26, prior to dinner at approximately 5:00 p.m., Family Member 6 was visiting with Resident B with the door partially closed. He was observed sitting and leaning into Resident B with his left arm over her shoulder, as he sat on the right side of the bed. His left hand was down Resident B's shirt, and he was fondling her left breast. The door was knocked on, the room was entered, and Family Member 6 was asked if Resident B needed anything. Family Member 6 seemed startled and removed his hand. Family Member 6 was not asked to leave the room, and the incident was not reported to anyone, as everyone acted as if the behavior was normal. Then on 7/31/26, at approximately 3:30 p.m., Resident B's door was partially closed. Resident B was in bed, awake, wearing a t-shirt and incontinence brief. She was rocking her head back and forth, and Family Member 6 was on the right side of the bed leaning over her, with his right hand in Resident B's brief against her skin. It could not be determined whether there was penetration because her brief was on, but his hand was against her skin down near her labia/perineal area. Family Member 6 was not asked to leave, and it was not reported to the Administrator. The observation was reported to the nurse standing at the medication cart and no guidance was given on what should be done. The staff acted as if Family Member 6 inappropriately touching Resident B was normal. The chain of command was followed, and no one seemed alarmed by the behavior. On 8/1/26, Resident B had a complete bed bath, was dressed, and transferred into her chair. Family Member 6 was in the building at that time, but left the room as staff cared for Resident B. At approximately 11:30 a.m., Family Member 6 was in Resident B's room. He requested staff to reposition Resident B and the nurse brought Resident B to the nurse's station. It was noticed that Resident B's undershirt had been changed from a white shirt to a gray shirt. It was indicated to the MDS Coordinator that Resident B had just been bathed and dressed, with her hair made neat. She was not wearing the same clothing, and her hair was a mess. It was explained about the previous observations on 7/30/26 and 7/31/26. The MDS Coordinator notified the Administrator and escorted Family Member 6 out of the facility. Family Member 6 creeped everyone out because he always had his hands on Resident B, but nothing inappropriate was brought to his attention. They thought maybe the family was just overly affectionate. A long time ago, there were conversations with the previous DON about Family Member 6 making them uncomfortable, but they were not aware of anything inappropriate that could be reported. Resident B once had a roommate who did not like the family, but no specific reason was named. Family Member 6 typically stayed in Resident B's room or in the dining area when he was at the facility. The door was always kept open when he was at the facility. Details could not be remembered well, but a long while back, in the chapel, something happened and Family Member 6 was to remain in the common area with Resident B during that time. It was uncomfortable to watch Family Member 6 kiss Resident B all over her mouth. It was reported to both the previous and current unit manager and the previous DON. A unit meeting was held at that time, and it was indicated for staff to watch Family Member 6 when he was in the building. In the past, Family Member 6 had been restricted from the facility and then they let him come back. Approximately a year ago, the way he kissed her all over the mouth was reported to leadership. It was uncomfortable the way Family Member 6 behaved with Resident B and she would not have liked it if she was cognitively intact. Two years ago, he was observed with his hand in her brief, and he indicated he was feeling to see if she was wet. He was educated to not put his hand in her brief to see if it was wet. Resident B was taken out of her room to the shower room to keep her away from him while administration checked into it. A couple of years ago, Resident B's roommate moved out because she was uncomfortable with Family Member 6. It was reported when the previous Administrator and DON were employed at the facility that Family Member 6 had been hanging all over Resident B, kissing her on the mouth, and with his hands in her shirt acting like he was adjusting her undershirt, and Resident B did not wear a bra. He was restricted from the unit and then allowed to come back. Staff were required to make certain the door was open. Actual dates could not be provided. Family Member 6 came to the facility daily for Resident B's lunch, and he left about 1:30 p.m. and returned around 4:00 p.m. to 5:00 p.m. and fed her supper and stayed until approximately 7:00 p.m. He was known to assist her around the facility in her wheelchair. He was unsupervised when he visited with her. He was known to have been inappropriate with her when he kissed her on the lips over a year ago, and this happened when the previous administrator worked at the facility. He was not allowed in the building for a while, then he was allowed to be in supervised areas, then he could be in her room with her with the door open. Staff were aware of the restrictions. A 6/2023 revised current facility policy, titled Abuse Prohibition, Reporting, and Investigation, provided by the Administrator on 8/4/26 at 12:00 p.m., 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 verbal abuse, sexual abuse.American Senior Communities will not permit residents to be subjected to abuse by anyone, including.family members.Investigation: The Executive Director is the designated individual responsible for coordinating all efforts in the investigation of abuse allegations, and for assuring that all policies and procedures are followed.Resident Abuse - Staff member, volunteer, or visitor: 1. The resident(s) involved in the incident will be protected and/or removed from the situation immediately. 2. Any individual who witnesses abuse, or has suspicion of abuse, shall immediately notify the charge nurse of the charge nurse of the unit, which the resident resides and to the Executive Director. 5. The resident(s) involved in the incident will be assessed for injuries. 6. The physician will be notified, and orders will be received for treatment and/or transfer to the hospital based upon the assessment. 7. The family of the resident(s) and/or responsible party will be notified. Reporting/Response: 1. All abuse allegations must be reported to the Executive Director immediately . The Immediate Jeopardy that began on 7/30/26 was removed on 8/6/26 but 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 of the need for continued monitoring of corrective actions. 410 Indiana Administrative Code (IAC) 16.2-3.1-27(a)(1) This citation relates to Intake 3131352.

Based on observation, interview, and record review, the facility failed to ensure staff reported an allegation of sexual abuse immediately to the administrator or designee when a visitor was observed fondling Resident B's breast for 1 of 3 residents reviewed for abuse. (Resident B) The failure to report led to the same staff member later observing the same visitor with his hand down Resident B's brief, fondling her perineal area. Using the reasonable person concept, it is likely Resident B would experience humiliation and fear related to the sexual abuse. The Immediate Jeopardy began on 7/30/26 when the staff failed to report and intervene when Resident B was sexually abused by Family Member 6. The Regional [NAME] President of Operations, Corporate Nurse Consultant, Administrator, and interim DON, were notified of the Immediate Jeopardy on 8/5/26 at 3:32 p.m. The Immediate Jeopardy was removed on 8/6/26 but remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: A facility reported incident, dated 8/1/26 at 1:49 p.m., indicated staff reported a family member being inappropriate with Resident B and the family member was removed from the facility pending an investigation. On 8/4/26 at 1:14 p.m., Resident B was observed in her room, dressed, and in her wheelchair. On 8/4/26 at 1:23 p.m., Resident B was observed in bed with her eyes closed.Resident B's clinical record was reviewed on 8/4/26 at 1:21 p.m. Diagnoses include unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Down syndrome, other specified depressive episodes, and legal blindness. A 7/13/26, quarterly, Minimum Data Set (MDS) assessment indicated she was rarely/never understood. She was dependent with toileting, personal hygiene, and upper and lower body dressing. Physician orders included to apply a brief under her while in bed, but keep it unfastened. Review of progress notes indicated the following: On 8/1/26 at 1:53 p.m., the Administrator was made aware of a reportable incident on 8/1/26 at approximately 12:00 pm. The legal guardian and the nurse practitioner were notified of the pending investigation. A local police case report, dated 8/1/26 at 2:24 p.m., indicated the Administrator indicated that CNA 2 had reported seeing Family Member 6 on 7/30/26 having his hand down Resident B's pants, and on 7/31/26 seeing Family Member 6 having his hand up her shirt. The Administrator further indicated that CNA 2 told her that she did not initially report it on 7/30/26 due to another nurse telling her that Family Member 6 might be checking Resident B's brief to see if she was wet (incontinent) or not. Resident B had been diagnosed with Down Syndrome, along with not being able to speak or walk. The Administrator indicated that it was reported on 8/1/26 due to her being notified by CNA 2 that day and that she later made contact with Family Member 6 and advised him of the allegations and that he was not to come back to the facility and he would not be let inside in the future. Family Member 6 indicated that he had never touched her breast and the only reason he would touch down there was to tuck in her shirt. When the police officer notified Resident B's guardian, she did not seem surprised to learn of the allegations made against Family Member 6 and stated that this is just the first time he was caught, implying that Family Member 6 may have done this before to Resident B. The officer advised the Administrator of the further investigation needed including a sexual assault exam (SANE) kit at a local hospital. Consent was received from Resident B's guardian to complete a SANE kit at the hospital with the stipulation that a nurse or trusted adult from the nursing home would also go with Resident B. The Administrator and the police officer escorted Resident B to the hospital. The SANE exam was performed, and the nurse from the hospital indicated that they did not notice anything abnormal or any injuries and there were pending DNA results. The touch DNA was expected from Family Member 6 if he had performed any kind of care and redness to Resident B's genitalia area was also expected due to her requiring to wear incontinence briefs.Confidential interviews were conducted during the survey and indicated the following:The door to Resident B's room was slightly open and she saw Family Member 6 with his right hand down inside the front of Resident B's brief. She went to the nurse's station and asked LPN 24 and CNA 9 about him placing his hands in the resident's pants. CNA 9 indicated that he typically did that to check to see if she was dry and LPN 24 agreed. No one else was notified, as it seemed the behavior was normal. On 7/30/26, prior to dinner at approximately 5:00 p.m., Family Member 6 was visiting with Resident B with the door partially closed. He was observed sitting and leaning into Resident B with his left arm over her shoulder, as he sat on the right side of the bed. His left hand was down Resident B's shirt, and he was fondling her left breast. The door was knocked on, the room was entered, and Family Member 6 was asked if Resident B needed anything. Family Member 6 seemed startled and removed his hand. Family Member 6 was not asked to leave the room, and the incident was not reported to anyone, as everyone acted as if the behavior was normal. Then on 7/31/26, at approximately 3:30 p.m., Resident B's door was partially closed. Resident B was in bed, awake, wearing a t-shirt and incontinence brief. She was rocking her head back and forth, and Family Member 6 was on the right side of the bed leaning over her, with his right hand in Resident B's brief against her skin. It could not be determined whether there was penetration because her brief was on, but his hand was against her skin down near her labia/perineal area. Family Member 6 was not asked to leave, and it was not reported to the Administrator. The observation was reported to the nurse standing at the medication cart and no guidance was given on what should be done. The staff acted as if Family Member 6 inappropriately touching Resident B was normal. The chain of command was followed, and no one seemed alarmed by the behavior. On 8/1/26, Resident B had a complete bed bath, was dressed, and transferred into her chair. Family Member 6 was in the building at that time, but left the room as staff cared for Resident B. At approximately 11:30 a.m., Family Member 6 was in Resident B's room. He requested staff to reposition Resident B and the nurse brought Resident B to the nurse's station. It was noticed that Resident B's undershirt had been changed from a white shirt to a gray shirt. It was indicated to the MDS Coordinator that Resident B had just been bathed and dressed, with her hair made neat. She was not wearing the same clothing, and her hair was a mess. It was explained about the previous observations on 7/30/26 and 7/31/26. The MDS Coordinator notified the Administrator and escorted Family Member 6 out of the facility. During an interview, on 8/6/26 at 3:00 p.m., the Administrator indicated normally an IDOH incident report was completed by the Administrator but could be delegated to the DON or the Regional [NAME] President in the Administrator's absence. A synopsis of what was reported to her was required on the report. She was not aware that she needed to include details on the incident report, such as a breast being touched or a hand in someone's pants. For abuse or suspected abuse, if they see something that did not look right or feel right, then staff were to contact the Administrator immediately. They were required to ensure the resident was safe and protected, then immediately report it to her. A 6/2023 revised current facility policy, titled Abuse Prohibition, Reporting, and Investigation, provided by the Administrator on 8/4/26 at 12:00 p.m., 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 verbal abuse, sexual abuse.American Senior Communities will not permit residents to be subjected to abuse by anyone, including.family members. Resident Abuse - Staff member, volunteer, or visitor: 1. The resident(s) involved in the incident will be protected and/or removed from the situation immediately. 2. Any individual who witnesses abuse, or has suspicion of abuse, shall immediately notify the charge nurse of the charge nurse of the unit, which the resident resides and to the Executive Director. 8. An incident report will be initiated within 2 hours of the allegation, following the guidelines for Unusual Occurrence Reporting via ISDH gateway portal.Reporting/Response: 1. All abuse allegations must be reported to the Executive Director immediately . Cross reference F600. The Immediate Jeopardy that began on 7/30/26 was removed on 8/6/26 but 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 of the need for continued monitoring of corrective actions. 410 Indiana Administrative Code (IAC) 16.2-3.1-28(c) This citation relates to Intake 3131352.

Based on observation, interview, and record review, the facility failed to ensure staff intervened to protect a resident when they were sexually abused by a visitor when the visitor was observed by the staff member fondling Resident B's breast The facility also failed to investigate and prevent further abuse as evidenced by the same visitor being later observed fondling Resident B's perineal area under her incontinence brief for 1 of 3 residents reviewed for abuse. (Resident B) Using the reasonable person concept, it is likely Resident B would experience humiliation and fear related to the sexual abuse. The Immediate Jeopardy began on 7/30/26 when Resident B was sexually abused by a visitor, and the staff failed to intervene to protect the resident and failed to investigate and prevent further abuse. The Regional [NAME] President of Operations, Corporate Nurse Consultant, Administrator, and interim DON, were notified of the Immediate Jeopardy on 8/5/26 at 3:32 p.m. The Immediate Jeopardy was removed on 8/6/26 but remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: A facility reported incident, dated 8/1/26 at 1:49 p.m., indicated staff reported a family member being inappropriate with Resident B and the family member was removed from the facility pending an investigation. On 8/4/26 at 1:14 p.m., Resident B was observed in her room, dressed, and in her wheelchair. On 8/4/26 at 1:23 p.m., Resident B was observed in bed with her eyes closed.Resident B's clinical record was reviewed on 8/4/26 at 1:21 p.m. Diagnoses included unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Down syndrome, other specified depressive episodes, and legal blindness. A 7/13/26 quarterly Minimum Data Set (MDS) assessment indicated she was rarely/never understood. She was dependent with toileting, personal hygiene, and upper and lower body dressing. Physician orders included to apply a brief under her while in bed, but keep it unfastened. On 8/1/26 at 1:53 p.m., the Administrator was made aware of a reportable incident on 8/1/26 at approximately 12:00 pm. The legal guardian and the nurse practitioner were notified of the pending investigation. A local police case report, dated 8/1/26 at 2:24 p.m., indicated the Administrator indicated that CNA 2 had reported seeing Family Member 6 on 7/30/26 having his hand down Resident B's pants, and on 7/31/26 seeing Family Member 6 having his hand up her shirt. The Administrator further indicated that CNA 2 told her that she did not initially report it on 7/30/26 due to another nurse telling her that Family Member 6 might be checking Resident B's brief to see if she was wet (incontinent) or not. Resident B had been diagnosed with Down Syndrome, along with not being able to speak or walk. The Administrator indicated that it was reported on 8/1/26 due to her being notified by CNA 2 that day and that she later made contact with Family Member 6 and advised him of the allegations and that he was not to come back to the facility and he would not be let inside in the future. Family Member 6 indicated that he had never touched her breast and the only reason he would touch down there was to tuck in her shirt. When the police officer notified Resident B's guardian, she did not seem surprised to learn of the allegations made against Family Member 6 and stated that this is just the first time he was caught, implying that Family Member 6 may have done this before to Resident B. The officer advised the Administrator of the further investigation needed including a sexual assault exam (SANE) kit at a local hospital. Consent was received from Resident B's guardian to complete a SANE kit at the hospital with the stipulation that a nurse or trusted adult from the nursing home would also go with Resident B. The Administrator and the police officer escorted Resident B to the hospital. The SANE exam was performed, and the nurse from the hospital indicated that they did not notice anything abnormal or any injuries and there were pending DNA results. The touch DNA was expected from Family Member 6 if he had performed any kind of care and redness to Resident B's genitalia area was also expected due to her requiring to wear incontinence briefs.Confidential interviews were conducted during the survey and indicated the following:The door to Resident B's room was slightly open and she saw Family Member 6 with his right hand down inside the front of Resident B's brief. She went to the nurse's station and asked LPN 24 and CNA 9 about him placing his hands in the resident's pants. CNA 9 indicated that he typically did that to check to see if she was dry and LPN 24 agreed. No one else was notified, as it seemed the behavior was normal. On 7/30/26, prior to dinner at approximately 5:00 p.m., Family Member 6 was visiting with Resident B with the door partially closed. He was observed sitting and leaning into Resident B with his left arm over her shoulder, as he sat on the right side of the bed. His left hand was down Resident B's shirt, and he was fondling her left breast. The door was knocked on, the room was entered, and Family Member 6 was asked if Resident B needed anything. Family Member 6 seemed startled and removed his hand. Family Member 6 was not asked to leave the room, and the incident was not reported to anyone, as everyone acted as if the behavior was normal. Then on 7/31/26, at approximately 3:30 p.m., Resident B's door was partially closed. Resident B was in bed, awake, wearing a t-shirt and incontinence brief. She was rocking her head back and forth, and Family Member 6 was on the right side of the bed leaning over her, with his right hand in Resident B's brief against her skin. It could not be determined whether there was penetration because her brief was on, but his hand was against her skin down near her labia/perineal area. Family Member 6 was not asked to leave, and it was not reported to the Administrator. The observation was reported to the nurse standing at the medication cart and no guidance was given on what should be done. The staff acted as if Family Member 6 inappropriately touching Resident B was normal. The chain of command was followed, and no one seemed alarmed by the behavior. On 8/1/26, Resident B had a complete bed bath, was dressed, and transferred into her chair. Family Member 6 was in the building at that time, but left the room as staff cared for Resident B. At approximately 11:30 a.m., Family Member 6 was in Resident B's room. He requested staff to reposition Resident B and the nurse brought Resident B to the nurse's station. It was noticed that Resident B's undershirt had been changed from a white shirt to a gray shirt. It was indicated to the MDS Coordinator that Resident B had just been bathed and dressed, with her hair made neat. She was not wearing the same clothing, and her hair was a mess. It was explained about the previous observations on 7/30/26 and 7/31/26. The MDS Coordinator notified the Administrator and escorted Family Member 6 out of the facility.During an interview, on 8/6/26 at 3:00 p.m., the Administrator indicated staff were required to ensure the resident was safe and protected, then immediately report to her with abuse or suspected abuse.A 6/2023 revised current facility policy, titled Abuse Prohibition, Reporting, and Investigation, provided by the Administrator on 8/4/26 at 12:00 p.m., 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 verbal abuse, sexual abuse.American Senior Communities will not permit residents to be subjected to abuse by anyone, including.family members.Investigation: The Executive Director is the designated individual responsible for coordinating all efforts in the investigation of abuse allegations, and for assuring that all policies and procedures are followed.Resident Abuse - Staff member, volunteer, or visitor: 1. The resident(s) involved in the incident will be protected and/or removed from the situation immediately. 2. Any individual who witnesses abuse, or has suspicion of abuse, shall immediately notify the charge nurse of the charge nurse of the unit, which the resident resides and to the Executive Director. 8. An incident report will be initiated within 2 hours of the allegation, following the guidelines for Unusual Occurrence Reporting via ISDH gateway portal. 9. Residents will be questioned (if alert) about the nature of the incident and their statement will be put in writing. 10. An investigation will be completed to assure other residents have not been affected by the incident or inappropriate behavior, and the results documented.Reporting/Response: 1. All abuse allegations must be reported to the Executive Director immediately .Cross reference F600.The Immediate Jeopardy that began on 7/30/26 was removed on 8/6/26 but 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 of the need for continued monitoring of corrective actions. 410 Indiana Administrative Code (IAC) 16.2-3.1-28(d)This citation relates to Intake 3131352.

Based on observation, interview, and record review, the facility failed to ensure an ice machine was maintained in a hygienic manner for 1 of 2 facility ice machines observed. (Willow Way hall) This deficient practice had the potential to affect 66 of 70 residents who received ice from the machine. Findings include:Review of an anonymous intake filed with the Indiana Department of Health (IDOH) indicated the facility's ice machine had mold growing inside of it. During a facility tour, on 8/6/26 at 3:37 p.m., accompanied by the Maintenance Director, CNA 5 filled three foam cups with ice from the ice chest located in the [NAME] Lane clean utility room. The ice machine on [NAME] Lane was observed to be unlocked, with the lock laying on top of the machine. The Maintenance Director opened the lid, and the cover panel inside the ice machine had a black/gray spotted substance across the entirety of the panel. Condensation on the panel dripped water into the half-empty ice bin below. The Maintenance Director wiped the substance with his finger, and the black/gray substance transferred onto his finger. He indicated the panel needed wiped down. He was unable to identify the substance and indicated that the ice machine was serviced quarterly. During the tour, he made a phone call and indicated the last service date was 6/23/26 and the next service was schedule for September. Documentation of the ice machine's last service date was requested but was not provided during the survey. During an observation of the [NAME] Lane ice machine with the Administrator, on 8/6/26 at 3:40 p.m., the lid was locked, and Housekeeper 12 was cleaning the outside of the machine. The Administrator indicated the ice machine had been cleaned the previous day and should not be dirty. Housekeeper 12 unlocked and opened the lid, and the Administrator observed the black/gray spots on the cover panel and condensation dripping into the ice storage bin that contained a half bin of ice. Housekeeper 12 removed a spot of the black/gray substance with his finger and indicated that he could clean the panel. The Administrator indicated that the panel could not just be cleaned, the ice needed to be removed, and then inside of the ice machine could then be cleaned. During an interview on 8/6/26 at 3:59 p.m., CNA 33 indicated that all but one resident on [NAME] Lane received ice from the ice cart located in the clean utility room, which was filled from the [NAME] Lane ice machine. Staff passed ice every shift and when the residents requested ice. During an interview, on 8/6/26 at 4:03 p.m., CNA 36 indicated all the residents she cared for on Golden Orchard Lane received ice, mostly for their sodas. During an interview, on 8/6/26 at 4:05 p.m., CNA 40 indicated all the residents she cared for on the Moving Forward hall received ice water, which she passed as soon as she arrived for her shift. The ice came from the ice cooler, which was filled from the [NAME] Lane ice machine. She had not noticed mold on the ice machine but had previously noticed gnats and small black chunks in the ice. She reported this to the nurse, and she didn't know what occurred afterward. On 8/6/26 at 4:23 p.m., the Scheduler, with the ADON present, indicated the facility census was 70 and 66 residents received ice from the ice machine. A 12/25 revised current facility policy, titled Cleaning Ice Machine and Scoop, provided by the Administrator on 8/6/26 at 3:58 p.m., indicated the following: .Procedure.Note: If self-dispensing ice machine, wash and clean only the outside of the machine. Sanitize the ice dispensing mechanism and drain area. Maintenance will clean and maintain the interior. 410 Indiana Administrative Code (IAC) 16.2-3.1-18(a) This citation relates to Intake 3136047.

Based on record review and interview, the facility failed to obtain surgical wound care instructions for a newly placed suprapubic catheter (a urinary drainage device inserted directly into the bladder) for 1 of 3 residents reviewed for wound care. (Resident C)Findings include:Resident C's clinical record was reviewed on 6/15/26 at 10:56 a.m. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, methicillin resistant staphylococcus aureus (MRSA) infection (antibiotic resistant infection), and obstructive and reflux uropathy candidiasis.A progress note, dated 5/21/2026 at 11:28 p.m., indicated a dressing to the suprapubic catheter was intact with minimal yellow drainage.A progress note, dated 5/23/2026 at 12:10 a.m., indicated a dressing to the suprapubic catheter was intact with minimal yellow drainage.A progress note dated 5/23/2026 at 11:28 a.m., indicated a suprapubic catheter dressing had a slight amount of drainage.A progress note, dated 5/26/2026 at 7:25 p.m., indicated the resident had some confusion, an elevated blood pressure of 172/102 mm/Hg (millimeters of mercury) and a temperature of 99.5 degrees Fahrenheit. The suprapubic area had some drainage noted at the insertion site. The resident was sent to the hospital for evaluation and treatment.An Internal Medicine History and Physical Note, dated 5/27/26, indicated the resident presented to the hospital with a fever of unknown source, but it was most likely from the site of the recently inserted suprapubic catheter. The suprapubic catheter site was believed to be the source of the fever/infection due to the bad smelling discharge at the site. The resident was given vancomycin (antibiotic).A hospital Discharge summary, dated [DATE], indicated the resident was admitted to the hospital with a temperature of 100.2 and a foul-smelling drainage around the recently placed suprapubic catheter site. Wound culture results indicated moderate growth of MRSA in the wound.The clinical record lacked interventions and orders related to the care of the newly placed suprapubic catheter until 5/28/26, following the resident's hospitalization.Review of the May 2026 medication administration record lacked orders for surgical wound care until 5/28/26, following the resident's hospitalization.During an interview on 6/17/26 at 8:47 a.m., the ADON indicated wound care orders should have been in place after the placement of the suprapubic catheter. The nurse should have identified the orders were missing and called the hospital for clarification. A current policy, dated 3/2010 and last revised 12/2025, titled Nursing Admission/Return admission Policy and Procedure. The policy indicated the following: . Physician Orders: Upon admission, physician orders must be obtained.6. Transcribe treatment orders to include the specific areas to be treated, frequently, dosage, and reason needed. This citation relates to Intake 3026817.3.1-37(a)

Based on interview and record review, the facility failed to provide residents and/or their representatives with written notice of transfer/discharge and bed hold policy for 1 of 3 residents reviewed for hospitalizations. (Resident 78)Resident 78's record was reviewed on 4/15/126 at 3:51 p.m. Diagnoses included liver cancer, altered mental status, and malnutrition.A 1/29/26 at 12:22 p.m. nurse's note indicated the resident was visited by a Nurse Practitioner (NP) and found to be lethargic and difficult to rouse. The NP ordered the resident sent to the emergency room (ER).A 1/29/26 6:30 p.m. nurse's note indicated the resident was admitted to the hospital.A 1/29/26 notice of transfer/discharge document, provided by the DON on 4/20/26 at 11:18 a.m., lacked an attached bed hold policy. The clinical record lacked documentation that the resident and/or their representative was provided with a written copy of the transfer/discharge form and/or bed hold policy.During an interview, on 4/20/26 at 11:34 a.m., RN 7 indicated when a resident was sent to the ER, a packet of paperwork including observation and event paperwork, a face sheet (summary of resident's chart), and a notice of transfer/discharge with bed hold policy, were provided to the resident prior to leaving the facility. If the resident was unstable or not cognitively intact, the paperwork was reviewed and signed by the resident representative in person or over the phone. The review of paperwork with the representative was then documented in a progress note.During an interview, on 4/20/26 at 12:50 p.m., the DON indicated when a resident was sent out to the ER, they were sent with a face sheet, continuing care document, and bed hold policy. If the resident was admitted , the paperwork was mailed to the family.A current facility policy, revised 4/18 and titled Emergency Transfer Notifications, provided by the Administrator on 4/20/26 1:54 p.m., included the following: .Policy: When a resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer may be provided to the resident and resident representative as soon as practicable. Copies of the notices must also be sent to the ombudsman, when practicable.Procedure: 1. Nursing will contact the responsible party/family member to inform them of the pending discharge/transfer to the acute care hospital. Bed hold policy/transfer notification will be reviewed with the responsible party at the time of notification and documented in the medical record.410 IAC (Indiana Administrative Code) 16.2-3.1-12(a)(6)(i-iii)(25)410 IAC 16.2-3.1-12(a)(6)(i-iii)(26)

Based on record review and interview, the facility failed to complete a required Preadmission Screening and Record Review (PASRR) Level I screening assessment to determine if a Level II assessment was required when the resident received a new major mental illness diagnosis for 1 of 1 resident reviewed for PASRR. (Resident 11)Finding includes:Resident 11's clinical record was reviewed on 4/17/26 at 3:43 p.m. The resident was admitted to the facility on [DATE]. Diagnosis included schizoaffective disorder, bipolar type. This diagnosis was added in July 2024. A 6/6/24, preadmission Level I PASARR Outcome document indicated a Level II assessment was not required. Rationale: There is no evidence of a PASARR condition of an intellectual/developmental disability or a serious behavioral condition. If changes occur or new information refutes these findings, a new screen must be submitted.A current care plan, initiated 7/11/24, indicated the resident had behavioral symptoms of delusions, tangential thoughts, agitation, grandiose thoughts, restlessness, and impulsivity related to schizoaffective disorder. Interventions included continued work with the clinical and psychiatric provider for alternate treatment plans or diagnosis reviews.A 4/13/26, quarterly, Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. The resident was not considered by the state Level II PASRR process to have a serious mental illness and /or intellectual disability or a related condition. Active diagnoses included schizophrenia.During an interview, on 4/20/26 at 11:00 a.m., the Social Services Director (SSD) indicated she was responsible for PASRR screening submissions. Resident 11's last PASRR screening was submitted on 6/6/24 and lacked a major mental diagnosis. She was unable to provide any further PASRR screening submissions since the resident's schizoaffective disorder diagnosis was received on 7/16/24. A PASRR screening should have been submitted when the diagnosis was received. The SSD believed it was overlooked. New diagnoses placed by the in-house providers were reviewed in morning meetings, but she was uncertain of a process to identify when a resident received a new major mental diagnosis from an outside provider.A current facility policy, dated 11/2017, titled PASRR Policy, provided by the Administrator on 4/20/26 at 11:30 a.m., indicated the following: Policy: It is the policy of this facility to ensure that any Pre-admission Screening and Resident Review (PASRR) recommendations which impact those with an Intellectual, Mental Disability or related conditions are completed as prescribed and PASRR assessments are updated with significant changes in mental or physical status.

Based on record review and interview, the facility failed to ensure communications with a dialysis provider were reviewed to prevent duplicate pneumococcal vaccinations and to ensure continuity of care for 1 or 1 residents reviewed for dialysis. (Resident 2) Findings include:Resident 2's clinical record was reviewed on 4/16/26 at 3:12 p.m. Diagnoses included hypertensive heart disease, chronic kidney disease with heart failure, and acute kidney failure. Current orders included dialysis on Monday, Wednesday, and Friday (1/6/26).A review of the resident's March 2026, Dialysis Communication facility binder indicated Resident 2 received the Pneumococcal 20-valent conjugate vaccine (Prevnar 20) in her left deltoid while at dialysis on 3/2/26.Review of the resident's clinical record vaccination history indicated a Prevnar 20 vaccination was provided, at the facility, on 3/26/26, in the resident's left deltoid.The clinical record lacked historical data of any previous immunizations.A 3/26/26, quarterly, Minimum Data Set (MDS) assessment indicated the resident was moderately cognitively impaired.During an interview, on 4/20/26 at 9:19 a.m., the DON indicated the staff member responsible for reviewing the dialysis communication binder was the Unit Manager (UM) or Infection Preventionist (IP), but there was a time when the facility was without a staff member in either of those positions. The vaccination given at the dialysis appointment should have been documented in the resident's clinical record at the facility.On 4/20/26 at 10:31 a.m., the Corporate Nurse Consultant indicated there was no UM or IP to review the dialysis communication binder at the time the resident would have gotten the Prevnar 20 vaccination at the dialysis appointment. The clinical staff should have been reviewing the communication binder, and the Prevnar 20 vaccination given on 3/2/26 should have been documented in the resident's clinical record.On 4/20/26 at 11:10 a.m., RN 4 indicated when a resident returned from dialysis, the communication binder should be reviewed by the nurse assigned to the hall. Important information from the communication binder should be documented in the resident's clinical record at the facility.On 4/20/26 at 11:12 a.m., the IP (Float) indicated the resident's clinical record should be reviewed prior to giving any vaccination. The facility followed the CDC guidelines for all vaccinations.A current facility policy, reviewed 11/17, titled, Dialysis Care, provided by the Administrator on 4/14/26 at 3:17 p.m., indicated the following: . 5. The nurse in charge at time of return will review paperwork for new orders and/or notes accompanying the resident. 6. The facility will employ a method of communication between the facility and the dialysis center to relay changes in condition and response to treatment . 410 IAC (Indiana Administrative Code) 16.2- 3.1-37(a)

Based on record review and interview, the facility failed to ensure pharmacy recommendations were completed in a timely manner and per facility policy for 3 of 5 residents reviewed for unnecessary medications. Findings include: 1.Resident 3's clinical record was reviewed on 4/16/26 at 1:01 p.m. Diagnosis included chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, and morbid obesity due to excess calories. Discontinued orders (on 3/11/26) included ipratropium-albuterol (to treat airflow) solution 0.5 milligrams (mg)-3 mg/3 milliliters (mL); use one vial by inhalation, every 6 hours as needed for shortness of breath; ondansetron (to treat nausea) disintegrating tablet 8 mg, give one tablet every 8 hours as needed for nausea and vomiting; polyethylene glycol 3350 powder (laxative) give 17 grams (gm) oral, mixed with 8 ounces (oz) of fluid, once daily as needed for constipation. A 1/7/26, pharmacy review indicated to see the report for irregularities. A 1/7/26, pharmacy recommendation indicated to consider discontinuation of the as needed orders of ipratropium-albuterol solution, ondansetron, and polyethylene glycol 3350 powder for the due to a lack of use within the previous 60 days. The provider signed the recommendation on 3/10/26 and indicated to discontinue the as needed orders. 2.Resident 5's clinical record was reviewed on 4/17/26 at 11:02 a.m. Diagnosis included COPD, coronary artery disease, and peripheral vascular disease. Discontinued orders included cetirizine (an antihistamine) 10 mg once daily. The order was discontinued on 4/14/26. A 1/7/26, pharmacy review indicated to see the report for irregularities. A 1/7/26, pharmacy recommendation indicated to discontinue cetirizine as administration should be limited to the allergy season in order to avoid adverse events attributed to daily long-term use. The provider signed the recommendation on 3/10/26 and indicated to discontinue the cetirizine with an end date of 4/14/26. 3. Resident 6's clinical record was reviewed on 4/15/26 at 3:50 p.m. Diagnoses included chronic atrial fibrillation, hypertensive heart disease with heart failure, and hemiplegia and hemiparesis following other cerebrovascular disease affecting left non-dominant side. Current orders included amiodarone (heart rhythm medication) 100 mg once daily and TSH (thyroid stimulating hormone) once (3/12/26). The clinical record lacked future orders for TSH every 6 months. Discontinued orders included cyclobenzaprine (muscle relaxer) 10 mg as needed at bedtime for muscle spasms. The order was discontinued on 3/11/26. A 12/22/25, quarterly, Minimum Data Set assessment indicated the resident was moderately cognitively impaired. A current care plan, dated 3/10/23, indicated Resident 6 was at risk for ineffective tissue perfusion related to atrial fibrillation, heart failure, and hemiplegia and hemiparesis related to a cerebrovascular accident (stroke). Interventions included labs as ordered (3/10/23). A 1/7/26 pharmacy review indicated to see the report for irregularities. A 1/7/26 pharmacy recommendation indicated to consider discontinuation of cyclobenzaprine due to a lack of use within the previous 60 days. The provider signed the recommendation on 3/10/26 and indicated to discontinue cyclobenzaprine. A 1/7/26 pharmacy recommendation indicated the resident received amiodarone but lacked a TSH lab in the medical record within the past six months. Amiodarone may cause hypothyroidism or hyperthyroidism due to its substantial iodine content. Please monitor TSH on the next convenient lab day and every six months thereafter. The provider signed the recommendation on 3/10/26 and ordered a TSH for 3/12/26. During an interview on 4/20/26 at 1:07 p.m., the DON indicated she was new to the pharmacy review process. She received the recommendations via email, printed the recommendations, and physically handed them to the provider immediately. The NP was at the facility on Tuesdays and Thursdays. The physician got them if he was available. Pharmacy recommendations were returned to her from the providers in varied time frames but as soon as possible. She tried to get the process completed within 30 days. The Pharmacist and DON restarted the process If there were missing recommendations during the monthly review. On 4/20/26 at 1:07 p.m., the Corporate Nurse Consultant indicated the facility aimed for 30 days or by the next review per regulation. The recommendations were reviewed in manager meetings. Some prioritization took place based on medication types and the residents' clinical conditions. Gradual drug reductions were a priority. Sometimes the urgency was less, and those recommendations might take longer to be completed. A current facility policy, last revised 10/2018, titled Medication Regimen Reviews and Pharmacy Recommendations, provided by the Administrator on 4/17/26 at 2:06 p.m., indicated the following: I. Purpose: It is the policy. that the facility maintains the resident's highest practicable level of physical, mental, and psychosocial well-being and prevents or minimizes adverse consequences related to medication therapy to the extent possible by providing oversight by a licensed Pharmacist, Attending Physician, Medical Director, and Director of Nursing. II. Policy Medication Regimen Review. The Pharmacist will review each resident's medication regimen at least once a month. The Consultant Pharmacist recommendations will be reviewed by the Director of Nursing and the Attending Physician will be notified promptly of any recommendations needing immediate attention. Pharmacy recommendations should be reviewed with follow up by the physician within 30 days of the facility receiving. Once reviewed by the Physician the pharmacy recommendations will be filed in the resident's medical record. 410 IAC (Indiana Administrative Code) 16.2-3.1-25(i)

Based on record review and interview, the facility failed to ensure pneumococcal vaccinations were provided following the Centers for Disease Control and Prevention (CDC) guidelines and facility policy to prevent duplication of administration for 1 of 6 residents reviewed for immunizations. (Resident 2) Findings include:Resident 2's clinical record was reviewed on 4/16/26 at 3:12 p.m. Diagnoses included hypertensive heart disease, chronic kidney disease with heart failure, and acute kidney failure. A review of the resident's March 2026, Dialysis Communication facility binder indicated Resident 2 received the Pneumococcal 20-valent conjugate vaccine (Prevnar 20) in her left deltoid while at dialysis on 3/2/26.Review of the resident's clinical record vaccination history indicated a Prevnar 20 vaccination was provided, at the facility, on 3/26/26, in the resident's left deltoid.The clinical record lacked historical data of any previous immunizations.A 3/26/26, quarterly, Minimum Data Set (MDS) assessment indicated the resident was moderately cognitively impaired.During an interview, on 4/20/26 at 9:19 a.m., the DON indicated the staff member responsible for reviewing the dialysis communication binder was the Unit Manager (UM) or Infection Preventionist (IP), but there was a time when the facility was without a staff member in either of those positions. The vaccination given at the dialysis appointment should have been documented in the resident's clinical record at the facility.On 4/20/26 at 10:31 a.m., the Corporate Nurse Consultant indicated there was no UM or IP to review the dialysis communication binder at the time the resident would have gotten the Prevnar 20 vaccination at the dialysis appointment. The clinical staff should have been reviewing the communication binder, and the Prevnar 20 vaccination given on 3/2/26 should have been documented in the resident's clinical record.On 4/20/26 at 11:10 a.m., RN 4 indicated when a resident returned from dialysis, the communication binder should be reviewed by the nurse assigned to the hall. Important information from the communication binder should be documented in the resident's clinical record at the facility.On 4/20/26 at 11:12 a.m., the IP (Float) indicated the resident's clinical record should be reviewed prior to giving any vaccination. The facility followed the CDC guidelines for all vaccinations.A current facility policy, reviewed 11/17, titled, Dialysis Care, provided by the Administrator on 4/14/26 at 3:17 p.m., indicated the following: . 5. The nurse in charge at time of return will review paperwork for new orders and/or notes accompanying the resident. 6. The facility will employ a method of communication between the facility and the dialysis center to relay changes in condition and response to treatment.A current facility policy, reviewed 12/24, titled, Pneumococcal Vaccination, provided by the Administrator on 4/20/25 at 11:24 a.m., indicated the following: . To reduce morbidity and mortality from pneumococcal disease by vaccination all residents who meet the criteria established by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices. The are three pneumococcal conjugate vaccines (PCV15, PCV 20, PCV21). The different vaccines are recommended for different people based on their age and medical status. If PCV 20 or PCV 21 is used, a dose of PPSV 23 isn't indicated. Regardless of which vaccine is used (PCV 20 or PCV 21), their pneumococcal vaccinations are complete. 8. Pneumonia vaccine administration procedure: .f. Document administration in the electronic medical record. 410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)(5)

Based on interview and record review, the facility failed to protect residents from misappropriation when residents' Institutional Special Needs Plan (ISNP) benefits were utilized by a staff member for purposes other than the individual resident's benefit for 3 of 3 residents reviewed for misappropriation of property (Resident D, Resident E, and Resident F). This deficient practice was corrected on 7/18/25, prior to the start of survey, and was therefore past noncompliance. Findings include: 1. Resident E's clinical record was reviewed on 8/28/25 at 11:21 a.m. Diagnoses included aphasia following cerebral infarction, cognitive communication deficit, and expressive language disorder. A quarterly Minimum Data Set (MDS) assessment, dated 6/4/25, indicated the resident was severely cognitively impaired. A progress note, dated 6/23/25 at 1:28 p.m., indicated the resident's representative was notified of a discrepancy with the resident's ISNP card and funds. The facility verified transactions and adjusted as needed for reconciliation. 2. Resident F's clinical record was reviewed on 8/28/25 at 1:39 p.m. Diagnoses included severe intellectual disabilities, unspecified dementia, cognitive communication deficit, other symptoms and signs involving cognitive functions and awareness, encephalopathy, and developmental disorder of speech and language. A quarterly MDS, dated [DATE], indicated the resident was severely cognitively impaired. A progress note, dated 6/23/25 at 1:30 p.m., indicated the resident's representative was notified of a discrepancy with the resident's ISNP card and funds. The facility verified transactions and adjusted as needed for reconciliation. 3. Resident D's clinical record was reviewed on 8/28/25 at 2:29 p.m. Diagnoses included metabolic encephalopathy. A quarterly MDS, dated [DATE], indicated the resident was moderately cognitively impaired. A progress note, dated 6/23/25 at 1:31 p.m., indicated the resident's guardian was notified of a discrepancy with the resident's ISNP card and funds. The facility verified transactions and adjusted as needed for reconciliation. During an interview, on 8/28/25 at 1:45 p.m., the Administrator indicated when the facility credit card was accessed to buy supplies for the activities department, it was noticed that several of the residents' ISNP accounts had zero balances, which was unusual. The Administrator was alerted and began an investigation. The Administrator discovered the Activities Director used multiple resident ISNP cards to purchase items for the activities program. She used the residents' individual ISNP benefits cards to purchase items for the facility. The Administrator indicated she believed the Activities Director did not think about what she was doing and had no intent to take anything from the residents' ISNP benefits. A review of the investigation file, provided by the Administrator on 8/28/25 at 2:26 p.m., indicated the following: According to the Timeline, the following occurred: On 6/17/25 at 1:30 p.m., the Business Office Manager informed the Administrator there was a concern with Resident D's ISNP benefits card. The transaction was identified that the Activities Director had gone to the grocery on that date to shop for the residents' needs. The Administrator spoke with the Activities Director about the expenses, asked her (Activities Director) to make a note of which resident to whom each item belonged and where the item was stored. The Activities Director indicated she had put all the items on one transaction and must have utilized the wrong residents' benefits cards for the items. She did not know why she had not done individual transactions for each resident. The Activities Director indicated the residents' items were labeled, then later indicated the items still needed to be labeled for the residents. The Activities Director indicated the items had been purchased for Residents D, H, J, and K. A discrepancy was found in what was purchased on the receipt versus what the residents received. The Business Office Manager and the Administrator searched the activity room and storage room for the missing items. On 6/18/25, the Administrator completed an audit of the items at the facility from the grocery store receipt. A facility interview, on 6/18/25 with Activity Assistant 4, indicated she had assisted the Activity Director remove groceries from the Activity Director's car on 6/10/25. Too much was in the car to tell if any groceries were left in the car. The Activity Director brought in five bags of groceries that she said were for her (Activity Director) dinner. Popsicles were in one of the bags; the Activity Director had indicated the popsicles were on sale. She saw the Activity Director drink a bottle of Dr Pepper. The Activity Director delivered some items to the residents and told Activity Assistant 4 the remaining items went towards Bingo prizes and some baking activities. On 6/18/25, the Activity Director told Activity Assistant 4 she was suspended, gave Activity Assistant 4 a black marker, and asked her to label some items in the supply room. She reviewed the items on the list that were purchased. She did not recall seeing the missing items on the activity cart on the day she unloaded the groceries. She recognized the missing popsicles and bottle of Dr Pepper as items that were in the Activity Director's bags she took home. An undated facility interview with the Business Office Manager indicated the Activity Director had gone to the grocery store to get drinks and snacks for the residents. When the Activity Director returned, she indicated should had forgotten the receipt and would need to look it up on her phone. She told the Activity Director she needed the receipt to track purchases An undated facility interview with the Activity Director indicated, when asked what items she purchased for Resident E, she had bought items for his birthday party. Later, she indicated she had purchased items for Resident D, H, J, and K. She had not purchased any items for Resident E. She indicated she was not thinking, had purchased all the items on one transaction, and should have purchased the items on separate transactions for each resident. She must have accidentally used Resident E's ISNP benefits card. The cards had gotten out of order. She wrote down the names of the residents for whom each item was purchased. An undated facility interview with Resident J indicated she had received a six pack of Sprite and cheese puffs. She had not asked for any additional items, nor had she received any additional items. An undated facility interview with Resident H indicated he had received some sodas and crackers. He had not asked for any additional items, nor had he received any additional items. An undated facility interview with Resident K indicated she had received a six pack of Diet Coke and a bag of [NAME] cups. She had not asked for any additional items, nor had she received any additional items. An undated facility interview with Resident D indicated she had not asked for any items that week, nor had she received any items that week. An accounting of the items purchased on the receipt indicated a total of 85 items were purchased. Fifty-five items were located in the activity room or the storage room. Nine items were located in the residents' rooms, or the residents indicated the items had been received. Twenty-one items from the receipt were not located. On 6/18/25, the Activity Directory brought in three items that had not been previously located. Review of transactions (ISNP card charges) included in the facility investigation indicated: Resident E had $150.00 charged to card on 6/10/25 at 11:46 a.m. The starting balance on the card was $150.00 with a remaining balance of $0.00. Resident F had $150.00 charged to card on 6/10/25 at 11:47 a.m. The starting balance on the card was $150.00 with a remaining balance of $0.00. Resident D had $83.39 charged to card on 6/10/25 at 11:47 a.m. The starting balance on the card was $150.00 with a remaining balance of $66.61 Total charges at the grocery store on 6/10/25 were $383.39. ($150.00 + $150.00 + $83.29 = $383.39) During a phone interview, on 8/29/25 at 9:41 a.m., the Activity Director indicated, on the shopping trip on 6/10/25, she had everything rung up on one transaction. She had realized when the cashier rang them up, she should have separated the transactions. She didn't want it to be a hassle for the cashier. She used three different residents' ISNP cards to purchase the items. She took the items purchased back to the facility, gave them to the residents, put them in the refrigerator or storage for items that were a bulk purchase. She gave the Administrator the receipt. She marked who received the specific items and where the additional items were stored. The right people may not have received what items they were supposed to have received. The facility did not tell her what items were not found. She was fired for basically stealing food, though she did not steal anything. During an interview, on 8/29/25 at 11:46 a.m., Activity Assistant 4 indicated the former Activity Director went to the grocery store by herself. She did not know what items were purchased by the Activity Director. The items had not been labeled with residents' names and had been used for all the residents as far as she knew. The Activity Director had put names on the items in the refrigerator. She had not noticed the Activity Director using anything that belonged to the residents. The ISNP benefits card program was new to the facility. During an interview, on 8/29/25 at 2:08 p.m., the Administrator indicated when a resident was eligible for ISNP benefits, they were enrolled, and they received a grocery benefits card. The program was new to the facility. The benefits were to be used for items the residents wanted, or if the resident was cognitively unable to make decisions, then the resident's representative could assist with spending those benefits. The Business Office Manager kept the cards in her office for the residents' cards that were at the facility. The Activity Director had taken the facility credit card to get supplies for activities that day. Since she was buying items for the residents, she also took the residents' ISNP benefits cards to make purchases for those residents. After the incident with the cards, the ISNP benefit cards were stored in the business office safe. The cards must be signed out. An accounting for products purchased are required by the provision of a receipt. She in-serviced all the staff on the abuse policy as a whole, then focused on resident purchases and misappropriation of property. The staff were in-serviced on who to notify when a resident requests items. Social Services and the Business Office Manager was permitted to purchase items for the residents. The three residents affected were reimbursed. The investigation file, provided by the Administrator on 8/28/25 at 2:26 p.m., contained copies of checks for Resident D for $83.39 and Resident E for $150.00. A petty cash withdrawal receipt for Resident F for $150.00 was provided with an account statement that showed the resident's account had been credited with a cash payment of $150.00. An in-service sign in sheet for abuse/neglect/misappropriation of property for 6/19/25 was included. The in-service sheet contained 62 staff signatures. During an interview, on 8/29/25 at 2:35 p.m., the Administrator indicated she had discussed the incident at the facility Quality Assurance and Performance Improvement (QAPI) meeting. The facility had a QAPI meeting every other month A facility QAPI tool provided by the Administrator on 8/29/25 at 2:49 p.m., indicated under the Quality Assurance information for abuse prohibition measures - a misappropriation of property incident had been substantiated. No trends were identified. All staff were educated on abuse/misappropriation of property policy. The system for the ISNP benefit cares was discussed. Social Services and the Business Office Manager were permitted to use the benefit cards for the residents. The Business Office Manager tracked the receipts. The representative for the Provider Partners Health Plan (PPHP) will come to the facility monthly and check the members' accounts.The deficient practice was corrected on 7/18/25 after the facility implemented a systemic plan that included the education of staff regarding the facility's abuse and misappropriation of property policy, interviewed and/or assessed other residents for abuse, completed an Interdisciplinary Team (IDT) review of the incident, and planned for Quality Assurance activities to mitigate reoccurrence of the deficient practice. A current facility policy, last revised 6/2023 and provided by the DON on 8/28/25 at 4:10 p.m., titled Abuse Prohibition, Reporting, and Investigation, indicated the following: It is the policy of American Senior Communities to provide each resident with an environment that is free from abuse, neglect, misappropriation of resident property, and exploitation.Misappropriation of Resident Funds or Property - Deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's property or money without the resident's consent. This citation relates to Intake 1630260. 3.1-28(a)

Based on interview and record review, the facility failed to ensure a resident's catheter was anchored according to the physician's orders for 1 of 3 residents reviewed for catheters. (Resident C) Findings include: Resident C's closed clinical record was reviewed on 8/27/25 at 3:36 p.m. Diagnoses included infection and inflammatory reaction due to indwelling urethral catheter, subsequent encounter, other obstructive and reflux uropathy, urinary tract infection, and benign prostatic hyperplasia with lower urinary tract symptoms. Physician orders included cefpodoxime (antibiotic) 200 milligrams (mg) every 12 hours for urinary tract infection (7/25/25 - 7/27/25), levofloxacin (antibiotic) 500 mg daily (7/30/25 - 8/5/25), trospium (for overactive bladder) 20 mg twice a day (7/24/25), Foley catheter: 16 French 5-10 milliliter (mL) bulb (7/25/24 - 7/30/25), Foley catheter: 18 French 10 mL bulb (7/30/25), If resident does not void in six hours anchor foley catheter (7/29/25 - 7/30/25), and May use 18 French catheter to re-anchor until a 16 French 10 mL is available (7/29/25). An admission Minimum Data Set (MDS) assessment, dated 7/30/25, indicated the resident was cognitively intact. He required substantial/maximal staff assistance with toileting and showering hygiene. He required partial/moderate staff assistance with transferring to the toilet and the tub. He had an indwelling catheter and was frequently incontinent of bowels. His primary medical condition was infection and inflammatory reaction due to indwelling urethral catheter, subsequent encounter. A care plan for urinary tract infection (UTI) (created and last reviewed/revised 7/24/25) had a goal that the resident will be free from symptoms of UTI. Approaches included administering antibiotic as ordered, assisting with incontinence care, and observing for continued or worsening symptoms of UTI such as acute dysuria (painful urination), fever, costovertebral angle pain or tenderness, suprapubic pain, hematuria, worsening incontinence, urgency, and frequency. A care plan for UTI prophylaxis related to foley removal (created and last reviewed/revised 7/30/25) had a goal that the resident will be free from symptoms of UTI. Approaches included administering antibiotic as ordered, assisting with incontinence care, and observing for continued or worsening symptoms of UTI such as acute dysuria (painful urination), fever, costovertebral angle pain or tenderness, suprapubic pain, hematuria, worsening incontinence, urgency, and frequency. A care plan for the resident required an indwelling catheter related to other obstructive and reflux uropathy (created and last reviewed/revised 8/5/25) had a goal that resident will have catheter care managed appropriately as evidenced by; Not exhibiting signs of urinary tract infection or urethral trauma. Approaches included avoid obstructions in the drainage, change catheter per physician order, provide assistance for catheter care, and use 18 French 10 mL foley catheter per physician order. A urology procedure visit report, dated 7/29/25, signed by the urologist on 7/29/25 at 11:26 a.m., indicated the resident's catheter was removed. A nursing progress note, dated 7/29/25 at 12:42 p.m., indicated the resident had been seen by the urologist that morning and returned with new orders. The staff nurse had the packet from the urologist. Family was aware of the appointment and the new orders sent back with the resident. A nursing progress note, dated 7/29/25 at 2:07 p.m., indicated the resident was seen by the urologist and returned with new orders. A nursing progress note, dated 7/29/25 at 5:06 p.m., indicated the resident had not voided. The resident requested the catheter to be re-anchored after supper. A grievance report, dated 7/29/25 at 8:25 p.m., indicated the resident representative emailed the Administrator regarding concern that the resident's catheter had not been re-anchored. The Administrator called the charge nurse at 8:32 p.m. on 7/29/25. The charge nurse indicated the resident had refused to have the catheter re-anchored earlier and wanted to wait until after dinner. The ordered catheter size was not available, and she had to wait to get an order from the nurse practitioner. The new order was received, and the catheter was placed at approximately 8:45 p.m. A nursing progress note, recorded on 7/30/25 at 3:04 a.m., dated 7/29/25 at 8:44 p.m., indicated the nurse went to see if the resident was ready to have his catheter anchored. He did not have any urinary output. An order for a 16 French 10 mL bulb catheter was ordered which was not available. The nurse practitioner was notified and gave an order for the resident to use an 18 French 10 mL bulb coude (type of catheter). The catheter was anchored with an immediate return of urine. The resident received an as needed pain medication at 8:12 p.m. prior to catheterization, had a fentanyl patch in place, and received routine acetaminophen to manage pain. The resident voiced no concerns. The physician's report, signed at 11:26 a.m., indicated the catheter was removed. The late entry nursing progress note, on 7/30/25 at 3:04 a.m., and the grievance report, on 7/29/25 at 8:25 a.m., indicated the catheter was re-anchored at approximately 8:45 a.m. The physician's order indicated to anchor a foley catheter if the resident did not void in six hours. The time between urinary catheter removal and re-anchoring of the urinary catheter was over nine hours. During an interview, on 8/29/25 at 11:05 a.m., RN 5 indicated when a urinary catheter was removed, the resident should go no longer than eight hours to void. She would follow the physician's orders on what actions should be taken if the resident did not void. If the correct size of the catheter was not available, she would use a smaller size catheter and get an order from the physician. Catheter supplies were kept in the large storeroom or sometimes in the tiny storeroom where a few supplies are also stored. The Scheduler was responsible for ordering and ensuring medical supplies were available. During an interview, on 8/29/25 at 11:51 a.m., the Unit Manager indicated when a resident had a foley catheter removed she would follow the physician's orders. She would expect the resident would need to have a catheter anchored in eight hours if the resident had not voided. During an interview, on 8/29/25 at 12:00 p.m., the Scheduler indicated she tried to keep one of every size of catheter in stock at the facility. They discussed in morning meeting when a new admission came in what needs the resident had such as sizes of catheters, feeding tubes, and tracheostomy supplies. During an interview, on 8/29/25 at 1:46 p.m., the DON indicated when a catheter was removed, per standard practice, the resident would need to be catheterized in eight hours or per the physician's orders if the resident did not void. The resident had declined the catheter earlier, and the nurse had to get a new order because she did not have the correct catheter size. She was uncertain if the nurse could not find the correct size catheter or if it was not available. During an interview, on 8/29/25 at 2:43 p.m., the DON indicated she had procedure steps for catheter care and emptying a urinary drainage bag. The facility did not have any additional policies for urinary catheters. According to the National Library of Medicine website from the National Institutes of Health (NIH) accessed on 8/29/25 at https://www.ncbi.nlm.nih.gov/books/NBK596722/, .When removing an indwelling urinary catheter, it is considered a standard of practice to document the time and track the time of the first void. This information is also communicated during handoff reports. If the patient is unable to void within 4-6 hours and/or complains of bladder fullness, the nurse determines if incomplete bladder emptying is occurring according to agency policy. The ANA [American Nurses Association] has made the following recommendations to assess for incomplete bladder emptying: The patient should be prompted to urinate. If urination volume is less than 180 mL, the nurse should perform a bladder scan to determine the post-void residual. A bladder scan is a bedside test performed by nurses that uses ultrasonic waves to determine the amount of fluid in the bladder. If a bladder scanner is not available, a straight urinary catheterization is performed. This citation relates to Intake 2582493. 3.1-41(a)(2)

Based on interview and record review, the facility failed to provide physician ordered pain medication in a timely manner for 1 of 3 residents reviewed for admission. (Resident C) Finding includes:Resident C's closed clinical record was reviewed on 8/27/25 at 3:26 p.m. Diagnoses included rheumatoid arthritis, polyneuropathy, post-laminectomy syndrome (syndrome after spinal surgery characterized by persistent or worsening pain, numbness, tingling, and weakness in the legs or back), and chronic pain due to trauma. Physician orders included fentanyl (opiate pain medication) patch 75 mcg (micrograms)/hour every other day (7/25/25), hydromorphone (opiate pain medication) 4 milligrams (mg) every four hours as needed (PRN) for moderate pain (7/24/25), ibuprofen (anti-inflammatory medication) 600 mg three times a day (7/25/25), acetaminophen (Tylenol) 650 mg every four hours PRN (as needed) for mild pain (7/24/25), and acetaminophen every four hours (7/24/25). An admission Minimum Data Set (MDS) assessment, dated 7/30/25, indicated the resident was cognitively intact. He received a scheduled pain medication and a PRN pain medication. He complained of frequent moderate pain that frequently affected his therapy, sleep, and day-to-day activities. A care plan for pain (created and last reviewed/revised on 7/29/25) had a goal that the resident will be free from adverse effects of pain. The approaches included administering medications as ordered, documenting effectiveness of medications, and notifying the physician if pain is unrelieved and/or worsening. A hospital discharge summary which included medications administered, dated 7/23/25, indicated the resident had last received a PRN hydromorphone on 7/23/25 at 12:05 p.m. The resident face sheet indicated he was admitted on [DATE] at 6:57 p.m. A nursing progress note, dated 7/23/25 at 6:57 p.m., edited by the nurse on 7/24/25 at 10:10 a.m. because more data was available, (recorded on 7/24/25 at 10:08 a.m.), indicated the resident arrived at the facility. The resident complained of pain and discomfort that shift and had an order for hydromorphone and a fentanyl patch. Placement of the patch on the resident's left arm was verified by two nurses. The resident complained of pain, but the medications had not yet been delivered. The nurse notified the pharmacy and confirmed orders. The pharmacy indicated the orders were sent out and should be there soon. Resident was made aware. Acetaminophen was offered and administered. The resident was told when the pharmacy arrived with the medications, the nurse would check on the resident to see if he needed stronger pain medications. The resident voiced understanding and voiced no other concerns. A nursing progress note, dated 7/24/25 at 12:50 a.m. (recorded as late entry on 7/25/25 at 12:14 p.m.), indicated the pharmacy delivered stat medications at that time. A nursing progress note, dated 7/24/25 at 2:30 a.m. (recorded as late entry on 7/25/25 at 12:21 p.m.), indicated the resident pressed his call light at that time and a PRN medication was administered with no concerns voiced. The nurse told the resident when the medication arrived the staff had checked on the resident, and the resident appeared to be resting peacefully. She waited until he woke up and pressed the call light for the PRN pain medication. The resident replied he had taken a little nap. A nursing progress note, dated 7/24/25 at 6:57 a.m., indicated the resident arrived at the facility. The resident complained of pain and discomfort that shift and had an order for hydromorphone and a fentanyl patch. Placement of the patch on the resident's left arm was verified by two nurses. The residents complained of pain, but the medications had not yet been delivered. The nurse notified the pharmacy and confirmed orders. The pharmacy indicated the orders were sent out and should be there soon. The resident was made aware. Acetaminophen was offered and administered. The resident was told when the pharmacy arrived with the medications, the nurse would check on the resident to see if he needed stronger pain medications. The resident voiced understanding and voiced no other concerns. The medication administration record for 7/2025 was reviewed. The PRN (as needed) medications given as mentioned in the 7/23/25 note on the resident's admittance were not documented. The first documented given dose of PRN hydromorphone indicated the resident took the medication at 6:53 a.m. with a pain rating of 8 on a 1 to 10 scale. A narcotic count sheet indicated the hydromorphone was received on 7/24/25 at 12:50 a.m. and given at 2:30 a.m. The resident routinely took between four and six PRN hydromorphone daily to manage pain from 7/24/25 through 7/29/25. During a phone interview, on 8/28/25 at 11:09 AM, Resident C's representative indicated the resident had called the resident representative on the night he was admitted . The resident indicated he was in pain. He told the resident representative the facility did not have his medications, and no one would help him. He asked the resident representative to help him and bring his medications from home. During an interview, on 8/29/25 at 11:19 a.m., LPN 7 indicated when a resident was admitted , the orders were transcribed, and everything not in the emergency drug kit was ordered stat (immediately). She expected to get all medications within four hours. If the resident was in pain and the ordered pain medication was not available, she would call the physician to see if could get something else until the ordered medication was available. During an interview, on 8/29/25 at 11:28 a.m., RN 5 indicated for a newly admitted resident, she ordered from the pharmacy the medications that were not in the emergency drug kit. The medications were supposed to arrive within four hours after ordering. If the resident was requesting a pain medication and it was not in the emergency drug kit, then she would call the physician and get a temporary order for a different pain medication until the original ordered medication was available. During an interview, on 8/29/25 at 11:51 a.m., the Unit Manager indicated for a newly admitted resident, she utilized the emergency drug kit and then called the pharmacy for everything else to be sent stat. When the medications were ordered stat, they came within four hours. If the ordered pain medication for the resident was requested and not available, she would call the nurse practitioner and get an alternative medication to give that was available in the emergency drug kit. During an interview, on 8/29/25 at 1:56 p.m., the DON indicated when the facility received a new admission, anything that was in the emergency drug kit would not be sent out stat to the facility. Anything not in the emergency drug kit would be sent by the next morning. She did not believe the medications were received the night the resident was admitted . If the resident needed a pain medication, she would call the pharmacy to have the pain medication sent stat. If the resident had another pain medication would try to use that first to see if the other pain medication would help. She indicated if the resident were on hydromorphone, she did not expect acetaminophen would be effective to manage the pain. The physician should be notified to see what should be done. A current facility policy, last revised 7/2024, provided by the DON on 8/29/25 at 12:17 p.m., titled Pain Management Policy, indicated the following: .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.Residents are assessed for pain upon admission.Interviewable Resident - Pain medications will be prescribed and given based upon the intensity of the pain as follows using the verbal descriptive, numerical scale (1-10) or Wong-Baker FACES Scale.SEVERE = (6-8).Documentation of administration of ordered PRN pain medication will be documented on the Electronic Medication Administration Record (EMAR). This citation relates to Intake 2582493. 3.1-37(a)

Based on interview and record review, the facility failed to ensure resident representatives of cognitively impaired residents were invited to participate in care plan processes for 2 of 3 residents reviewed for notifications. (Resident B and Resident D) Findings include: 1. Resident B's clinical record was reviewed on 6/9/25 at 9:20 a.m Diagnoses included dementia, depressive episodes, gastric ulcer, migraine, gastro-esophageal reflux disease, scoliosis, dysphagia, and hypothyroidism. A quarterly MDS (Minimal Data Set) assessment, dated 3/26/25, indicated the resident was severely cognitively impaired. A care plan summary dated 1/10/25, indicated Resident B was in attendance for the meeting. No resident representative was listed in attendance. No resident representative was listed as being invited to the summary. A Care Plan Summary dated 3/26/25, indicated Resident B was in attendance for the meeting. No resident representative was listed in attendance. No resident representative was listed as being invited to the summary. Progress notes, dated December 2024 through April 2025, lacked documentation for notification or invitation of the resident's responsible party to the care plan meetings. 2. Resident D's clinical record was reviewed on 6/9/25 at 11:00 a.m. Diagnoses included Parkinson's disease, schizophrenia, gastro-esophageal reflux disease, and hypertension. A quarterly MDS assessment, dated 4/2/25, indicated the resident was severely cognitively impaired. A care plan summary dated 1/24/25, indicated Resident D was in attendance for the meeting. No resident representative was listed in attendance. No resident representative was listed as being invited to the summary. A care plan summary dated 3/17/25, indicated Resident D was in attendance for the meeting. No resident representative was listed in attendance. No resident representative was listed as being invited to the summary. A care plan summary dated 4/2/25, indicated Resident D was in attendance for the meeting. No resident representative was listed in attendance. No resident representative was listed as being invited to the summary. Progress notes, dated January 2025 through April 2025, lacked documentation for notification or invitation of the resident's responsible party to the care plan summaries. During an interview on 6/9/25 at 11:20 a.m., the Social Services Director (SSD) indicated care conferences were documented in the electronic record. She documented resident representative invitations in the progress notes. During an interview on 6/9/25 at 11:36 a.m., the SSD indicated if an invitation to the care plan summary was not sent to the resident/resident representative, she called the them to schedule the meeting. If the resident representative could not attend the meeting, she would offer for them to attend over the telephone. She would document the conversation in the progress notes. During an interview on 6/10/25 at 10:56 a.m., the DON indicated resident representatives/residents should be notified about the care plan summaries. If the resident is cognitively intact, they could decide if they want family to attend the meeting. There should be something documented in the clinical record saying they were present or declined to attend the meeting. The DON indicated the process for notifications and scheduling care plan summaries needed to be reviewed. During an interview on 6/10/25 at 11:46 a.m., Resident D's representative indicated she was not invited to a care plan summary meeting. A current facility policy, dated 8/2023 and titled IDT Comprehensive Care Plan Policy provided by the SSD on 6/9/25 at 11:46 a.m., indicated the following: Procedure: Resident , resident's representative, or others as designated by resident will be invited to the care plan review. The care plan review may be conducted face to face, via phone conference, video conference, or through written communication per resident and/or representative preference. A current undated copy of Resident Rights was provided by the SSD on 6/10/25 at 10:00 a.m., and indicated the following: Free Choice The resident has the right to Participate in planning care and treatment or changes in care and treatment unless adjudged incompetent or otherwise found to be incapacitated under state law This citation relates to Complaint IN00459983. 3.1-3(n)(3)

Based on interview and record review, the facility failed to provide transportation to a medical procedure appointment as previously arranged for 1 of 3 residents reviewed for transportation concerns, resulting in the resident missing the appointment. (Resident C) Findings include: Resident C's clinical record was reviewed on 3/19/25 at 12:09 p.m Diagnoses included emphysema, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, atherosclerotic heart disease of native coronary artery, angina pectoris, diabetes mellitus with diabetic neuropathy, peripheral vascular disease with arterial ulcers to bilateral lower extremities, hypertension, and alcohol abuse. The most recent quarterly MDS (Minimal Data Set) assessment, dated 11/27/25, indicated the resident was cognitively intact. The resident required substantial to maximum assistance for toilet hygiene, lower body dressing, putting on/taking off footwear, chair to bed/chair transfers, toilet transfers, and shower transfers. Method of mobility was a wheelchair. A care plan, dated 11/8/24, indicated the resident had skin impairment as evidenced by arterial wounds noted to the left lateral foot, 4th toe of left foot, and right great toe. On 12/24/24, an arterial wound was noted to the right great toe. Interventions included vascular follow up with physician, dated 12/12/24, off loading boots- encourage off loading pillows while in bed if boot refused. A care plan, dated 12/10/24, indicated the resident made choices with potential risk. The staff were to educate resident regarding the risk and mitigate the risk as possible. The resident refused showers and care. Interventions included revisiting options as needed, provide resident with education regarding risk and benefits of choices. The January 2025 Medication Administration Record indicated, on 1/20/25, the resident missed an appointment scheduled for 7:00 a.m. The appointment was for a stent placement to treat the peripheral vascular disease. The method of transport was documented as the facility bus. A progress note, dated 1/17/25 at 11:28 a.m., indicated the resident had an appointment scheduled for 1/20/25 for a medical procedure. The resident needed to arrive at the hospital at 7:00 a.m. for pre-operative testing. Pre-operative medication orders were received. A progress note, dated 1/20/25 at 8:20 a.m., indicated the resident's scheduled procedure was missed due to a transportation conflict. The physician's office was called in an attempt to reschedule the appointment for later that same day. The facility waited for a call back from the physician office. A progress note, dated 1/20/25 at 3:48 p.m., indicated a call was received from the physician office with a rescheduled appointment for 1/31/25 at 9:00 a.m. (11 days later). During an interview on 3/19/25 at 3:14 p.m., LPN 1 indicated, on the morning of 1/20/25, the facility called and informed the DON that Transport Driver 5 did not report for work to transport the resident to the 7:00 a.m. appointment nor did they call into the facility. The DON and LPN 1 made multiple unsuccessful attempts to call Transport Driver 5. The facility did not have a back up plan for transportation. Transport Driver 5 no longer worked at the facility and was unavailable for interview. During an interview on 3/20/25 at 10:30 a.m., the DON indicated, on 1/20/25, the transport driver had a family emergency. The facility did not have a back up driver. During an interview on 3/20/25 at 11:20 a.m., the Administrator indicated Transporter Driver 5's employment was terminated on 2/22/25. During an interview on 3/20/25 at 11:23 a.m., RN 2 indicated, on 1/20/25, the resident was supposed to be picked up at 6:00 a.m. At 6:15 a.m., RN 2 became concerned that no one had come to get the resident. RN 2 called LPN 1 and the DON and informed them of the concern. There were not many transport services in the area, and there had not been enough time to contact one. The appointment was eventually rescheduled. A current policy, dated 8/2011, and last revised 7/2023, titled, ASC Facility Transpiration Guidelines, was provided by the DON on 3/20/25 at 12:43 p.m. The policy included the following: Transportation will be provided by the facility bus/van for residents going to and from physician appointments (local) when no other option is available. Outside transport should be the chosen option prior to utilizing facility van for physician and/or other medical related appointments This citation relates to complaint IN00455522. 3.1-37(b)

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 69 of 70 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 higher risk for infection with an indwelling urinary catheter or a feeding tube, for 3 of 5 residents reviewed for infection control. (Residents 8, 10, and 9) Findings include: A1. During a continuous observation on 2/10/25 from 10:24 a.m. to 10:29 a.m., Laundry Attendant 9 pushed the laundry rack onto the Golden Orchard Unit with the curtains in place over the clothing rack. Without performing hand hygiene and using both hands, she opened the curtain on the clothing rack and removed clothing on hangers from the clothing rack. The curtain was placed back over the clothing on the rack. She entered room [ROOM NUMBER], opened the closet in the room closest to the door with her bare hand, and placed the clothing on hangers in the closet as she touched the fabric. Laundry Attendant 9 closed the closet door with her hands. Then, she exited room [ROOM NUMBER], opened the curtain on the clothing rack with both hands, and removed more clothing on hangers. The curtain on the clothing rack was placed back down over the cart. Then she entered room [ROOM NUMBER], opened the closet door closest to the door with the handle, and placed the clothing on the hangers in the closet as she touched the fabric. She exited room [ROOM NUMBER], opened the clothing rack curtain with both hands, removed more clothing on hangers, and placed the curtain back over the clothing rack. Then she entered room [ROOM NUMBER], opened the closet door with the handle, and placed the clothing on hangers in the closet as she touched the fabric. Laundry Attendant 9 closed the closet door with her hands. She exited room [ROOM NUMBER], lifted the curtain on the clothing rack with both hands, and removed more clothing on hangers. The curtain on the clothing rack was placed back down over the cart. Then she entered room [ROOM NUMBER], opened the closet door with the handle, and placed the clothing on the hangers in the closet as she touched the fabric. Laundry Attendant 9 closed the closet door with her hands. She exited room [ROOM NUMBER], grabbed hold of the linen cart with both hands, and went on down the hallway. Hand hygiene was not performed at any time during the continuous observation. During a continuous observation on 2/12/25 from 11:49 a.m. to 11:52 a.m., Laundry Attendant 8 pushed the clothing rack down the hallway on the 300 Unit. She opened the covered clothing rack, removed clothing on hangers, and entered room [ROOM NUMBER]. Once in the room, Laundry Attendant 8 used her left hand to open and close the closet near the window. She moved to the closet closest to the door in room [ROOM NUMBER], opened the closet door with her left hand, and placed the clothing on hangers in the closet with her right hand as she touched the fabric. Laundry Attendant 8 closed the closet door and exited room [ROOM NUMBER]. She lifted the curtain on the clothing rack with both hands, and removed more clothing on hangers with her left hand. Then Laundry Attendant 8 entered room [ROOM NUMBER], used her right hand to open the closet door near the window, closed the window closet door, then opened the closet near the door. She hung the clothing on the hangers in the closet with her right hand that touched the fabric. Then she exited room [ROOM NUMBER], opened the clothing rack curtain with both of her hands as she moved on down the hallway. She removed more clothing from the rack on hangers with her right hand and entered room [ROOM NUMBER]. She opened the closet near the door with her left hand, hung the clothes on hangers in the closet with her right hand, and closed the closet door with her left hand. Laundry Attendant 8 stopped and asked a staff member about a specific resident. She picked up a blanket from the clothing rack with both hands as she touched the top and bottom of the blanket, then placed it back on the clothing rack stacked against the stack of clean blankets. She then removed more clothes on hangers with her left hand and entered room [ROOM NUMBER]. She opened the closet near the door with her right hand and hung the clothes in the closet with her left hand as she touched the fabric. Up to this point of the continuous observation, Laundry Attendant 8 had not used any hand hygiene throughout the observation. Another staff member motioned for her to use hand hygiene. She utilized alcohol based hand rub as she exited room [ROOM NUMBER] and prior to touching the curtain on the clothing rack. During an interview on 2/12/25 at 11:54 a.m., Laundry Attendant 8 indicated she should have used hand hygiene when she went into each of the resident's rooms during the continuous laundry delivery observation, but she had not used hand hygiene. During an interview on 10/14/25 at 10:31 a.m., the Infection Preventionist indicated hand hygiene was required upon exiting one room and prior to the entrance of another room when laundry was delivered. The facility had current residents who were positive for COVID-19, Influenza A, and Clostridium difficile (a bacteria found in the gastrointestinal tract). A lack of hand hygiene was a potential risk for transmission of infections. During an interview on 2/14/25 at 3:05 p.m., the Laundry Supervisor indicated all of the laundry attendants delivered clean laundry to all the units in the building. Hand hygiene was required upon entry to each room, after a resident's personal items were touched, and upon exit of each room. This included the laundry delivery process. Laundry staff were required to follow standard and isolation precautions just like the nursing staff. This prevented the spread of germs from the residents' personal items. During an interview on 2/14/25 at 3:35 p.m., the DON indicated 69 residents received laundry services from the facility. B1. During an interview on 2/11/25 at 11:22 a.m., Resident 8 was in bed. The urine in the urinary catheter tubing was cloudy and yellow. An enhanced barrier precautions (EBP) sign was hung above the resident's head of bed. Resident 8's clinical record was reviewed on 2/11/25 at 2:40 p.m. Diagnoses included dementia of unspecified severity, neuromuscular dysfunction of the bladder, pyuria, stage 4 chronic kidney disease, and moderate protein-calorie malnutrition. A current physician order, dated 4/7/24, indicated the resident had a supra-pubic catheter. A quarterly Minimum Data Set (MDS) assessment, dated 1/9/25, indicated the resident had moderate cognitive impairment. She was dependent on staff assistance for toileting, bathing, dressing, personal hygiene, turning and transfers. The resident had an indwelling urinary catheter and was always incontinent of bowel. The resident had been on a antibiotic during the assessment period. A current care plan, dated 4/11/24, indicated the resident was at risk of transferring or being colonized with a multi-drug resistant organism (MDRO) and required enhanced barrier precautions due to a suprapubic catheter. Interventions included, enhanced barrier precautions (4/11/24) and a gown and gloves were required prior to high contact resident care activities (4/11/24). A current care plan, dated 6/6/18, indicated the resident was at risk for potential infection related to a supra-pubic urinary catheter due to neurogenic bladder and urinary retention. Interventions included, provide assistance for catheter care (6/6/18) and report signs of a urinary tract infection (UTI) which included concentrated urine (6/6/18). During a catheter care observation on 2/14/25 at 9:33 a.m., CNA 7 entered the resident's EBP room and washed her hands. Gloves were donned and the undated urinal was picked up from the back of the toilet in the resident's restroom with her left hand. A towel was placed on the floor underneath the urinary drainage bag, with her right hand, to serve as a barrier. The spigot of the urinary catheter drainage bag was removed from the holder using her right gloved hand. While she attempted to press the button to drain the urine from the bag, the spigot of the catheter touched the walls of the urinal three different times. Once emptied, she used her right hand to place the spigot back into the holder on the outside of the urinary catheter bag. The spigot was not cleansed at any time during the observation. The urinal contained 100 milliliters of concentrated cloudy yellow urine. CNA 7 did not don a gown during the catheter care observation. During an interview at the time of observation on 2/14/25 at 10:15 a.m. CNA 7 indicated she would have to check into the specifics for EBP. She assumed a sign would have been on the door when a resident required enhanced barrier precautions. She would not have typically touched the tip of the urinary catheter spigot on the urinal when the catheter was emptied, but it slipped in her hand. The spigot should have been cleansed with a disinfectant wipe, but she had not cleansed it during the catheter care observation. She walked into the resident's room and indicated she had not previously seen the EBP sign that remained over the head of the bed. She had not worn a gown during the catheter observation. She expected the EBP signs to be on the door of the resident's room rather than in the resident's room above the head of the bed. During an interview on 2/14/25 at 10:31 a.m., the Infection Preventionist indicated residents were required to have EBP when they had urinary catheters, feeding tubes, and chronic wounds. The facility required staff to wear a gown and gloves for EBP. High contact care included manipulation of a urinary catheter or feeding tube. A urinary catheter drainage bag spigot that touched the canister when it was emptied, increased the resident's risk for an infection. During an interview on 2/14/25 at 1:05 p.m., the DON indicated the facility was unable to provide a policy regarding urinary catheter maintenance. 51985 B2. During observation on 2/10/25 at 11:03 a.m., Resident 10 had an enhanced barrier precaution (EBP) sign hung on the wall beside her bed. During a continuous observation on 2/10/25 from 11:26 a.m. to 11:29 a.m., the resident self propelled a wheelchair for half of the hallway length, with her urinary catheter bag hung below her wheelchair and dragging the floor. QMA 3 assisted the resident for the remainder of the hallway into the dining room. During an observation on 2/10/25 at 2:14 p.m., the resident's catheter bag hung from under her wheelchair and touched the floor. Resident 10's clinical record was reviewed on 2/13/25 at 10:22 a.m. Diagnoses included dementia, urinary tract infection, and chronic obstructive pyelonephritis. A physician's order, dated 1/20/25, included cefazolin (antibiotic) 2 gram intravenously every 12 hours for UTI (discontinued on 1/23/25). A current physician's order, dated 02/12/2025, included cephalexin (antibiotic) 500 mg by mouth every 12 hours for UTI. An admission Minimum Data Set (MDS) assessment, dated 1/13/25, indicated the resident had severe cognitive impairment. The resident was dependent on staff assistance for toileting and personal hygiene. The resident required a urinary catheter and was always incontinent of bowel. A current care plan, dated 1/7/25, indicated the resident required an indwelling urinary catheter due to obstructive uropathy. Interventions included do not allow tubing or any part of the drainage system to touch the floor, provide assistance for catheter care, and store collection bag inside a protective dignity pouch. A current care plan, dated 1/7/25, indicated the resident was at risk of transferring or becoming colonized with an MDRO and required enhanced barrier precautions due to an indwelling catheter. Interventions included enhanced barrier precautions, use standard precautions including hand hygiene in addition to EBP, and wear gown and gloves prior to high contact resident care activities. During an observation on 2/13/25 11:53 a.m., the resident's catheter bag was covered with an open bottom dignity covering. The resident's urinary collection bag was hung under her wheelchair. The catheter bag touched the floor from the opening at the bottom of the dignity covering. During a catheter care observation on 2/14/25 at 9:53 a.m., CNA 11 placed several clean towels directly on the bed linens of the resident's bed. Hand hygiene was performed prior to her putting on gloves. With gloved hands, she entered the bathroom where the water faucets were turned on and off. She exited the bathroom wearing the same gloves. She used her left gloved hand to operate the resident's bed remote to lower the resident's head of bed. She then used both of her gloved hands to move the contaminated towel from the foot of the bed to be utilized as a barrier between the resident's urinary catheter and bed linens. With her gloved hands she unfastened the resident's incontinent brief and noted that resident had been incontinent of bowel. Without changing gloves, she adjusted the urinary catheter tubing and then went over to the resident's closet. Using her gloved hands, she opened the closet door and retrieved a clean incontinence brief from packaging on the lower shelf of the closet. Once back at the resident's bedside, and without changing gloves, she began to cleanse the resident's groin area. She rolled the resident to her left side and provided bowel incontinence care. She placed the dirty wash cloths in a trash bag at the foot of the bed. After removing the soiled incontinence brief, she rolled it up and placed it directly on the bed linens at foot of bed. She then cleansed the resident's catheter tubing. She placed the resident on her back . She then removed her gloves. Without performing hand hygiene, she put on another pair of gloves. With gloved hands, she opened the top drawer of the night stand and went through the drawer, indicating that she was looking for cream to apply to the resident, but could not locate it. The CNA removed her gloves and left the resident's room. She returned with the Infection Preventionist (IP). Both staff members put on gloves. The IP applied cream to resident's buttocks and indicated there was a compromised area. CNA 11 then completed the rest of the resident's catheter care. Neither CNA 11 nor the IP donned a gown during high contact care. During an interview on 2/14/25 10:09 a.m., CNA 11 indicated when a resident was on isolation there was a cart outside of the residents room and instructions were posted on the door. She had seen an EBP sign previously, but needed to ask her nurse what it meant exactly. EBP was used for catheters and wounds. EBP meant staff should have worn a gown and gloves, and sometimes a mask. She was required to wear a gown when she emptied urine from a urinary drainage bag. Only gloves were required to be worn when providing incontinence and catheter care. A resident on EBP should have had a cart with gowns and isolation supplies available. During an interview on 2/14/25 02:25 p.m., RN 4 indicated that a urinary catheter drainage bag required a dignity cover. When a urinary collection bag touched the floor, the bag was considered contaminated and a new bag applied. B3. During an observation on 2/12/25 at 10:10 a.m., Resident 9 had an EBP sign hung on the wall beside her bed. A personal protective equipment (PPE) cart and trash can was located inside the resident's room by the door. During a medication administration observation on 2/13/25 at 1:12 p.m., RN 5 wore gloves when he administered a feeding tube medication to the resident. The RN did not don a gown. Resident 5's clinical record was reviewed on 2/13/25 at 1:57 p.m. Diagnoses included congenital cerebral cysts-schizencephaly, gastrostomy status, and epilepsy. A current care plan, dated 4/11/24, indicated that the resident was at risk of transferring or becoming colonized with an MDRO and required enhanced barrier precautions. Interventions included enhanced barrier precautions and wear gown and gloves prior to high contact resident care activities. During an interview on 2/13/25 at 2:29 p.m., RN 5 indicated that EBP would be used for residents who had wounds, an ostomy, feeding tube, or tracheostomy. EBP procedures were new for the company. EBP included a gown, gloves, and hand hygiene before and after giving specific care. He should have gowned up when he gave a feeding tube medication. A current facility policy, last revised 12/2021, titled Laundry/Linen, provided by the DON on 2/14/25 at 1:18 p.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 A skills competency document, last reviewed 2/2023, titled Emptying Urinary Drainage Bag, provided by the DON on 2/14/25 at 1:18 p.m., indicated the following: Procedure Steps: .2. Perform hand hygiene. 3. [NAME] gloves. 4. Unhook the emptying spout from its holder on the urinary drainage bag. 5. Position the graduated container underneath the emptying spout. 6. Unclamp the emptying spout and allow all the urine to drain into the graduated container, being sure to avoid touching the tip of the spout with hands, side of the container, or the floor. Note: If the spout touches container immediately cleanse with alcohol pads. Cleanse in a circular motion from approximately 1/4 inch from spout end downward. Do not repeat motion, unless using a new alcohol pad. 7. Re-clamp the empty spout after all urine had drained. 8. Wipe the emptying spout with an alcohol wipe and return to its holder. 9. Measure and record amount of urine. 10. Dispose of urine, clean and return graduated container to plastic bag in bathroom or designated area if semi-private room. 11. Remove gloves. 12. Perform hand hygiene. 13. Document pertinent information A current facility document, undated, titled Enhanced Barrier Precautions (EBP) Education, provided by the DON on 2/14/25 at 1:18 p.m., indicated the following: How will I identify someone in Enhanced Barrier Precautions (EBP): 1. They will have a sign posted in their room, on their side of the room in which they reside . What are the high contact activities that require the use of a gown and gloves by all residents in Enhanced Barrier Precautions: 1. Dressing 2. Bathing/showering 3. Transferring . 6. Changing briefs or assisting with toileting 7. Device care or use . Before providing care to a resident with Enhanced Barrier Precautions (EBP): 1. Perform hand hygiene. 2. Correctly put on gown and gloves. Gown before gloves. 3. After care, throw away gown and gloves. Remove gloves first. Roll gown away from you. 4. Perform hand hygiene. 5. Finish all steps before moving on to another resident A current facility policy, last revised on 5/2023, titled Infection Prevention and Control Program Policy, provided by the DON on 2/14/25 at 1:18 p.m., indicated the following: POLICY: The facility shall . 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 . GOALS: The goals of the infection prevention and control program are to: . 5. Maintain compliance with state and federal regulations relate to infection prevention and control 3.1-18(l) 3.1-18(b)(2)

Based on observation, interview, and record review, the facility failed to ensure urinary output was monitored as ordered and abnormalities reported to the provider for 1 of 2 residents reviewed for urinary catheters. (Resident 8) Finding includes: On 2/10/25 at 11:35 a.m., Resident 8 was asleep in her bed with her catheter hung on the left side of her bed. Urine in the catheter drainage tube was observed to be milky-white. During an interview on 2/11/25 at 11:22 a.m., Resident 8 indicated she was unaware of any current treatment for infections. The urine in the urinary catheter tubing was cloudy and yellow. Resident 8's clinical record was reviewed on 2/11/25 at 2:40 p.m. Diagnoses included dementia of unspecified severity, neuromuscular dysfunction of the bladder, pyuria, stage 4 chronic kidney disease, and moderate protein-calorie malnutrition. A quarterly Minimum Data Set (MDS) assessment, dated 1/9/25, indicated the resident had moderate cognitive impairment. She was dependent on staff assistance for toileting, bathing, dressing, personal hygiene, turning and transfers. The resident had an indwelling urinary catheter and was always incontinent of bowel. She had been on an antibiotic during the assessment period. A current care plan, dated 6/6/18, indicated the resident was at risk for potential infection related to a supra-pubic urinary catheter due to neurogenic bladder and urinary retention. Interventions included, provide assistance for catheter care (6/6/18) and report signs of a urinary tract infection which included concentrated urine (6/6/18). A current care plan, dated 6/5/18, indicated the resident was at risk for unintentional weight loss related to dementia and frequent urinary tract infections. Interventions included a nutritional shake at lunch (2/7/25). A current physician order, dated 4/7/24, indicated the resident had a supra-pubic catheter. A current physician order, dated 4/7/24, indicated nursing was required to document the catheter output every shift. Review of the resident catheter urine outputs for January 2025 and February 2025 indicated urinary output was not recorded on day shift for 1/12/25, 1/26/25, and 2/9/25. Urinary output was not documented on night shift on 1/15/25, 1/20/25, 1/29/25, and 2/3/25. During an observation on 2/12/25 at 10:43 a.m., the resident was in bed. The urinary catheter drainage tubing contained cloudy yellow urine with a moderate amount of sediment. During an observation on 2/14/25 at 9:23 a.m., the resident was in bed. The urinary catheter tubing contained cloudy yellow urine with a small amount of sediment. During a catheter care observation on 2/14/25 at 9:33 a.m., CNA 7 entered Resident 8's room and washed her hands. Gloves were donned and the undated urinal was picked up from the back of the toilet in the resident's restroom with her left hand. A towel was placed on the floor underneath the urinary drainage bag, with her right hand, to serve as a barrier. The spigot of the urinary catheter drainage bag was removed from the holder using her right gloved hand. While she pressed the button and drained the urine from the bag, the spigot tip of the catheter touched the walls of the urinal three different times. Once emptied, she used her right hand to place the spigot back into the holder on the outside of the urinary catheter bag. The spigot was not cleansed at any time during the observation. The urinal contained 100 milliliters of concentrated cloudy yellow urine. A gown was not worn at any time during the catheter care observation. During an interview at the time of observation, CNA 7 indicated the urine she emptied from the resident's catheter was cloudy, thick, and yellow. She was required to report the thick cloudy urine to the nurse. During an interview on 2/14/25 at 9:42 a.m., CNA 7 indicated it was the CNAs' duty to empty the residents' urinary catheters. They were required to report the urine amount, color and clarity to the nurse. The nurse charted the outputs in the residents' clinical records. The CNAs had a place in the electronic clinical record in which they could chart a description of the urine. She had worked on 2/12/25. She emptied the resident's catheter that day and she had not noticed the resident's urine to be cloudy and thick when she worked earlier in the week prior to 2/14/24. She had not reported any concerns with the description of the resident urine on 2/12/25. CNAs were required to report a description of any urine abnormalities to the nurse. Urine abnormalities included cloudiness, mucous, foul odors, or blood. Abnormal findings were required to be reported to the nurse immediately. The facility required the staff to also document the exact amount of urine output. They would not have a way to determine if the resident had adequate urine output without the documentation of the exact output. During an interview on 2/14/25 at 12:07 a.m., LPN 10 indicated urinary catheter outputs should have been obtained every shift as ordered and documented in the Treatment Administration Record (TAR). If a resident did not have any urinary output on a shift, it should have been documented in the nurses notes. She had provided care for the resident on 2/12/25 and no one had reported any abnormalities to the resident's urine. She indicated the resident was known for frequent urinary tract infections. Typically, the resident only wanted to drink coffee. The resident's urine was typically a thicker consistency and frequently cloudy with sediment. The CNAs were required to report any urine abnormalities to the nurse, which would be documented in the nurses notes. When the urine description was not documented, one did not have a way to identify when the urine had changed. During an interview on 2/14/25 at 1:05 p.m., the DON indicated urinary catheter outputs should have been completed as ordered every shift. She was unable to provide documentation of the resident's urine output on all the above mentioned dates in January and February 2025. She was unable to provide a policy regarding urinary catheter maintenance or urinary outputs. During an interview on 2/14/25 at 2:03 p.m., the DON indicated she was unable to find anything in the resident clinical record regarding the resident's typical urine description. The resident had not received any diagnostic urine testing from 2/10/25 to 2/14/25 related to abnormal urinary signs or symptoms. When a resident had a urinary change, it should have been charted in the resident's nurse's notes. A skills competency document, last reviewed 2/2023, titled Emptying Urinary Drainage Bag, provided by the DON on 2/14/25 at 1:18 p.m., indicated the following: Procedure Steps: .2. Perform hand hygiene. 3. [NAME] gloves. 4. Unhook the emptying spout from its holder on the urinary drainage bag. 5. Position the graduated container underneath the emptying spout. 6. Unclamp the emptying spout and allow all the urine to drain into the graduated container, being sure to avoid touching the tip of the spout with hands, side of the container, or the floor. Note: If the spout touches container immediately cleanse with alcohol pads. Cleanse in a circular motion from approximately 1/4 inch from spout end downward. Do not repeat motion, unless using a new alcohol pad. 7. Re-clamp the empty spout after all urine had drained. 8. Wipe the emptying spout with an alcohol wipe and return to its holder. 9. Measure and record amount of urine. 10. Dispose of urine, clean and return graduated container to plastic bag in bathroom or designated area if semi-private room. 11. Remove gloves. 12. Perform hand hygiene. 13. Document pertinent information 3.1- 41(a)(2)

Based on observation, interview, and record review, the facility failed to assure staff handled medications in a sanitary manner and performed hand hygiene during a medication administration observation on the [NAME] Lane Unit. Findings include: During a medication administration observation on the [NAME] Lane unit, on 3/21/24 at 8:48 a.m., RN 2 was preparing medications for a resident. She punched six capsules from the medication card into her bare hand. She opened each capsule with bare hands and emptied the contents into a medication cup. She proceeded to administer the medication to the resident with other crushed medications. RN 2 did not sanitize her hands following administration. At 8:59 a.m., RN 2 prepared an as needed pain pill for a resident and administered the medication. She failed to sanitize her hands. At 9:01 a.m., RN 2 prepared medications for a resident and administered the medications. Upon returning to the medication cart, LPN 3 spoke with RN 2 regarding sanitizing her hands. RN 2 performed hand hygiene using an alcohol based hand rub. During the observation, RN 2 indicated she should have been sanitizing her hands between preparing medications for residents. She indicated gloves should have been worn when opening capsules to administer medications ordered to be crushed. A current facility policy, revised 7/2023, titled, Medication Administration, provided by the DON on 3/22/24 at 3:15 p.m., indicated .Procedure Steps: .5. Medications are opened without contaminating A current facility policy, revised 5/2023, titled, Infection Prevention and Control Program Policy, provided by the Administrator following entrance conference on 3/22/24, 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 Goals: .5. Maintain compliance with state and federal regulations related to infection prevention and control 3.1-18(l)

Based on observation, interview, and record review, the facility failed to provide dressing assistance to physically dependent residents with developmental disabilities, to protect each resident's dignity while sleeping, for 4 of 4 residents reviewed for dignity (Residents 5, 6, 9 and 43). Findings include: 1. During observations on the following dates and times, Resident 5 was in bed without any clothing (such as a shirt, t-shirt, pajama top or hospital gown), exposing his chest and torso, as follows: 3/31/23 at 10:15 a.m., 3/31/23 at 1:16 p.m., 4/3/23 at 9:33 a.m., 4/0/23 at 10:07 a.m., 4/3/23 at 11:23 a.m., 4/3/23 at 1:01 p.m., 4/3/23 at 1:48 p.m., 4/3/23 at 2:51 p.m., 4/4/23 at 9:10 a.m., 4/4/23 at 9:58 a.m., 4/4/23 at 10:44 a.m., 4/4/23 at 11:39 a.m., 4/4/23 at 2:39 p.m., and 4/5/23 at 8:45 a.m. No clothing was observed as removed and in the resident's bed or in the surrounding area, during any of the above observations. Resident 5's clinical record was reviewed 4/05/23 at 10:28 a.m. Current diagnoses included legally blind, intellectual disabilities, epilepsy, deaf-nonspeaking, depression, and cerebral palsy. The resident had a current, 7/29/22, physician's order for a continuous feeding by g-tube. The resident had a current, 3/30/23, physician's order to receive no food orally. The resident had a current, 11/22/2010, care plan/problem/need regarding the resident's inability to complete ADLs due to intellectual disabilities. Approaches to this problem included anticipate wants and needs. The resident had a current, 11/22/2010, care plan/problem/need regarding being mute and unable to communicate wants and needs. Approaches to this problem included staff to anticipate needs. A current, 3/20/23, annual, Minimum Date Set (MDS) indicated the resident was severely cognitively impaired, was non-speaking, required staff assistance for all activities of daily living including dressing, displayed no maladaptive behaviors during the assessment period, and was rarely or never understood. The clinical record lacked a plan of care or documentation regarding the resident desiring/needing to sleep without clothing to the upper body. 2. During observations on the following dates and times, Resident 6 was in bed without any clothing (such as a shirt, t-shirt, pajama top or hospital gown), exposing his chest and torso, as follows: 3/30/23 at 11:17 a.m., 3/31/23 at 10:10 a.m., 3/31/23 at 1:15 p.m., 4/3/23 at 9:32 a.m., 4/3/23 at 10:06 a.m., 4/3/23 at 11:22 a.m., 4/3/23 at 12:58 p.m., 4/3/23 at 1:47 p.m., 4/3/23 at 2:50 p.m., 4/4/23 at 9:08 a.m., 4/4/23 at 10:00 a.m., 4/4/23 at 10:43 a.m., 4/4/23 at 11:38 a.m., 4/4/23 at 2:35 p.m., 4/4/23 at 2:38 p.m., and 4/5/23 at 8:44 a.m. No clothing was observed as removed and in the resident's bed or in the surrounding area, during any of the above observations. Resident 6's clinical record was reviewed 3/31/23 at 1:33 p.m. Current diagnoses included spastic quadriplegic cerebral palsy, depression, and anxiety. The resident had a current, 7/21/22, physician's order for feeding by g-tube two times per day. The resident had a current, 7/1/19, physician's order for no food orally. The resident had a current, 6/29/29, care plan/problem/need regarding requiring assistance with all activities of daily living. Approaches to this problem included Assist with dressing/grooming/hygiene as needed . A 2/15/23, quarterly, MDS assessment indicated the resident was severely cognitively impaired, did not speak, displayed no maladaptive behaviors during the survey process, was dependent on staff for all activities of daily living including dressing and was rarely or never understood. The clinical record lacked a plan of care or documentation regarding the resident desiring/needing to sleep without clothing to the upper body. 3. During observations on the following dates and times, Resident 9 was in bed without any clothing (such as a shirt, t-shirt, pajama top or hospital gown), exposing his chest and torso, as follows: 3/31/23 at 1:16 p.m., 4/3/23 at 9:33 a.m., 4/3/23 at 10:07 a.m., 4/3/23 at 11: 30 a.m., 4/3/23 at 1:00 p.m., 4/3/23 at 2:51 p.m., 4/4/23 at 9:10 a.m., and 4/4/23 at 9:58 a.m. No clothing was observed as removed and in the resident's bed or in the surrounding area during any of the above observations. Resident 9's clinical record was reviewed 3/31/23 at 1:41 p.m. Current diagnoses included dementia, Down syndrome, anorexia, epilepsy, and dysphasia. The resident had a current, 1/22/21, care plan/problem/need regarding requiring assistance with activities of daily living. A 2/19/23, significant change, Minimum Date Set (MDS) assessment indicated the resident was severely cognitively impaired and required staff assistance with all activities of daily living including dressing. The clinical record lacked any documentation of the resident refusing clothing, did not desire clothing in bed, or removing clothing. 4. During observations on the following dates and times, Resident 43 was in bed without any clothing (such as a shirt, t-shirt, pajama top or hospital gown), exposing his chest and torso, as follows: at 11:17 a.m., 3/31/23 at 10:10 a.m., 3/31/23 at 1:14 p.m., 4/3/23 at 9:32 a.m., 4/3/23 at 10:06 a.m., 4/3/23 at 11:21 a.m., 4/3/23 at 12:58 p.m., 4/3/23 at 1:47 p.m., 4/3/23 at 2:50 p.m., 4/4/23 at 9:08 a.m., 4/4/23 at 9:59 a.m., 4/4/23 at 10:42 a.m., 4/4/23 at 11:37 a.m., 4/4/23 at 2:37 p.m., and 4/5/23 at 8:43 a.m. No clothing was observed removed and in the residents bed or in the surrounding area during any of the above observations. Resident 43's clinical record was reviewed 3/31/23 at 1:28 p.m. Current diagnoses included dementia, Down syndrome, anxiety and epilepsy. The resident had a current, 6/14/18, care plan/problem/need requiring assistance with activities of daily living. Approaches to this problem included, Assist with dressing/grooming/hygiene as needed . A current, 3/21/23, quarterly, MDS assessment indicated the resident was severely cognitively impaired, had unclear speech, had no maladaptive behaviors during the assessment period, and required assistance of staff for all activities of daily living including dressing. The clinical record lacked any documentation of the resident refusing clothing, did not desire clothing in bed, or removing clothing. During an interview on 4/05/23 at 8:49 a.m., LPN 5 indicated there were no residents on the unit who had a bed rest order or any medical reason to not be out of bed. During an interview on 4/5/23 at 8:53 a.m., the Life Path Unit Manager ( the unit for residents which provides services for residents with development/intellectual disabilities) indicated there were no residents on the unit with bed rest orders or who could not get out of bed. The staff may not get residents out of bed or dressed because they felt overwhelmed and unable to get everything done. The Administrator had been aware that dependent residents were frequently not out of bed. However, the problem had not yet been corrected. No residents on the unit had orders or care plans to only wear briefs when in bed. During an interview on 4/05/23 at 9:00 a.m., CNA 6 indicated most of the CNAs had a habit of not putting clothes on Resident's 5, 6,9, and 43 when in bed. She had been told these four residents did not like clothing. However, there was no guidance on the CNA assignment sheet to say not to put sleeping clothes on them. Residents 5, 6, 9, and 43 all appeared to need more things to do, like activities, when they were out of bed, in order to stay up and happy. During a confidential interview, a staff member indicated heavy - care residents might not be assisted to get out of bed when there was a call in and staffing was tight. A current, 2/2010, facility policy, titled, AM [morning care] which was provided by the DON on 4/5/23 at 9:53 a.m., indicated: .Assist resident with dressing, including applying make-up and/or jewelry as requested 3.1-3(a)

Based on observation, interview, and record review, the facility failed to manage resident funds using acceptable accounting principals (Residents 6 and 27). This deficient practice had the potential to impact 16 of 16 residents with diagnoses of intellectual/developmental disabilities, for whom the facility managed funds. Findings include: A current, 4/3/23, facility document titled, Trial Balance, provided by the Business Office manager on 4/3/23 at 2:50 p.m., indicated the facility managed resident funds for 54 of the facility's residents. Sixteen of the 54 residents for whom the facility managed funds resided on the unit designated to address the needs of individuals with development and/or intellectual disabilities. A review of four individual resident funds were reviewed with the Business Office Manager on 4/4/23 at 10:10 a.m. The last two quarterly statements (7/1/22 to 9/30/22 and 10/1/22 to 12/30/22) and March 20 2023 were reviewed for individual withdrawals for Social Events. The Social Events charges billed were reviewed and lacked corresponding receipts and reconciliation as follows: 1. Resident 6: 7/6/22- Social Event-$25.00 8/3/22-Social Events- $10.00 10/5/22-Social Events--$10.00 10/25/22-Social Events-$20.00 11/15/22-Social Events-$50.00 12/21/22-Social Events-$10.00 3/9/23-Social Event -$4.00 3/17/23-Social Events-$10.00 2. Resident 27: 9/2/22-Social Events-$25.00 9/14/22-Social Events-$50.00 11/10/22-Social Events-$30.00 During an interview on 4/4/23 at 10:15 a.m., the Business Office Manager indicated she did not believe she had a receipt for each Social Event withdrawal to each resident account. Residents would go on outings with their OBRA (socialization and mental stimulation services offered for residents with intellectual/developmental disabilities) services provider. The facility would have the OBRA service provider sign for the money. The facility did not have the OBRA provider provide a receipt, observe any items purchased, or have the change from the outing returned to the resident account for each outing. The OBRA provider would sometimes keep receipts and change for a month. The facility did not reconcile the receipts with the money taken to ensure all resident funds were recorded and accurately accounted. She did received various receipts from the OBRA provider throughout the month. During the interview, the Business Office Manager provided various receipts for the time periods above, but she could not reconcile the receipts to the dates of withdrawal and the amount taken. The facility did not have any system to ensure each withdrawal was balanced out to provided accountability for each dollar withdrawn by an outside service provider. Residents 6 and 27 had special needs/developmental disabilities and did not make decisions for themselves. Other residents received OBRA services for their developmental disability and the same system was used for them. She had been handling resident funds for two years and this was the method she was taught when she began managing the funds. Her consultant had identified a problem with OBRA services withdrawals on 3/7/23 and indicated changes should be made moving forward. She had made changes after 3/7/23 but her changes were not to develop a system to ensure reconciliation of every Social Event OBRA withdrawal with a corresponding receipt, visual proof of items purchased, and/or the receipt of returned funds to ensure accountability for all money received. During an interview on 4/4/23 at 11:27 a.m., the Business Office Manager indicated after review all receipts for the above Social Events for Residents 6 and 27, she was still unable to reconcile the total accountability for all funds received. A current, 2/2019, facility policy titled Resident Trust Funds Policy, provided by the Business Office Manager on 4/4/23 at 4:00 p.m., indicated the following: .6. The Business Office Manager during the next business day will reconcile each resident's account based on the withdrawals A Resident Census and Conditions of Residents (CMS -672 form), completed by the facility on 3/30/23, indicated 16 of the facility's 70 residents had intellectual and/or developmental disabilities. 3.1-3(v)(1)

Based on record review and interview the facility failed to prevent the development and worsening of pressure ulcers for 1 of 5 resident observed for wounds. (Resident 47) This deficient practice resulted in unstageable pressure ulcers developing and worsening. Findings include: Resident 47's clinical record was reviewed on 2/25/22 at 2:52 p.m diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 47 had a quarterly Minimum Data Set assessment (MDS) on 1/24/22 which indicated the resident had severe cognitive impairment, required extensive assistance of two staff for bed mobility, was always incontinent of bowel and bladder and had a stage IV pressure ulcer. A care plan, dated 4/22/21, indicated the resident was at risk for skin breakdown related to incontinence of bowel and bladder, decreased mobility, impaired cognition, [CONDITION(S)], peripheral vascular disease and history of fracture. A New Skin Event note, dated 9/28/21 at 9:42 a.m., indicated the resident had a scabbed abrasion to her right hip, measuring 2.3 cm (centimeters) by 1.7 cm. An IDT (interdisciplinary team) note, dated 9/28/21 at 9:31 a.m., indicated the abrasion originated from transfer to a wheelchair. A Wound Management note, dated 9/28/21, indicated the resident had an abrasion to her right hip measuring 2.3 cm x 1.7 cm. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Weekly Skin and Vital Sign Assessment, dated 10/4/21, indicated the resident had an alteration of skin integrity described as a scabbed abrasion to her right hip. The assessment lacked indication of measurements or assessment details of the area. A Weekly Skin and Vital Sign Assessment, dated 10/18/21, indicated the resident had an alteration of skin integrity described as a skin tear to her right hip. The assessment lacked indication of measurements or assessment details of the area. A review of the resident's progress notes from 9/28/21 through 10/21/21 regarding the resident's right hip, indicated no signs or symptoms of infection and that treatment continues as ordered. The record lacked any measurements or assessments details of the area. A healed/discontinued information entry was made on 10/22/21, indicating the area worsened and presented with pressure related alterations. No further documentation was present in the Wound Management record for the abrasion to her right hip. A New Skin Event note, dated 10/21/21 at 1:33 a.m., indicated the resident had an open area to her right hip measuring 5 cm x 3 cm. A nursing progress note, dated 10/21/21 at 3:54 p.m., indicated the resident's wound to her right hip was assessed. The area measured 3.7 cm x 5.7 cm x 1.2 cm with undermining at 3 o'clock of 2 cm. The area was covered with slough (moist dead tissue). The resident preferred to lie on her right side when in bed and had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The family had declined a referral to the wound center. A Wound Management note, dated 10/22/21, indicated the resident had an unstageable wound on her right hip measuring 3.7 cm in length by 5.5 cm in width, and 0.6 cm in depth. An IDT note, dated 10/22/21, indicated the unstageable ulcer to right hip root-cause determination was recent traumatic wound to site, end stage dementia, low body weight, protein-calorie malnutrition, resident preference to remain on right side, [CONDITION(S)], artificial joint to right hip, history of blood clot, and a recent onset of loose stools. During an interview on 2/28/22 at 11:23 a.m., the Director of Nursing (DON) indicated there was no documentation regarding the incident involving the transfer to wheelchair resulting in the abrasion to the resident's right hip. The documentation in the IDT note was the only clinical documentation of the event resulting in the abrasion to the resident's right hip. The DON indicated there was no further documentation regarding the abrasion to the resident's right hip after discover on 9/28/21 through 10/21/21 when the unstageable pressure wound was observed. A current facility policy, revised 7/2021, titled, Skin Management Program, provided by the DON on 2/28/22 at 10:45 a.m. included, but was not limited to, the following: Purpose: To promote the prevention of pressure ulcer /injury development . PROCEDURE FOR ALTERATIONS IN SKIN INTEGRITY - PRESSURE AND NON-PRESSURE . 5. The wound nurse/designee will be notified of alterations in skin integrity. a. The wound nurse/designee is responsible for communicating to IDT on a weekly basis for pressure and non-pressure wounds. b ii) Wound management entries will be completed for non-ulcers (bruises, skin tear, abrasion, rashes). If no signs of complications or worsening in condition of skin alteration and doesn't meet the guideline for IDT Weekly Wound Review the wound management entry can be closed after 72 hours. 3.1-40(a)(2)

Based on interview and record review the facility failed to provide supervision for cognitively impaired residents on an unlocked memory care unit resulting in an sexual behaviors between two residents (Resident A and Resident B). This deficient practice had the potential to effect 1 of 17 male residents currently on the unlocked memory care unit. This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on 3/2/16 and began on 2/28/16. The Executive Director and the Director of Nursing were notified of the Immediate Jeopardy on 3/2/16. The Immediate Jeopardy was removed on 3/3/16 as confirmed by the placement of a mirror in the hallway near the television room; the closing of the television room bathroom; the locking of and limited access to the program room bathroom; the placement of an audio motion sensor in the television room; the placement of a video monitor in the television room and staff inservices on the changes for resident security Findings include: 1. The clinical record for Resident A was reviewed on 3/1/16 at 3:29 p.m. [DIAGNOSES REDACTED]. The most recent annual Minimum Data Set (MDS) assessment, dated 1/17/16, was reviewed on 3/1/16 at 3:29 p.m. The MDS indicated Resident A was severely cognitively impaired with a BIMS (Brief Interview for Mental Status Score) of 5. Resident A received the following Activities of Daily Living (ADL) assistance; transfer-extensive assist with 2 person physical assist, toilet use- extensive assist with 2 person physical assist. Resident A had no impairments to range of motion in all extremities. Resident A's height was documented as 60 inches and a weight of 152 pounds. Review of a nursing note, dated 2/28/16 at 4:00 p.m., indicated Resident A was observed by CNA #1 sitting on a sofa in the television room while Resident B was sitting on a sofa opposite Resident A. The note indicated, within a few minutes, CNA #1 noticed both Resident A and Resident B were no longer on the sofas and the television room bathroom door was closed. CNA #1 knocked on the door and received no answer. CNA #1 opened the door and observed the residents engaged in oral sexual behavior. Review of CNA #1's written statement indicated the following: I was walking past the TV room and I didn't see (Resident A's name) or (Resident B's name), but noticed the bathroom door was closed. I knocked on the door no one said anything. I went in and (Resident B's name) was pushing his penis in (Resident A's name) mouth. (Resident A's name) was trying to push away. I called (Resident B's name) he jumped and pulled his pants up. I sent (Resident B's name) to his (sic) and (Resident A's name) to the program room and told the nurse. During an interview on 3/2/16 at 3:37 p.m., CNA #1 indicated both residents were sitting in the television room on separate couches. I walked past and they were gone and the bathroom door was closed. CNA #1 indicated when the bathroom door was opened I saw (Resident B's name) holding (Resident A's name) head down and putting his penis in (Resident A's name) mouth. (Resident A's name) was pushing (Resident B's name) away. (Resident B's name) did not react until I called his name. I think (Resident B's name) was forcing it on (Resident A's name). After that (Resident B's name) went to his room and took a nap. I reported it to (RN #2's name) and she assessed both residents. CNA #1 indicated Resident A appeared to be upset at that time. During an interview on 3/3/16 at 1:36 p.m., RN #2 indicated Resident B walked past the nursing station going to his room and shortly after she was informed by CNA #1 of the incident observed in the bathroom. I assessed (Resident A's name) in the bathroom. Resident A went to the program room. RN #2 indicated the program room was supervised by staff. The program room has someone in there to watch the residents. Some of our residents require close supervision. (Resident B's name) wanted to go to the television room not the program room. RN #1 indicated the television room was not supervised unless both male and female residents were present. In the TV room if there is mixed company there is usually a staff member present. RN #2 indicated if the television room were occupied by all males or all females, no staff member would be present. During an observation on 3/1/16 at 4:00 p.m., Resident A was observed in the television room with several other residents present. A staff member was also present. Resident A was sitting on a sofa with a coloring book. Resident A was unable to answer screening questions but wanted to talk about his coloring book. Resident A indicated he did not remember the incident. I don't remember anything bad. Resident A was pleasant and smiled and waved to others during the observation. 2. The clinical record for Resident B was reviewed on 3/1/16 at 2:36 p.m. [DIAGNOSES REDACTED]. The most recent annual Minimum Data Set (MDS) assessment, dated 12/23/15, was reviewed on 3/1/16 at 2:36 p.m. The MDS indicated Resident B was moderately cognitively impaired with a BIMS (Brief Interview for Mental Status Score) of 8. Resident B received the following Activities of Daily Living (ADL) assistance; transfer-extensive assist with 1 person physical assist, toilet use- extensive assist with 2 person physical assist. Resident B had no impairments to range of motion in all extremities. Resident B's height was documented as 68 inches and a weight of 141 pounds. Review of a Behavioral Medicine progress note, dated 1/15/16, indicated the following: .Inappropriate behaviors of masturbation in common areas. Re directs easily. Staff transports to bathroom for privacy. Behavior has been occurring x several weeks approx 1-2 x/wk. No hx (history) psych meds. No current psych meds .Clinical Status and Impressions: Mental Retardation challenges POC (point of care). Inappropriate masturbation in common areas x several weeks ago with occurrence rate 1-2 x/week. Will start SSRI (an antidepressant) to attempt to control behavior such that he refrains until he is in private area eg (sic) bathroom to maintain personal integrity Resident B was started on Lexapro 5 mg daily for 7 days on 1/16/16 through 1/23/16. Lexapro 10 mg daily was started on 1/24/16. Review of a current behavior care plan, dated 3/13/15, indicated Resident B initiated physical contact with female residents when in close proximity. Interventions included, but were not limited to, staff to encourage resident to sit in program room after meals and offering resident to watch television in his room. Review of a current behavior care plan, dated 7/18/14, indicated Resident B exhibited socially inappropriate behavior as evidenced by masturbating in common areas. Interventions included, but were not limited to, staff to assist resident to his room if observe me masturbating in public areas and assist to his room in the afternoon for quiet time. An Immediate Jeopardy was identified on 3/2/16 at 3:22 p.m. The IJ began on 2/28/16 when the facility failed to provide supervision for cognitively impaired residents on an unlocked memory care unit resulting in an oral sexual behavior between two male residents. The Immediate Jeopardy was removed on 3/3/16, when the surveyor confirmed the facility had implemented the plan of action submitted and approved to abate the Immediate Jeopardy. During an interview on 3/3/16 at 12:05 p.m., CNA #7 indicated an inservice on the changes in security was provided today. Changes included: 1. A mirror in the hallway near the television room was placed to make supervision from the hallway possible. 2. A video monitor was placed in the television room. The nurse carried the monitor for visual access, 3. A motion sensor monitor to detect entry and exit into and out of the television room had been placed. 4. The bathroom located in the television room was now closed and was not to be used. The door is locked and maintenance had the only key. 5. The bathroom located in the program room was locked and the nurse carried the key. During an interview on 3/3/16 at 12:10 p.m., RN #11 indicated the same inservice education and interventions for resident security on the Life Path unit. In addition, CNA #14, LPN #8,and CNA #15 indicated the same inservice education and interventions for resident security on the Life Path unit. During a tour of the Life Path unit on 3/3/16 at 11:45 p.m., the following was observed: 1. Half circle mirror in the hallway near the television room, allowing visual supervision of the television room from anywhere in the hallway. 2. Video monitor in the television room that the nurse carried for visual access. The monitor was portable. 3. Motion sensor monitor with audio alert to detect entry and exit to and from the television room had been placed to alert staff of activity in the television room. 4. The bathroom located in the television room was now locked and was not to be used. The door was locked and maintenance had the only key. 5. The bathroom located in the program room was locked and the nurse carried the key. During a tour of the Life Path unit on 3/3/16 at 1:40 p.m., 13 residents were observed in the television room with 3 staff members present. The Unit Director was present and indicated she was providing the supervision at that time. This Federal tag relates to Complaint IN 521. 3.1-45(a)(2)

Based on record review and interview, the facility failed to assure supervision for 1 (Resident A) of 3 residents reviewed for choking risk, among the sample of 5. This deficient practice resulted in death by asphyxiation for Resident (A). This deficient practice resulted in an immediate jeopardy. The immediate jeopardy was identified on [DATE] at 2:16 P.M. and began on [DATE]. The Administrator and the Director of Nursing were notified of the immediate jeopardy at 2:16 P.M. on [DATE]. The immediate jeopardy was removed on [DATE], but the facility remained out of compliance at the level of isolated, with no actual harm but potential for more than minimal harm that is not immediate jeopardy, because ongoing monitoring of the dining room and residents at risk for choking needs to be done, and chart audits need to be completed. Findings include: Family member #1 of Resident (A) was interviewed by telephone at 1:40 P.M., on [DATE]. Family member #1 indicated she had entrusted Resident (A) to the facility for care which had resulted in "a wrongful death." Family member #1 indicated both the Director of Nursing (DoN) and Licensed Practical Nurse (LPN) #1 had told her Resident (A) was not supervised at the time he had choked on food. The record of Resident (A) was reviewed at 11:50 A.M., [DATE], and indicated a [DATE] admission. [DIAGNOSES REDACTED]. A [DATE], care plan indicated a concern of a choking risk and aspiration related to over stuffing the mouth and consuming foods too fast with a recent episode of choking. The goal was no episodes of choking or aspiration. Interventions included serving the diet as ordered, and placing the food in bowls and the fluids in sippy cups. Updated interventions on [DATE], were to cut the food into small bites and provide full supervision with meals. A [DATE], care plan concern indicated episodes of placing inappropriate materials in the oral cavity. The goal was no self harm by putting items in the mouth. Interventions included observing Resident (A) when in the program room, continually encouraging him not to put things in the mouth that do not belong, placing a lock at the top of the bathroom door, placing trash covers on the medication carts, and securing the refrigerator in the activity room. A [DATE], 5:15 P.M., nursing note indicated Resident (A) was given a meal tray by the psychiatrist. The meat had been cut up in pieces. Documentation indicated staff saw the resident shovel hand fulls of food into the mouth. Resident (A) choked and turned blue in the face. Staff placed Resident (A) on the floor. The Heimlich maneuver was performed with success. Documentation indicated lodged food was expelled and the resident returned to his natural color. The physician, family, and DoN were notified of the incident. A [DATE], 9:00 A.M., nursing note indicated the interdisciplinary team met to discuss the [DATE], choking episode which required the Heimlich maneuver. Recommendations were for small portions of food at one time and a speech therapy consult. A [DATE], nursing note, interdisciplinary meeting, indicated Resident (A) had been grabbing items from the nursing station, the medication carts, and the refrigerator in the Life Path unit dining room. The intervention was to place covers on the trash containers on the medication carts. A [DATE], 1:00 P.M., nursing note indicated the interdisciplinary team met to discuss the compulsive behavior displayed by Resident (A) of putting items in the mouth. No changes were recommended. An undated 12:50 P.M., nursing note (documented above a note dated [DATE]) indicated a certified nursing assistant (CNA) had summoned the nurse because Resident (A) was choking. Documentation indicated Resident (A) was looking forward with the mouth open. The face was red. When asked if he was all right, Resident (A) replied, no. Documentation indicated the resident was not breathing. Documentation indicated the Heimlich maneuver was performed until the resident became unconscious. Resident (A) was lowered to the floor and the Heimlich continued until the food was dislodged. Documentation indicated the color returned to normal and the lung sounds were diminished. Resident (A) wanted to return to eating by himself. The CNA on duty was summoned to feed the resident. The DoN and the speech therapist were notified of the incident. A [DATE], 9:10 P.M., nursing note indicated the Speech therapist had assessed Resident (A). The diet was changed to mechanical soft without bread. The food was to be cut into small bites and served in individual bowls. Resident (A) was to be supervised at meals. The physician was notified of the choking episode. A [DATE], nursing note indicated an interdisciplinary review of the [DATE], incident. Documentation indicated Resident (A) was overstuffing the mouth with food, and had poor safety awareness related to [DIAGNOSES REDACTED]. Documentation indicated Resident (A) had been administered a "quarter size sandwich (sic)" as previously directed. Documentation indicated the speech therapist had been present when the episode occurred. Documentation indicated Resident (A) compulsively stuffed the sandwich into the mouth and choked. The team indicated the Heimlich was successfully performed. Documentation indicated the plan of care was updated to include the change in diet. The nursing staff was inserviced and the CNA sheets were updated. An [DATE], nursing note indicated an interdisciplinary meeting for behavior management. Documentation indicated Resident (A) had been putting inappropriate items in the mouth at the time of admission. Documentation indicated Resident (A) was currently putting only food items in the mouth. The team indicated Resident (A) had attempted to take pudding off the medication carts. An [DATE], nursing note indicated an interdisciplinary meeting for behavior management regarding incidents on ,[DATE], and [DATE]. The team indicated on [DATE], at 4:45 P.M., Resident (A) had been in the Life Path dining room, had gotten into the refrigerator and had eaten a large cup of pudding. Resident (A) had been removed from the area. On [DATE], at 1:55 P.M., Resident (A) had been in the activity room, and had gotten into the refrigerator and had broken a glass. The new care plan intervention was to secure the activity room refrigerator. A [DATE], 11:48 A.M., nursing note, documented by Licensed practical Nurse #1, indicated notification by staff, (Resident A) was leaning over in the wheel chair. LPN #1 indicated he went to the dining room and observed Resident (A) leaning over in the wheel chair, unresponsive to verbal or physical stimuli. LPN #1 indicated he immediately checked the airway and attempted a finger sweep of the mouth. Documentation indicated zero foreign object detected. LPN #1 indicated zero radial or carotid pulse. LPN #1 indicated he verified the code status as full resuscitation. LPN #1 called the code. The [DATE], 11:53 A.M., note indicated LPN #1 assisted Resident (A) to the floor and began chest compressions. 911 was called. Documentation indicated cardio pulmonary resuscitation (CPR) was continued until the emergency medical service arrived. Certified nursing assistant (CNA #1) was interviewed at 2:15 P.M., [DATE], and indicated she had worked in activities in the Life Path unit (a special care unit with programming for residents with mental retardation and developmental disabilities) the week-end of [DATE]. CNA #1 indicated she had passed LPN #1 in the hall and he had said something about Resident (A) in the Life Path dining room. CNA #1 indicated it was close to meal time and she went to the dining room and saw Resident (A) in the wheel chair, slumped over. CNA #1 indicated the face, lips, and arms, were blue. CNA #1 indicated there were two other residents in the dining room. CNA #1 indicated CNA #2 came to the doorway and they placed Resident (A) on the floor. CNA #1 indicated two nurses from the other halls arrived and started CPR. CNA #1 indicated LPN #1 had returned with the crash cart and had called 911. CNA #1 indicated she had observed food on the floor, which appeared to be eggs, in front of the dining room refrigerator. CNA #1 indicated there had also been food about the mouth of Resident (A). CNA #1 indicated she believed the Life Path dining room door was to be kept locked at the time. LPN #1 was interviewed at 2:50 P.M., [DATE], and indicated a laundry guy had come up to him [DATE], about 11:30 A.M., and had said a resident was slumped over in the dining room. LPN #1 indicated he ran to the dining room and found Resident (A) slumped over in a high back wheel chair with the head bent almost to the knees. LPN #1 indicated he had shaken Resident (A) and had done a chest rub. LPN #1 indicated the skin was cool, the extremities were white, the face was very blue, and the lips were cyanotic. LPN #1 indicated there was no response, nor jugular or radial pulse. LPN #1 indicated he did a finger sweep of the mouth, depressed the tongue and did not see anything. LPN #1 indicated he had suctioned the resident and got nothing. LPN #1 indicated he had run to the nursing station and checked the chart for the resuscitation status which was full code. LPN #1 indicated he called the code, another nurse started compressions while he was using the ambu bag. LPN #1 indicated there was no emesis and nothing was spit up by Resident (A) during the process. LPN #1 indicated he did not know the Life Path dining room was to be kept locked. LPN #1 indicated after the [DATE], incident, there was an inservice on keeping it locked. Housekeeper #1 was interviewed by telephone at 3:10 P.M., [DATE], and indicated on [DATE], he had cleaned the dining room on Life Path, left and shut the door, cleaned 2 or 3 resident rooms, went to lunch, and when he returned the incident with Resident (A) was over. House keeper #1 indicated the Life Path dining room was to be kept locked. House keeper #1 indicated he was unsure if the lock rule was in place before or after the [DATE], incident. The DoN was interviewed at 3:35 P.M., [DATE], and indicated Resident (A) had arrested in the dining room before meal time and the cause could have been aspiration. The DoN indicated particles of food had been found about the resident during the [DATE], incident. The DoN indicated an autopsy had been performed and had listed asphyxia as the cause of death. The DoN indicated Resident (A) had been transferred to a local hospital and had expired there. The DoN indicated it was unknown where Resident (A) had obtained the food or what it was. The DoN indicated Resident (A) could have obtained the food anywhere because he self propelled about the facility and got into things continually. The DoN indicated following the [DATE] incident, the facility had put an intervention in place to assure the Life Path unit dining room was kept locked other than during meals and at clean up times. The DoN indicated there had not been a requirement the dining room was to be locked prior to the [DATE], incident with Resident (A). The DoN indicated the refrigerator in the Life Path dining room would have been secured at the time of the [DATE], incident. Laundry Assistant #1 was interviewed at 3:45 P.M., [DATE], and indicated he had gone to the Life Path dining room about 11:45 A.M., on [DATE], to take in the clothing protectors before lunch. Laundry assistant #1 indicated he saw Resident (A) slumped over in the wheel chair with no response. Laundry assistant #1 indicated he had patted Resident (A) and the skin was cool. Laundry assistant #1 indicated Resident (A) was blue. Laundry assistant #1 indicated there was food all about Resident (A), on the clothes, the table, and a lot on the floor. Laundry assistant #1 indicated he had gone to get LPN #1, returned and removed one of the two residents who were also in the dining room. Laundry assistant #1 indicated the other two residents were not eating. On [DATE], the DoN provided a copy of the [DATE], Life Path safety improvement plan, which she indicated was put in place following the [DATE], incident with Resident (A).. Interventions included programming 7 days a week, assigned persons to open the Life Path dining room during breakfast, lunch, and dinner. supervision until all residents were out of the dining room, then the door was to be locked.. Documentation indicated the interdisciplinary team discussed plans to secure the unit for specialized residents. A visit was made to the local hospital on [DATE], and the [DATE], emergency service records for Resident (A) were reviewed. The emergency response record indicated Resident (A) was found at the nursing facility lying on the floor supine, pulseless and apneic. CPR was started and an airway was placed. Oxygen was applied. The monitor showed asystole (no heart rhythm). The emergency room record indicated a 12:04 P.M., arrival, an unresponsive state with asystole, and the respirations had ceased at 12:10 P.M., [DATE]. At 12:00 P.M., [DATE], the DoN provided a copy of the [DATE], autopsy report on Resident (A). The autopsy had been requested by the county coroner. The clinical summary included a history of choking with eating precautions needed. The findings were asphyxia by choking. A large solid food particle had obstructed the larynx at the level of the epiglottis, indicating choking by complete obstruction of the airway. A foreign body ingestion of a plastic cup and paper was found in the stomach. The pathologist listed contributory factors as neuropsychiatric disorders, and possible seizure disorder. The manner of death was classified as an accident. At 1:00 P.M., [DATE], Housekeeper #2 was interviewed and indicated the door to the Life Path dining room was always to be locked other than during meal times. House keeper #2 indicated the policy had gotten real strict following the [DATE], incident. The DoN was interviewed at 1:20 P.M., [DATE], and indicated the Life Path dining room, which was currently closed for construction, had television monitors in place at the time of the [DATE], incident. The DoN indicated there had not been a scheduled monitoring system of the video at the time. An immediate jeopardy was identified on [DATE], at 2:16 P.M. This immediate jeopardy began on [DATE], when the facility failed to provide supervision in the dining room for Resident (A), who choked on food, leading to cardiac arrest and death. The administrator and the Director of Nursing were notified of the immediate jeopardy related to lack of supervision of a resident with known behaviors of placing objects/large amounts of food in mouth and at risk for choking, at 2:16 P.M. on [DATE]. The immediate jeopardy was removed on [DATE] at 4:10 p.m. when through observations, interviews and record reviews, it was determined the facility had implemented the plan of action to remove the immediate jeopardy and that the steps taken removed the immediacy of the problem. Interviews of licensed nursing staff, certified nursing assistants, and dietary and house keeping staff, representative of each shift, demonstrated knowledge of the recognition of swallowing difficulties, including silent aspiration, immediately notifying the charge nurse of a swallowing difficulty, and the system of monitoring the special care dining room, and securing it other than during clean up and/or meal times. The monitoring system including assigned persons unlocking the dining room at meal times and securing it following the meals and/or clean up, a nurse or department head remaining in the dining room at meals until each resident was removed, assuring the activity room and special care unit refrigerators were locked at all times, training staff on the Heimlich maneuver, on-going assessment of choking and/or swallowing difficulties with care planned interventions and identification of the individualized needs on the CNA assignment sheets with implementation of those interventions, weekly meal observations by the speech therapist, quarterly screening by the social services director of resident behaviors with a potential for choking hazards, and quarterly and as needed inservicing of staff with a review of the signs and symptoms of aspiration and subsequent therapy referral, was in progress. Even though the facility's corrective action removed the immediate jeopardy, the facility remained out of compliance at a reduced scope and severity level of isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy. This federal tag relates to Complaint Number IN 574. 3XXX,[DATE](a)(2)