Every finding on record at Paoli Health and Living Community

Based on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and homelike environment in 3 of 4 resident halls observed. Resident rooms contained used towels/washcloths on the floors, resident bed pans were stored uncovered in shared restrooms, resident toothbrushes were stored uncovered and unlabeled in shared restrooms, and odors were present 2 of 2 days during the survey. (100 hall, 200 hall, 300 hall, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER])Findings include:1. During a review of the facility grievance log on 1/14/26 at 11:00 A.M., a grievance was filed on 12/18/25 that dirty laundry was left in a resident's room. 2. On 1/14/26 at 11:15, Hall 300 contained a urine odor. On 1/15/26 at 2:16 P.M., Hall 300 contained a urine odor. 3. During an observation on 1/14/26 at 2:30 P.M., the shared restroom in room [ROOM NUMBER] contained two resident toothbrushes, uncovered and unlabeled. On 1/14/26 at 2:40 P.M., room [ROOM NUMBER] contained a towel on the floor near the restroom door. The shared restroom contained two toothbrushes, unlabeled and uncovered on the back of the sink, and one automatic toothbrush unlabeled and uncovered on the back of the commode. On 1/15/26 at 12:24 A.M., room [ROOM NUMBER] contained a washcloth on the floor next to the nearest bed to the door. On 1/15/26 at 12:45 A.M, room [ROOM NUMBER] contained a washcloth on the floor under the foot of the bed nearest the door. On 1/15/26 at 1:30 A.M., the shared restroom in room [ROOM NUMBER] contained a bed pan resting between a handrail and the bathroom wall, uncovered. On 1/15/26 at 10:15 A.M., room [ROOM NUMBER] contained a washcloth on the floor under the foot to bed nearest the door.On 1/15/26 at 11:30 A.M., the shared restroom in room [ROOM NUMBER] contained a bed pain resting between a handrail and the bathroom wall, uncovered. During an interview on 1/15/26 at 11:00 A.M., LPN 4 indicated resident bed pans should be covered if being stored in a shared restroom and that resident toothbrushes should be stored away and covered when in a shared restroom. During interview on 1/15/26 at 2:05 P.M., QMA 12 indicated staff should not leave linens or washcloths lying on the floor after providing care and should clean up after themselves following care. On 1/25/26 at 1:55 P.M., RN 7 supplied a facility policy titled [Company Name] Infection Control Precautions, dated 10/28/14. The policy included, Linens Handle, Transport and process used linens in a manner in which it prevents skin and mucous membrane exposure and contamination of clothing. Avoids (sic) transfer of pathogens to other patients and or the environment . Patient care equipment Handle equipment soiled with blood, body fluids, secretions and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of pathogens to other patients or the environment .This citation relates to intake 2700726. 3.1-19(f)(5)3.1-19(g)(1)

Based on observation, interview, and record review, the facility failed to ensure infection control practices were maintained during 3 of 4 observations of resident care. Staff failed to change gloves when completing a dirty task and prior to starting a clean task, failed to perform hand hygiene between glove uses, and failed to implement enhanced barrier precautions for a resident per the physician's order. (Resident C, Resident D, Resident F)Findings include:1. During an observation on 1/15/26 at 1:23 A.M., CNA 2 and CNA 4 provided incontinence care for Resident C. CNA 2 and CNA 4 removed a wet brief and provided perineal care while wearing gloves. CNA 4 then applied a new brief wearing the same gloves, then opened the top drawer of a bedside table and retrieved a tube of cream and applied the resident's peri-area. CNA 4 placed the tube back in the drawer, removed gloves, pulled new gloves from a pants pocket and put on new gloves without performing hand hygiene. CNA 2 and CNA 4 then pulled the resident up in bed and adjusted the resident's pillow before removing gloves and washing their hands.2. During an observation on 1/15/26 at 2:10 A.M., CNA 6 and CNA 4 provided incontinence care for Resident D. CNA 6 removed a soiled brief, provided peri-care, and removed a soiled draw sheet from under the resident. CNA 6 then removed gloves and donned new gloves without performing hand hygiene. CNA 6 held a clean sheet against his scrub top as he rolled the sheet and placed it under the resident. A new brief was applied, and CNA 6 and CNA 4 adjusted the resident and the resident's pillow prior to removing their gloves and performing hand hygiene.During an interview on 1/15/26 at 10:30 A.M., RN 7 indicated staff should perform hand hygiene when removing gloves when changing from a dirty to clean task. On 1/15/26 at 1:15 P.M., RN 7 provided a facility policy titled Infection Control, dated 6/6/19. The policy included, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment to help prevent and manage transmission of diseases and infections . The hand hygiene procedures to be followed by staff involved in direct contact .3. During an observation on 1/15/26 at 1:40 A.M., CNA 6 and LPN 9 assisted Resident F up from her bed to the restroom. CNA 6 and LPN 9 then assisted the resident back from the commode and back to her bed. Neither CNA 6 nor LPN 9 wore a gown or implemented enhanced barrier precautions while providing assistance. During a record review on 1/5/26 at 11:00A.M , Resident F's physician orders included but were not limited to, enhanced barrier precautions (started 1/14/26). Resident F's nurse's progress notes included but were not limited to; 1/14/26 at 5:09 P.M. - Physician contacted. Resident had positive methicillin-resistant Staphylococcus aureus (MRSA) from nare swab at hospital on 1/11/26. Physician replied that the resident is colonized and to place resident in enhanced barrier precautions (EBP). During an observation on 1/15/26 at 11:30 A.M., Resident F's restroom did contain a container with personal protective equipment (PPE) supplies, however no signage that indicated either resident in the room required EBP.During an interview on 1/5/26 at 12:10 P.M., LPN 15 indicated Resident F had recently received an order for EBP and still needs a sign in the room to indicate to staff that PPE should be used for all personal care since no specific care is not specified in the physician's order. On 1/15/26 at 1:40 P.M., RN 7 supplied a facility policy titled Enhanced Barrier Precautions Policy and Procedure, dated 1/15/25. The policy included, Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of Multidrug-resistant Organisms (MDROs). EBP employs targeted gown and glove use during high contact resident care activities .This citation relates to intake 2700726. 3.1-18(b)(2)3.1-18(l)

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 3 residents reviewed for pharmaceutical services. A resident received an incorrect dose of an ordered medication for three days for a total of four doses due to incorrectly transcribed physician's order. (Resident B)Finding includes:During review on 1/14/26 at 11:00 A.M., a facility reported incident, dated 1/2/26, indicated Resident B had admitted to the facility following a hospitalization and with an order for the medication metoprolol 25 milligrams (mg), give 1/2 tablet twice a day. During transcription from the hospital discharge orders to the facility medication administration record, the order was entered as metoprolol 25 mg one tablet twice a day. As a result, the resident received three doses of the metoprolol 25 mg tablet. During therapy, the resident became weak and short of breath. The hospital did keep the resident for observation. Record review on 1/14/26 at 2:00 P.M., Resident B's diagnoses included but were not limited to heart disease, obesity, heart failure, and atrial fibrillation.Resident B's hospital discharge orders, dated 12/31/25, included but were not limited to metoprolol tartrate 25 mg oral tablet, 0.5 tablet twice a day. Resident B's facility physician orders included, metoprolol tartrate 25 mg tablet, 1 tablet twice a day, (started 12/31/25 and discontinued 1/6/26).Resident B's medication administration record (MAR) indicated the resident received metoprolol tartrate 25 mg tablet, 1 tablet the evening of 12/31/25, the morning of 1/1/26, the evening of 1/1/26, and the morning of 1/2/26. Resident B's nurse's progress notes included but were not limited to:1/2/26 at 4:55 P.M. - Resident was receiving therapy and became short of breath. Vital signs were obtained with a blood pressure of 86/48 millimeters of mercury (mm Hg), and a pulse of 42 beats per minute (BPM). Resident bradycardic and hypotensive. Emergency Medical Services (EMS) called, and resident was transported to the hospital emergency department. During an interview on 1/14/26 at 11:45 A.M., RN 7 indicated Resident B's hospital discharge order for metoprolol tartrate was entered incorrectly into the facility's MAR and resulted in the resident receiving twice the ordered dose. During an interview on 1/15/26 at 11:00 A.M., LPN 4 indicated the admitting nurse used an admission checklist when admitting a new resident to the facility. On 1/15/26 at 1:40 P.M., RN 7 supplied an undated Nurse admission Checklist and indicated the checklist was a tool to be used by the admitting nurse but was not required to be filled out and was not part of the resident's record. The checklist included, Physician Orders Prescription Physician Orders from Transfer Papers, make sure medications have appropriate (diagnosis) [space to Initial] . Orders verified by two nurses [Initial Nurse One, Initial Nurse Two] .On 1/15/26 at 1:54 P.M., RN 7 supplied an undated Transcribing Orders policy. The policy included, Physician orders will be transcribed to dedicated medical records timely, completely and accurately using acceptable standards of practice . Copying Physician Orders 1. Occasionally physician orders may need to be transcribed from one physician order form to another . 2. Great care must be taken to ensure accuracy and completeness when transcribing orders .This citation relates to intakes 2700726 and 2713037.3.1-48(a)(1)3.1-48(c)(2)

3. On 4/8/25 at 10:03 A.M., Resident 41's clinical record was reviewed. Diagnoses included, but were not limited to, malignant neoplasm of external lower lip and dysphasia. A progress note, dated 11/6/25 at 3:48 P.M., indicated Resident 41 was scheduled to leave the facility the following day for a surgery. Resident was discharged on 11/7/24 at 6:23 A.M. and returned 11/14/24. A Discharge Minimum Data Set (MDS) assessment was completed and signed on 11/7/24. Resident 41's clinical record lacked documentation that a Notice of Transfer or Discharge form was completed and/or sent with the resident and representative at the time of discharge on [DATE]. 4. On 4/8/25 at 9:47 A.M., Resident 48's clinical record was reviewed. Diagnoses included, but were not limited to, right hip fracture and dementia. Resident 48 was transferred to the hospital on 3/10/25 following a fall. Notification to the Ombudsman was lacking. 5. On 4/8/25 at 9:33 A.M., Resident 56's clinical record was reviewed. Diagnoses included, but were not limited to, dementia and anxiety. Resident 56 was transferred to the hospital on 1/9/25 following a fall. Notification to the Ombudsman was lacking. On 4/8/25 at 10:20 A.M., the Assistant Director of Nursing (ADON) indicated when a resident was transferred, staff should sent a Continuity of Care Document (CCD), a transfer observation form, face sheet, and bed hold policy. She indicated the documents sent with a resident should have been scanned into the resident's clinical record. On 4/9/25 at 2:29 P.M., the Social Services Director (SSD) indicated she was unaware that the ombudsman should have been notified of Resident 41, Resident 48, or Resident 56's transfer or discharge, and did not know how the previous SSD did the notifications as she had taken over the position in February of this year. On 4/11/25 at 10:04 A.M., the Administrator indicated the previous SSD had been responsible for the notification to the ombudsman, but was only able to go back 90 days in the old email and unable to see if notification had been sent. The facility did not have record of the notifications. On 4/11/25 at 11:50 A.M., the Administrator provided a current Bed Hold policy, dated 12/15/22, and indicated at that time the policy would have been the same for the transfer or discharge forms. The policy indicated [Company name] and its member communities will provide the resident and resident representative written notice which specifies the duration of the bed-hold policy when a resident is admitted and again if the resident is hospitalized or on a therapeutic leave 3.1-12(a)(6)(A)(iv) Based on interview and record review, the facility failed to ensure a notice of transfer or discharge was given to residents or resident representatives for 3 of 5 residents reviewed for hospitalizations, and the ombudsman was not notified for 5 of 5 residents reviewed for hospitalizations. The transfer discharge form was not completed. There was no documentation of a resident, representative, and the ombudsman receiving a notice of transfer or discharge at the time of hospitalization. (Resident 15, Resident 56, Resident 48, Resident 41, Resident 231) Findings include: 1. On 4/9/25 at 9:03 A.M., Resident 15's clinical record was reviewed and indicated they were admitted from the facility to the hospital on 8/9/24 and returned back to the facility from the hospital on 8/13/24. Resident 15's clinical record lacked documentation of ombudsman notification for Resident 15's transfer. 2. On 4/8/25 at 1:29 P.M., Resident 231's clinical record was reviewed. Diagnoses included, but were not limited to, stroke (cerebral infarction), hypertension (HTN), and congestive heart failure (CHF). The most recent Annual MDS assessment, dated 3/27/25, indicated Resident 231 was cognitively intact. The clinical record indicated Resident 231 was hospitalized on the following dates: 1/15/25-1/17/25 1/24/25-2/7/25 2/17/25-2/20/25 2/28/25-3/21/25 The Ombudsman was not notified of the transfers.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for 2 of 5 residents reviewed for unnecessary medications, 1 of 2 residents reviewed for skin conditions, and 1 of 4 residents reviewed for accidents. Residents were taking an anticoagulant, antiplatelet, and anticonvulsant medications and a resident had falls that were not listed on the MDS assessments. (Resident 231, Resident 57, Resident 15, Resident 56) Findings include: 1. On 4/8/25 at 1:29 P.M., Resident 231's clinical record was reviewed. Diagnoses included, but were not limited to, stroke (cerebral infarction), hypertension (HTN), and congestive heart failure (CHF). The most recent Annual MDS assessment, dated 3/27/25, indicated Resident 231 was cognitively intact and did not take an antiplatelet or anticoagulant medication. Current Physician's Orders included, but were not limited to, the following medications: Aspirin (antiplatelet) 81 milligram (mg) tablet, give one tablet orally once a day upon Rising, ordered 3/21/25 Eliquis (anticoagulant) 5 mg tablet, give one orally twice a day upon Rising and before bedtime, ordered 3/21/25 A current Antiplatelet Care Plan, dated 2/20/25 and last reviewed 2/20/25, included an intervention to administer medications as ordered, initiated 2/20/25. The Medication Administration Record (MAR) for March of 2025 indicated resident received both aspirin and Eliquis daily starting on 3/21/25. During an interview on 4/10/25 at 10:15 A.M., the MDS Coordinator indicated the MDS Assessment erroneously lacked the correct information and should have listed an anticoagulant and antiplatelet on the resident's current medication list. 38770 2. On 4/8/25 at 10:28 A.M., Resident 56's clinical record was reviewed. Diagnoses included, but were not limited to, dementia and anxiety. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 2/16/25, indicated cognition could not be assessed, and no falls since the last assessment (11/18/24) or re-entry (1/9/25 emergency room visit). From 11/18/24 through 2/16/25, Resident 56 experienced falls on 11/19/24, 1/9/25, and 1/30/25. On 4/11/25 at 10:28 A.M., the MDS Coordinator indicated Resident 56's falls should have been marked on the 2/16/25 Quarterly MDS assessment. 45933 3. On 4/9/25 at 9:03 A.M., Resident 15's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus, depression, and hypertension. The most recent Annual Minimum Data Set (MDS) assessment, dated 1/27/25, indicated Resident 15 received injections and insulin on 2 of the 7 days during the 7 day look back period. The MDS lacked documentation that Resident 15 received an anticonvulsant. Current Physician Orders included, but were not limited to, Mounjaro (insulin) pen injector 7.5 milligrams (mg) per 0.5 milliliters (ml) subcutaneous once a day, dated 4/1/25. Gabapentin (anticonvulsant) 600mg tablet once a day before bedtime, dated 7/5/22. Novolog flexpen U-100 insulin 100 unit/ml sliding scale three times a day, dated 9/18/24 Resident 15's Medication Administration Record (MAR) indicated he received the following medications on the following dates from 1/21/25 through 1/27/25: Mounjaro (insulin injection) on 1/22/25 Novolog (insulin injection) on 1/23/25 and 1/24/25 Gabapentin (anticonvulsant) 1/21/25, 1/22/25, 1/23/25, 1/24/25, 1/25/25, 1/26/25, 1/27/25 During an interview on 4/10/25 at 9:27 A.M., MDS Staff 38 indicated both the insulin and injections should have been marked for 3 days and the anticonvulsant should have been marked on the MDS. 4. During an interview on 4/6/25 at 10:44 A.M., Resident 57 indicated she had cancer on her forehead. On 4/7/25 at 1:10 P.M., Resident 57's clinical record was reviewed. Current diagnoses included, but was not limited to, malignant melanoma of scalp and neck (cancer), anemia, and anxiety disorder. The most recent Quarterly MDS, dated [DATE] indicated Resident 57 was cognitively intact. The MDS failed to indicate Resident 57 had cancer. During an interview on 4/10/25 at 9:24 A.M., MDS Staff 38 indicated cancer should have been marked on the MDS. During an interview on 4/10/25 at 9:30 A.M., MDS Staff 38 indicated the facility utilized the Resident Assessment Instrument (RAI) manual as their policy.

Based on observation, interview, and record review, the facility failed to maintain medical records on residents that are complete and accurate for 2 of 2 residents reviewed for self administration of medications, and 2 of 4 residents reviewed for activities of daily living. Two residents who self-administered medication did not have assessments documented. Ancillary services were not documented accurately for two residents. (Resident 10, Resident 66, Resident 44, Resident 64) Findings include: 1. On 4/8/25 at 10:54 A.M., Resident 10's clinical records were reviewed. Diagnosis included, but was not limited to, Type 2 diabetes mellitus without complications. The most recent Quarterly Minimum Data Set, dated dated [DATE], indicated Resident 10 was cognitively intact, was independent with eating and bed mobility, needed set up or clean up assistance with toilet use, and needed supervision with transfers. Physician's Orders included, but were not limited to, the following: Humalog KwikPen Insulin (insulin lispro) insulin pen; 100 unit/mL (milliliter); amt: Per Sliding Scale; If Blood Sugar is less than 60, call MD (Medical Doctor). If Blood Sugar is 151 to 200, give 14 Units. If Blood Sugar is 201 to 250, give 16 Units. If Blood Sugar is 251 to 300, give 18 Units. If Blood Sugar is 301 to 350, give 20 Units. If Blood Sugar is 351 to 400, give 22 Units. If Blood Sugar is greater than 400, give 22 Units. If Blood Sugar is greater than 400, call MD. subcutaneous Special Instructions: Resident may administer insulin per self after nurse has drawn it up. IF over 400 give SSI (Sliding Scale Insulin) and call MD With Meals, dated 8/10/2023 1/30/2025 (DC Date) Lantus Solostar U-100 Insulin (insulin glargine) insulin pen; 100 unit/mL (3 mL); amt: 55 units; subcutaneous Special Instructions: Resident may administer insulin per self after nurse has drawn it up. Once A Day, Before Bedtime, dated 8/10/2023 1/29/2025 (DC Date) A current Diabetic Care Plan indicated resident has potential for hypo/hyperglycemia and diabetic complications related to diabetes mellitus. resident prefers to inject own insulin after nurse doses, initiated on 10/8/20 and last revised on 4/06/25, included, but was not limited to, an intervention to administer medications per MD order, initiated on 10/8/20. The clinical records lacked documentation that Resident 10 was assessed and could safely administer insulin herself. On 4/9/25 at 10:30 A.M., the Director of Nursing was asked for document that some type of assessment was done to show that Resident 10 could safely administer her own insulin, and not provided. During an interview on 4/10/25 at 11:35 A.M., Regional Clinical Specialist 1 indicated they didn't fill out a self administration assessment on Resident 10 for the insulin because none of the questions apply to her. During an interview on 4/10/25 at 11:43 A.M., Regional Clinical Specialist 1 indicated she did not have any documentation in medical record that Resident 10 was observed injecting insulin safely. She indicated they charted by exception. 2. On 4/10/25 at 2:29 P.M., Resident 66's clinical records were reviewed. Diagnoses included, but were not limited to, cerebral infarction, need for assistance with personal care, and abnormalities of gait and mobility. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 2/5/25, indicated Resident 66 had moderate cognitive impairment, required set up for eating, supervision for toilet use, was independent for bed mobility and required partial/moderate assistance, helper does less than half the effort for transfers. Current Physician Orders included, but were not limited to, the following: Flonase Allergy Relief (fluticasone propionate) OTC (over the counter) spray,suspension; 50 mcg/actuation (microgram/actuation); amount: 1 spray both nostrils; Once A Day Upon Rising, dated 4/1/25. The clinical record lacked an order for Resident 66 to administer Flonase to herself, and a care plan that it was her preference to administer Flonase herself. There was no documentation that Resident 66 was observed being able to give Flonase correctly. 46416 3. During an interview on 4/8/25 at 2:17 P.M., Resident 44's family indicated she was not made aware of when dental services was coming to the facility and she did not know when the last time was that Resident 44 was seen but she paid for the services. At that time, she indicated his teeth were not cleaned and his nails were dirty underneath and long. The most recent Care Plan Conference for Resident 44, dated 4/3/25, indicated ancillary service preferences were reviewed and updated. The clinical record lacked dental and podiatry notes indicating the resident had been seen by ancillary services while he was in the facility. 4. On 4/8/35 at 1:44 P.M., Resident 64 was observed to have long toenails and dark substance underneath his long fingernails during incontinence care. On 4/8/25 at 4:07 P.M., Resident 64 was observed to have a very strong odor from his mouth and the skin inside his mouth was peeling and sticking on his teeth. The most recent Care Plan Conference for Resident 64, dated 3/27/25, indicated ancillary service preferences were reviewed and updated. The clinical record lacked dental and podiatry notes indicating the resident had been seen by ancillary services while he was in the facility. The clinical record lacked a signed ancillary services consent that information for ancillary services was provided. During an interview on 4/9/25 at 12:39 P.M., the Administrator indicated the ancillary podiatrist came to the facility every other month, the ancillary dental hygienist came every other month, and the ancillary dentist came as needed to the facility to see residents. She provided notes on Resident 44 from the ancillary providers that his last completed dental exam, dated 5/15/24, indicated resident has poor oh [oral health], heavy plaque. The resident had appointments scheduled with the hygienist since then, but the resident refused care on those dates. Podiatry last saw him on 2/26/25 for trimming dystrophic (misshapen or unhealthy) nails and debrided (damaged or infected parts of the nail are removed) 5 nails or less. At that time, she indicated these notes were not scanned into the resident's clinical record and were not part of the clinical record. She indicated Resident 64 was admitted in September of 2024 and there was not a signed refusal or consent to ancillary services in his clinical record at that time and they would be following up with family about that. During an interview on 4/11/25 at 10:03 A.M., the Assistant Director of Nursing (ADON) indicated there should be documentation that the resident and/or representative were notified what ancillary services were available. There was a refuse and consent box for ancillary services that they should mark and sign at admission and/or during their first care conference. At that time, she indicated there should be documentation of dental and podiatry visits, refusal of care, and notification of all to family in the resident's clinical record. On 4/11/25 at 10:00 A.M., a current Accurate Documentation Policy was requested. At that time, the Administrator indicated there was not a policy for that but they would use the Nurse Job Description provided, last revised April 2012, that indicated . The employee must be able to perform each essential function effectively to be successful in this position . 2. Completes assigned and required daily and weekly documentation including any ancillary assessment . On 4/11/25 at 10:20 A.M., a current Dental Services Policy, dated 6/1/18, was provided by the Administrator and indicated [company name] and its member Communities are committed to ensuring all residents have access to routine and emergency dental care . 3.1-50(a)

Based on observation, interview, and record review, the facility failed to ensure each resident was treated with respect and dignity for 2 of 3 residents reviewed for dignity concerns and one random observation. Staff leaned over a resident to provide care and remove a fitted sheet, a resident's hair was disheveled, food was observed on a resident's face, blood ran down a resident's neck and staff failed to wipe it off, a resident had a gauze dressing on her forehead that was not covered, water was observed on the bedside table of a (nothing by mouth) NPO resident, and staff indicated they would provide water with a mouth sponge to a resident and failed to provide it. (Resident 57, Resident 44, Resident 64) Findings include: 1. On 4/7/25 at 1:10 P.M., Resident 57's clinical record was reviewed. Diagnoses included, but was not limited to, anemia, hypertension, and anxiety disorder. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 2/6/25, indicated Resident 57 was cognitively intact and had a skin tear. During an observation on 4/6/25 at 10:44 A.M., Resident 57 was observed in bed with an undated, uncovered yellow gauze dressing. During an observation of care on 4/10/25 at 11:01 A.M., Licensed Practical Nurse (LPN) 36 placed a yellow gauze dressing on Resident 57's forehead and failed to secure or cover the dressing. During an interview on 4/10/25 at 11:22 A.M., LPN 36 indicated sometimes a border dressing is placed over the gauze dressing for dignity reasons. During an interview on 4/10/25 at 1:12 P.M., Resident 57 indicated she liked for the bandage on her head to be covered up. During an interview on 4/10/25 at 1:17 P.M., the Assistant Director of Nursing (ADON) indicated Resident 57 would sometimes have the gauze covered because the gauze would fall down and Resident 57 felt like people were starring at her if it was not covered. 46416 2. On 4/7/25 at 3:00 P.M., Resident 64's clinical record was reviewed. Diagnoses included, but were not limited to, traumatic brain injury, post traumatic stress disorder, schizophrenia, and dysphagia. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 1/9/25, indicated Resident 64's cognition was not able to be assessed, he had no behaviors, and was totally dependent on staff. On 4/8/25 at 1:44 P.M., a Styrofoam cup of water with a lid and a straw were observed on the nightstand of Resident 64. While performing incontinence care, Certified Nurse Aide (CNA) 34 leaned over the resident and yanked on the upper corner of the fitted sheet to remove it from the mattress. The residents back was laying on the urine soaked sheet. CNA 34 leaned over the resident's legs and roughly wiped the buttocks of the resident. The resident's back was not wiped after laying on the soiled sheet. CNA 16 returned to the bedside and indicated the resident's sore on his chin was bleeding and the blood was going down his neck. CNA 34 went to the bathroom to remove gloves and wash their hands and all staff left the room. Resident 64 was left with blood running down his neck from his chin not wiped off and staff did not notify the nurse that the sore needed attention. On 4/8/25 at 4:07 P.M., Resident 64 was observed having medication administered through his g-tube (a tube inserted directly into the stomach through the abdominal wall) by Registered Nurse (RN) 66. Upon entrance into the room, blood was observed on the bed sheet, the resident's chin had dried blood on it, and there was dried blood observed down the resident's neck. During the medication administration, the resident repeatedly indicated I need water three times. RN 66 indicated she would use the oral sponges on him after she was finished with the medication administration. At that time, the resident's breath was observed to have a very strong odor and the skin inside his mouth was peeling and sticking on his teeth. The resident's bed sheet was not changed after the medication administration was over, the sore on his chin was not cleaned, the blood was not wiped off his neck, and the nurse did not return with the oral sponges to care for Resident 64. On 4/9/25 at 11:55 A.M., Resident 64 was laying in his bed and a Styrofoam cup of water with a lid and straw was sitting on his bedside table beside his bed. During an interview on 4/9/25 at 12:40 P.M., CNA 26 indicated if the sore on his chin was actively bleeding and it was going down his chin and neck, she would use an incontinence care wipe or wash cloth to clean it off and tell the nurse to look at it. At that time, she indicated Resident 64 was not to have anything by mouth (NPO) and they put the Styrofoam cup of water in his room for the nurse's to use when they flush his g-tube but it shouldn't have a straw in it because the resident can't have water. She indicated Resident 64 would ask for water and food especially if he saw his roommate getting it. She indicated they should use oral sponges to moisten his mouth. 3. On 4/7/25 at 10:13 A.M., Resident 44 was observed sitting in his room with dried food visible on his mouth and shirt, long fingernails with brown substance under them, and a thick white film covering his teeth. He indicated he had a shower earlier that morning. On 4/7/25 at 2:09 P.M., Resident 44's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's disease, dementia without behaviors, schizophrenia, and anxiety. The most recent Annual MDS assessment, dated 3/8/25, indicated Resident 44's cognition was not able to be assessed, he had no behaviors, was partial to moderate assistance of staff (resident performed over half the effort) for oral hygiene, substantial to maximum assistance of staff (staff performed over half the effort) for personal hygiene, and dependent on staff for showering. On 4/8/25 at 2:17 P.M., Resident 44 was observed sitting in the bed in his room with dried food on his mouth and shirt, long fingernails with brown substance under them, and a thick white film covering his teeth. At that time, family indicated that they had brought concerns up with the staff about his cleanliness in the past and nothing had been done about it. They indicated when they visited, they took care of it or it wouldn't get done. On 4/9/25 at 11:55 A.M., Resident 44 was observed sitting in his wheelchair in the main lobby with his hair disheveled. During an interview on 4/09/25 12:34 PM CNA 26 indicated after resident's were done eating, the staff should make sure the resident doesn't have food on their face or clothing. She indicated Resident 44 was dependent on staff to do that for him, along with showering, combing his hair, and trimming his fingernails although his family sometimes did it for him too when they visit. During an interview on 4/10/25 at 1:42 P.M., the Assistant Director of Nursing (ADON) indicated staff should always treat the residents with dignity and respect when they were providing care to the residents. On 4/10/25 at 3:00 P.M., a current Resident Rights Policy, dated 6/6/19, was provided by Regional Clinical Support 2 and indicated [company name] and it's member communities are committed to protecting and promoting the rights of the residents who reside in out communities. It is our policy that residents shall be treated with kindness, respect and dignity by associates, volunteers, contractors, and visitors 3.1-3(a) 3.1-3(t)

2. On 4/8/25 at 10:03 A.M., Resident 41's clinical record was reviewed. Diagnoses included, but were not limited to, malignant neoplasm of external lower lip and dysphasia. A progress note, dated 11/6/25 at 3:48 P.M., indicated Resident 41 was scheduled to leave the facility the following day for a surgery. Resident was discharged on 11/7/24 at 6:23 A.M. and returned 11/14/24. A Discharge Minimum Data Set (MDS) assessment was completed and signed on 11/7/24. Resident 41's clinical record lacked documentation that a Bed Hold policy was provided to the resident and representative at the time of discharge on [DATE]. On 4/8/25 at 10:20 A.M., the Assistant Director of Nursing (ADON) indicated when a resident was transferred, staff should sent a Continuity of Care Document (CCD), a transfer observation form, face sheet, and bed hold policy. She indicated the documents sent with a resident should have been scanned into the resident's clinical record. On 4/11/25 at 11:50 A.M., the Administrator provided a current Bed Hold policy, dated 12/15/22, that indicated [company name] and its member communities will provide the resident and resident representative written notice which specifies the duration of the bed-hold policy when a resident is admitted and again if the resident is hospitalized or on a therapeutic leave 3.1-12(a)(25) 3.1-12(a)(26) Based on interview and record review, the facility failed to ensure a bed hold policy was given to residents or resident representatives for 2 of 5 residents reviewed for hospitalizations. The bed hold form was not completed. There was no documentation of a resident or representative receiving a bed hold at the time of hospitalization. (Resident 15, Resident 41) Findings include: 1. On 4/9/25 at 9:03 A.M., Resident 15's clinical record was reviewed and indicated they were admitted from the facility to the hospital on 8/9/24 and returned back to the facility from the hospital on 8/13/24. Resident 15's clinical record lacked documentation of a bed hold policy given to the resident or a representative at the time of the transfer.

Based on observation, interview, and record review, the facility failed to ensure residents requiring assistance with Activities of Daily Living (ADLs) received adequate assistance with bathing, nail care and oral care for 3 of 3 residents reviewed for ADL care. (Resident 44, Resident 64, Resident 14) Findings include: 1. During an interview on Monday 4/7/25 at 10:44 A.M., Resident 14 indicated she was supposed to get a bath on Monday and Thursday but didn't always get them. She indicated she couldn't remember the last bath she got but knew she didn't get one last Thursday. She indicated the aides would tell her they were too busy. On 4/8/25 at 10:32 A.M., Resident 14 was observed lying in bed. She indicated she did not get a bath the previous day (Monday). She indicated an aide had asked her if she would like a washcloth to wash her face and hands, but no one else had asked her that. On Thursday 4/10/25 at 11:00 A.M., Resident 14 was observed lying in bed. She indicated she had the same dress on since she had went to her doctor's appointment a week ago yesterday. She indicated she had not had a bath yet today. The aide had offered her a shower, but she prefers a bed bath and couldn't do it by herself. On 4/7/25 at 2:21 P.M., Resident 14's clinical records were reviewed. Diagnoses included, but were not limited to, infection and inflammatory reaction due to internal right knee prosthesis, thrombocytopenia, pain in right knee, and unsteadiness on feet. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 3/26/25, indicated Resident 14 was cognitively intact, required substantial/maximal assistance, helper does more than half the effort, for toilet use, bed mobility, shower/bath and hygiene. Resident 14's preference to choose between a tub bath, shower, bed bath or sponge bath was very important. A current Resident has specific personal preferences care plan, start date 10/12/20, included, but was not limited to, an intervention to honor resident's bathing preference if applicable-resident's preference is: (per facility schedule), start date 10/12/20. March-April ADLs-Type of Bath 3/7/25 Complete Bath 3/10/25 Complete Bath 3/13/25 Complete Bath 3/20/25 Complete Bath 3/24/25 Complete Bath No other complete baths recorded thru 4/7/25, no refusals documented. During an interview on 4/9/25 at 11:42 A.M., Certified Nurse Aide (CNA) trainee 28 indicated Resident 14 was a bath. Residents got 2-3 baths per week depending on their choice. She indicated she was able to get her work done during her shift, and if a bath wasn't able to be done she would tell the next shift. 46416 2. On 4/7/25 at 10:13 A.M., Resident 44 was observed sitting in his room with dried food visible on his mouth and shirt, long fingernails with brown substance under them, and a thick white film covering his teeth. He indicated he had a shower earlier that morning. On 4/8/25 at 2:17 P.M., Resident 44 was observed sitting in the bed in his room with dried food on his mouth and shirt, long fingernails with brown substance under them, and a thick white film covering his teeth. At that time, family indicated that they had brought concerns up with the staff about his cleanliness in the past and nothing had been done about it. They indicated when they visited, they sometimes took care of it or it wouldn't get done. On 4/9/25 at 11:55 A.M., Resident 44 was observed sitting in his wheelchair in the main lobby with his hair disheveled. On 4/7/25 at 2:09 P.M., Resident 44's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's disease, dementia without behaviors, schizophrenia, and anxiety. The most recent Annual MDS assessment, dated 3/8/25, indicated Resident 44's cognition was not able to be assessed, he had no behaviors, was partial to moderate assistance of staff (resident performed over half the effort) for oral hygiene, substantial to maximum assistance of staff (staff performed over half the effort) for personal hygiene, and dependent on staff for showering. The most recent Care Plan Conference for Resident 44, dated 4/3/25, indicated ancillary service preferences were reviewed and updated. Wife had raised concerns of recent issues with personal care of resident in recent visit [nails had some dirt under, some food fallen on shirt and wheelchair] The clinical record indicated Resident 44 missed showers on the following dates from February 1, 2025 through April 9, 2025 without documentation of refusals: 2/3/25 3/10/25 3/20/25 3/27/25 4/3/25 3. On 4/8/35 at 1:44 P.M., Resident 64 was observed to have long toenails and dark substance underneath his long fingernails during incontinence care. On 4/8/25 at 4:07 P.M., Resident 64 was observed during a medication administration. He repeatedly indicated I need water three times. Registered Nurse (RN) 66 indicated she would use the oral sponges on him after she was finished with the medication administration. At that time, the resident's breath was observed to have a very strong odor and the skin inside his mouth was peeling and sticking on his teeth. The nurse did not return with the oral sponges to provide oral care for Resident 64. On 4/7/25 at 3:00 P.M., Resident 64's clinical record was reviewed. Diagnoses included, but were not limited to, traumatic brain injury, post traumatic stress disorder, schizophrenia, and dysphagia. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 1/9/25, indicated Resident 64's cognition was not able to be assessed, he had no behaviors, and was totally dependent on staff. The clinical record indicated Resident 64 missed the following showers February 1, 2025 through April 9, 2025 without documentation of a refusal: 2/12/25 2/15/25 2/22/25 3/1/25 3/15/25 3/29/25 During an interview on 4/9/25 at 12:39 P.M., the Administrator indicated the ancillary podiatrist came to the facility every other month, the ancillary dental hygienist came every other month, and the ancillary dentist came as needed to the facility to see residents. She provided notes on Resident 44 from the ancillary providers that his last completed dental exam, dated 5/15/24, indicated resident has poor oh [oral health], heavy plaque and podiatry last saw him on 2/26/25 for trimming dystrophic (misshapen or unhealthy) nails and debrided (damaged or infected parts of the nail are removed) 5 nails or less but indicated these notes were not part of the clinical record. At that time, she indicated Resident 64 was admitted in September of 2024 and there was not a signed refusal or consent to ancillary services in his clinical record at that time and they would be following up with family about that. During an interview on 4/9/25 at 12:34 P.M., CNA 26 indicated each hall had a shower schedule and provided the 300 Hall schedule at that time. At the bottom of the shower schedules, it indicated on shower days, bed linens were to be changed, nails were to be cleaned and trimmed, and resident may be shaven with showers on shower days and shaven daily. If resident refuses a shower, staff must notify assigned nurse and the nurse must make a progress note and notify the unit manager. Resident 64 should have a shower on Wednesday evenings and Saturday evenings according to the shower schedule and she would let the nurse know if his fingernails or toenails were long and needed attention because she wouldn't feel comfortable trimming his. She indicated oral care was part of the resident's morning care and she would use oral sponges on Resident 64 twice a shift when she worked and it was documented as A.M. care and not listed separately. CNA 26 indicated Resident 44 should have showers on Monday and Thursday during day shift, was dependent on staff to comb his hair, and trim his fingernails, although his family would sometimes did it for him when they visit. She indicated they would refuse care at times and the nurse was notified. During an interview on 4/10/25 at 10:32 A.M., the Director of Nursing (DON) indicated oral care should be performed at least once a day and as needed. During an interview on 4/10/25 at 1:42 P.M. the Assistant Director of Nursing (ADON) indicated CNAs should be looking at and cleaning the resident's nails every shower and letting the nurses know if the toenails or fingernails need clipped. Nurses should be clipping them or sending outside of the facility if they are not able to do it safely. Showers were done according to the shower schedule and documented on paper shower sheets and in the Point of Care section of the Electronic Medical Record. At that time, she indicated the shower sheets were not scanned into the resident's clinical record. On 4/10/25 at 3:00 P.M., a current Activities of Daily Living Policy was requested. At that time, Regional Clinical Support 2 indicated they did not have a policy for that but would use the Resident Rights Policy provided, dated 6/6/19, which indicated [company name] and it's member communities are committed to protecting and promoting the rights of the residents who reside in out communities. It is our policy that residents shall be treated with kindness, respect and dignity by associates, volunteers, contractors, and visitors . 3.1-38(a)(2)(A) 3.1-38(a)(3)(C) 3.1-38(b)(1)(2)

Based on interview and record review, the facility failed to ensure care and services were provided to a resident with an open skin area for 1 of 3 residents reviewed with skin conditions. Assessments including measurements and description of the area were not completed for an open skin area. (Resident 60) Finding includes: On 4/7/25 at 2:05 P.M., Resident 60's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus and depression. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 2/9/25, indicated cognition status could not be assessed, the resident required partial to moderate assistance (helper does less than half the effort) with toileting, bathing, and transfers, and no skin concerns were identified. Physician orders included, but were not limited to: Observe (to right hip/buttock) dressing to open area every shift for soil or dislodgement. Observe for signs and symptoms of pain or infection, dated 4/4/25. Observe (right upper thigh/buttock) every shift. Observe for signs and symptoms of pain or infection, dated 3/4/25. mupirocin ointment; 2 %; apply a small amount to right upper thigh/buttock area twice a day, dated 3/4/25 through 3/6/25. mupirocin ointment; 2 %; apply a small amount to right upper thigh/buttock area twice a day, dated 3/6/25 through 3/18/25. A current care plan, revised 4/6/25, indicated resident had a boil to the buttocks. Interventions included, but were not limited to, record the location, size (length, width, and depth), color, distribution, contour, consistency of boil, dated 3/3/25. A Skin Integrity Event, dated 3/4/25, indicated a right upper thigh and buttock area was identified 3/3/25. The area was 1.5cm (centimeters) x 1cm, round, red, and an open boil like area that had popped. The area had scant, clear drainage. Progress notes included, but were not limited to, the following: 3/4/25 at 3:43 P.M. Area to right upper thigh/buttock. A new order was placed for mupirocin twice a day. 3/4/25 at 5:42 P.M. Area to buttocks measured today. (The clinical record lacked the measurement that was completed) 3/4/25 at 11:42 P.M. Area to right buttock, treatment completed per order. 3/5/25 at 10:09 A.M. Area to buttock, treatment in place. 3/6/25 at 1:48 A.M. Area to buttock, treatment completed per order. 3/6/25 at 11:35 P.M. Area to buttock, treatment in place. 3/29/25 at 11:46 A.M. A Physician note indicated resident getting wound care to area on buttock. 4/6/25 at 2:16 P.M. A Social Services note indicated family was updated that a couple of the nursing staff resident was familiar and comfortable with were able to observe and treat the area/boil on the resident's buttock. A Quarterly/Annual nursing assessment, dated 3/28/25, indicated no skin conditions. Resident 60's clinical record lacked any assessments of the open area to the buttock after the Skin Integrity Event, dated 3/4/25. Resident 60's clinical record lacked a reason for discontinuing the mupirocin ointment used for the buttock on 3/18/25. On 4/8/25 at 10:08 A.M., the Assistant Director of Nursing (ADON) indicated the resident had refused observation of the area on her buttock. However, she indicated at that time the resident did allow her to observe the area. She indicated there was not a dressing and the area was closed. She indicated that the area was one that had opened and closed many times. On 4/9/25 at 9:45 A.M., the ADON indicated the wound physician did rounds weekly, and the floor nurses did assessments of wounds on Fridays. At that time, she indicated she was not sure when Resident 60's buttock wound was healed, and would look for additional assessments on the wound (information was not provided). On 4/9/25 at 10:04 A.M., the ADON indicated after an initial assessment that included measurements, only pressure ulcers, vascular wounds, incisions, and diabetic wounds would continue to get measured routinely. She indicated a boil was not considered a wound and would be treated the same as a skin tear, observing daily visually but no documentation. She indicated the order for the open boil was to observe and not to monitor, therefore no measurements or other assessments were completed. On 4/9/25 at 11:23 A.M., the Director of Nursing (DON) provided a current Wound Management policy, dated 2/1/19, that indicated The Wound Team meets each week, preferably the same day and time to benefit the resident(s) being assessed. Each wound will be observed by the wound team to provide oversight of the care plan interventions and ensure that each resident's condition is accurately assessed in a timely manner. The skin conditions that the Wound Team should evaluate include, but are not limited to, the following: New wounds or open areas . Existing pressure and non-pressure open areas . Any other skin condition that has the potential to worsen without adequate management . Healed area for four (4) weeks after healing 3.1-37(a)

Based on observation, interview, and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 1 residents reviewed for behavioral health. A resident's clinical record lacked documentation of behavior monitoring. (Resident 64) Finding includes: On 4/8/25 at 1:44 P.M., Certified Nurse Aide (CNA) 34 and CNA 16 were observed performing incontinence care on Resident 64. During the care, the resident indicated Let her do it. At the conclusion of care, when CNA 34 was leaving the room, the resident yelled A--hole. On 4/7/25 at 3:00 P.M., Resident 64's clinical record was reviewed. Diagnoses included, but were not limited to, traumatic brain injury (TBI), post traumatic stress disorder, schizophrenia, and dysphagia. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 1/9/25, indicated Resident 64's cognition was not able to be assessed, he had no behaviors, and was totally dependent on staff. A current Antipsychotic Medication Care Plan, dated 10/15/24, included, but was not limited to, the following intervention: Monitor resident's behavior and response to medication, created 11/15/24 A current Antidepressant Medication Care Plan, dated 12/31/24, included, but was not limited to, the following intervention: monitor resident's mood and response to medication, created 12/31/24 The clinical record lacked documentation of behaviors exhibited by Resident 64. During an interview on 4/8/25 at 3:15 P.M., the Director of Nursing (DON) indicated Resident 64 sometimes called staff names, covered up in his blanket in a cocoon, and would roll away from staff. During an interview on 4/8/25 at 4:03 P.M., the Administrator and Regional Clinical Support 1 indicated Resident 64 did not have a care plan that he had behaviors of refusing care or yelling out, because with a TBI, they weren't sure what behaviors he might have. During an interview on 4/9/25 at 12:40 P.M., Certified Nurse Aide (CNA) 26 indicated Resident 64 really doesn't complain or refuse much. He will sometimes if he was sleeping and wrapped up with his blanket over his head, but otherwise he was pretty easy going. During an interview on 4/10/25 at 10:13 A.M., the Administrator indicated all behavior documentation had been provided for Resident 44. On 4/10/25 at 3:00 P.M., A current Behavioral Health Management Program Policy, dated January 2024, was provided by Regional Clinical Support 2 and indicated [company name] communities provide services to our residents with specific diseases and disorders. Some of our residents have medical disabilities that can lead to disruptive behaviors and these behaviors have the potential to create a negative effect on the resident, other residents, visitors, and staff. It is [company name]'s policy that each community will have a behavior program that: identifies, monitors, manages, and disseminates (whenever possible) all behavior events . each individual resident will receive services according to their needs . Residents who demonstrate any of the following characteristics should be involved in the behavior program . any resident demonstrating new or worsening behaviors . unresolved repetitive behaviors . currently has a doctor's order to use antipsychotic, antidepressant . Each [company name] facility will use the following documents to track behaviors and document ongoing services/interventions . The nurse or social services will complete a behavioral event in the electronic medical record for each new or worsening behavior the resident demonstrates .CNAs are able to document . during the clinical meeting, when the IDT [Interdisciplinary team] is present, each behavior will be discussed . IDT will write a note . It is [company name] policy to ensure etiology of a resident's behavior is thoroughly investigated, documented, and care planned . 3.1-37(a) 3.1-43(a)(1)

Based on interview, observation, and record review, the facility failed to maintain proper infection control practices and provide a safe and sanitary environment for 1 of 2 residents observed for incontinence care and 1 of 1 residents reviewed for feeding tube care. Staff did not sanitize their hands between glove changes, wash cloths were laid on the side of the bathroom sink and then used for wiping the resident during incontinence care, clean linens and a resident's bare skin were touched with soiled gloves, and a bed sheet with blood on it was not changed. (Resident 64, Resident 281) Findings include: 1. On 4/8/25 at 1:44 P.M., Certified Nurse Aide (CNA) 34 and CNA 16 were observed performing incontinence care on Resident 64. CNA 34 rolled resident from left to right while pulling down the resident's pants and pulling out the lift pad that was underneath him. CNA 34 grabbed two wash cloths and went into the bathroom. CNA 34 laid the washcloths on the side of the sink while he washed his hands. After getting the wash cloths wet, CNA 34 took the wash cloths back to the bedside. CNA 34 unfastened Resident 64's incontinence pad. While CNA 16 was washing her hands, the resident was laying on his left side and urinated on the bed sheets. CNA 16 went out of the room to get clean linens while CNA 34 removed the residents wet pants and socks and laid them at the foot of the bed. CNA 34 laid the resident on his back, wiped the head of the penis with a wash cloth, and then quickly wiped the rest of the groin area with the same cloth. CNA 34 proceeded to touch the residents knee with the soiled gloves. CNA 16 returned with clean linens and laid them at the foot of the bed near the soiled clothing and went to the bathroom to wash her hands. CNA 34 reached across Resident 64 and yanked on the upper corner of the fitted sheet to remove it from the mattress. When the sheet was pulled down, the mattress was wet where Resident 64 had urinated through the sheet. CNA 34 touched the clean linens at the bottom of the bed with soiled gloves, grabbed the other wet wash cloth, and wiped the wet area on the mattress. When CNA 16 returned to the bedside, CNA 34 went into the bathroom and laid two wash cloths on the side of the sink while they washed their hands with a five second lather. CNA 16 proceeded to roll the soiled linens under the resident, put the clean fitted sheet over the wet area on the left side of the mattress, put the clean incontinence pad under the resident, , and then went to the bathroom to remove her gloves and wash her hands in the bathroom. Resident 64 was quickly rolled from his back to his right side in the fetal position by CNA 34. The residents back was laying on the urine soaked sheet while he was laying on his back. CNA 34 leaned over the resident's legs and roughly wiped the buttocks of the resident with a wet wash cloth wearing the same gloves. The resident had moisture associated skin damage to his sacrum. CNA 34 quickly rolled Resident 64 to his left side, touching the resident with the same gloves, pulled out the dirty linen from under the resident, and put them at the bottom of the bed on the clean fitted sheet. Then proceeded to pull the clean fitted sheet and incontinence pad from under the resident, put the sheet on the mattress, and fasten the incontinence pad. The resident's back was not wiped after laying on the soiled sheet. CNA 16 returned to the bedside and indicated the resident's sore on his chin was bleeding and the blood was going down his neck. CNA 34 went to the bathroom to remove gloves and wash their hands. They put gloves back on and proceeded to put the soiled linens that were laying on the clean fitted sheet at the bottom of bed into a trash bag. The bag tore and the soiled linens fell on the clean sheet again. CNA 34 double bagged the soiled linens and took them out of the room. Resident 64 was left with blood running down his neck from his chin. On 4/8/25 at 4:07 P.M., Resident 64 was observed having medication administered through his g-tube (a tube inserted directly into the stomach through the abdominal wall) by Registered Nurse (RN) 66. Upon entrance into the room, blood was observed on the bed sheet, the resident's chin had dried blood on it, and there was dried blood observed down the resident's neck. The resident's bed sheet was not changed after the medication administration was over, the sore on his chin was not cleaned, and the blood was not wiped off his neck. During an interview on 4/10/25 at 1:15 P.M., the Infection Preventionist (IP) indicated when staff performed incontinence care, they should sanitize hands and change gloves between dirty and clean tasks. Staff should not touch the resident with soiled gloves and the soiled linens should be placed into a bag, not on the clean bed linens. If dirty linen was laid on a clean sheet, the whole bed should be changed. Staff should not lay wash cloths on the side of the sink because it contaminates them and staff should not lean over the resident to do care. If a resident urinated in the bed, it soaked through the sheets, and the mattress was wet, she would expect staff to get the resident back out of bed and clean the mattress with purple top container cleaning wipes and let the mattress dry before putting the clean sheets on the mattress. If the resident was actively bleeding and there was blood on the bed sheets, she would expect staff to address the site of bleeding immediately and put a clean sheet on the bed. 46882 2. On 4/7/25 at 1:16 P.M., Resident 281's clinical records were reviewed. Resident 281 was admitted on [DATE]. Diagnoses included, but were not limited to, dysphagia following unspecified cerebrovascular disease, traumatic subdural hemorrhage with loss of consciousness, and chronic pain syndrome. The current Admission Minimum Data Set (MDS) assessment was in process. Current Physician's Orders included, but were not limited to, the following: Raise head of bed at least 30 degrees at all times while in bed. Every Shift, dated 3/25/2025 Enhanced barrier precautions, dated 3/26/2025 NPO (nothing by mouth), dated 3/31/2025 Feeding type: Nova Source Renal. Bolus at 240 mls (milliliters) QID (four times a day). Check placement prior to hooking up feeding, dated 4/2/2025 Flush G-tube (gastrostomy tube) with 90 mL of water prior to feeding and after feeding. Before flush,verify placement, check GI (gastrointestinal) contents for residual, hold flush and feeding if residual is greater than 100 mL. Notify MD (Medical Doctor) if GI content residual is greater than 100 mL. Four Times A Day, dated 4/2/2025 On 4/10/25 at 11:09 A.M., Licensed Practical Nurse (LPN) 32 was observed doing G-tube feeding for Resident 281. LPN 32 put gloves on, did not observe LPN 32 clean hands before or after entering room, and took a washcloth with a dried black substance on it from Resident 281, who indicated it was stool, took glove off but did not wash hands, put gloves on, then mask and gown, asked resident to lie down to do feeding, used remote to raise bed with gloves on, took one glove off and put clean glove on, did not clean hands, listened to stomach, opened G-tube, put syringe on G-tube, added 90 ml of water, poured in Novasource Renal 237 ml gravity infusion, 90 ml water added after infusion, G-tube clamped shut and placed under abdominal binder, rinsed syringe and placed in plastic bag, cleaned up bedside table, removed gloves, gown and mask, washed hands with 23 second lather, lowered bed, took trash bag out of trash can and tied, put clean trash bag in trash can, carried tied trash bag with soiled linen out to dirty linen closet. During an interview on 4/10/25 at 1:42 P.M., the Infection Preventionist (IP) indicated if staff took a soiled washcloth from resident with gloves on and removes gloves, hands should be sanitized or washed any times gloves were removed and before putting clean gloves on. On 4/11/25 at 10:00 A.M., the Administrator provided an undated Incontinence Care Skills Validation form which indicated .5. Wash hands and apply gloves . 3.1-18(b) 3.1-18(l) 3.1-19(g)(1) 3.1-19(g)(2)

Based on interview and record review, the facility failed to ensure a sufficient and competent behavioral and mental health training program for all staff was implemented, as determined by staff needs and the facility assessment. Resident clinical records lacked documentation of behavior monitoring and staff were unaware of a resident's diagnosis. (Resident 64) Finding includes: 1. The current facility assessment, last reviewed 3/21/25, indicated the facility cared for an average of 80 long term care residents daily. Current diseases/conditions, physical, and cognitive disabilities of those residents included, but were not limited to, psychosis (hallucinations, delusions, etc), impaired cognition, mental disorder, depression, Bipolar disorder, Schizophrenia, PTSD, anxiety, TBI, Down Syndrome, autism, Alzheimer's disease, non-Alzheimer's dementia, and behaviors that need intervention. Eleven of those residents were indicated to have had behavioral health needs. It indicated the following mental health and behavior services were offered based on the resident's needs: manage the medical conditions and medication-related issues causing psychiatric symptoms and behaviors, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, and other psychiatric diagnoses, intellectual and/or developmental disabilities. 2. On 4/10/25 at 11:33 A.M., the Assistant Director of Nursing (ADON) provided in services conducted in the last year. The in services lacked documentation of education given on individualized care needed, monitoring behaviors, non pharmacological interventions, and interacting with residents diagnosed with Schizophrenia, PTSD, and TBI. 3. Insufficient behavioral health in services and training resulted in behavior monitoring not being implemented. Cross reference F740. During an interview on 4/9/25 at 12:34 P.M., CNA 26 indicated staff did do in services but she did not remember talking about Schizophrenia, TBIs, or PTSD specifically. The in services talked about dementia, what to do when a resident refused care, and how to redirect residents. She was unaware of a resident having behaviors and PTSD, what his triggers were, and what to do about them. During an interview on 4/10/25 at 11:13 A.M., Regional Clinical Support 2 indicated the corporation had in services the employees have to do on their electronic training program, but in person in services were decided by the facility depending on what their resident's needs were and depending on what it dealt with, it usually wasn't for all employees. During an interview on 4/10/25 at 11:33 A.M., the ADON indicated they don't give in services based on specific mental health diagnoses, such as schizophrenia, PTSD, or TBI, but they will in the future. On 4/10/25 at 3:00 P.M., a current Behavioral Health Management Program Policy, dated January 2024, was provided by Regional Clinical Support 2 and indicated [company name] communities provide services to our residents with specific diseases and disorders. Some of our residents have medical disabilities that can lead to disruptive behaviors and these behaviors have the potential to create a negative effect on the resident, other residents, visitors, and staff. It is [company name]'s policy that each community will have a behavior program that: identifies, monitors, manages, and disseminates (whenever possible) all behavior events . each individual resident will receive services according to their needs . Residents who demonstrate any of the following characteristics should be involved in the behavior program . any resident demonstrating new or worsening behaviors . unresolved repetitive behaviors . currently has a doctor's order to use antipsychotic, antidepressant . Each [company name] facility will use the following documents to track behaviors and document ongoing services/interventions . The nurse or social services will complete a behavioral event in the electronic medical record for each new or worsening behavior the resident demonstrates .CNAs are able to document . during the clinical meeting, when the IDT [Interdisciplinary team] is present, each behavior will be discussed . IDT will write a note . It is [company name] policy to ensure etiology of a resident's behavior is thoroughly investigated, documented, and care planned . On 4/11/25 at 9:00 A.M., a current In service Education Meeting excerpt from the Employee Handbook was provided by the administrator and indicated Regular training and education for associates is provided to promote an informed and competent staff and to maintain a high quality of resident service and care . This training is provided in compliance with all relevant State and Federal regulations . 3.1-37(a) 3.1-43(a)(1)

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from sexual abuse by staff for 1 of 3 residents reviewed for abuse allegations. (Resident C) This deficient practice resulted in an alert and oriented female resident alleging staff to resident sexual abuse on 12/28/24 when Resident C indicated that Certified Nurse Aide (CNA) 13 lifted her gown during care and licked or sucked on her breast a week prior. CNA 13 indicated to a police detective on 12/21/24 that, she asked me to do it, so I done it, to shut her up. This Immediate Jeopardy began on 12/18/24 at approximately 4:00 P.M. when Resident C alleged that CNA 13 had lifted her gown and placed his mouth on her breasts. Resident C was tearful during staff interviews and indicated that she did not want the staff member to place his mouth on her breasts. On 12/21/24 local law enforcement placed CNA 13 under arrest after admitting the allegation. CNA 13 indicated to the police detective that he was assisting Resident C and she was flirting with him so he did it for like two seconds. The Facility Administrator 2 was notified of Immediate Jeopardy on 1/22/25 at 1:05 P.M. The Immediate Jeopardy was removed, on 1/24/25 at 1:44 P.M., and the deficient practice was corrected on 12/21/24, prior to the start of the survey and was therefore Past Noncompliance. Finding includes: An Indiana Department of Health (IDOH) Facility Reportable Incident (FRI) form, dated 12/18/24 at 4:15 P.M., indicated Resident C reported, a CNA made contact with her chest area during care . CNA 13 was suspended during the investigation. The facility's investigation of Resident C's allegation included an untimed, typed note, signed by the Social Service Director (SSD), dated 12/18/24. The note indicated when asked if anyone that worked at the facility had ever made her uncomfortable or scared, Resident C began to cry and stated, yes, [CNA 13]. When asked what CNA 13 had done to make her feel that way, Resident C indicated, he sucked my boob, and it felt weird. An untimed and unsigned, typed, facility interview summary with CNA 13, dated 12/19/24, indicated CNA 13 assumed the allegation of abuse came from Resident C because Resident C said things like that, rubbed his arm, and tried to hug him. The interview summary indicated CNA 13 identified he was always by himself in the resident's room. An undated local PD investigation report indicated a police officer arrived at the facility, on 12/20/24, and spoke with Facility Administrator 1 and the Social Service Director (SSD). Staff informed the police officer that Resident C had alleged that CNA 13 had, sucked on her nipples . for a while. CNA 13 had told her not to tell anyone. On 1/21/24, CNA 13 was placed under arrest for an offense of sexual battery after indicating to local PD that, .she asked me to do it, so I done it . The follow-up FRI, dated 12/26/24, indicated a police report was made by the facility. The police department started their investigation. The police department did notify the facility that the alleged employee was detained and that their investigation is ongoing. During an interview, on 1/21/25 at 12:30 P.M., Facility Administrator 2 and Registered Nurse (RN) 4 indicated CNA 13 admitted to sucking Resident C's nipples during a local Police Department (PD) investigation. During record review, on 1/22/25 at 10:45 A.M., Resident C's diagnoses included, but were not limited to cerebrovascular disease, major depressive disorder, anxiety, dysphagia, altered mental status, and chronic pain. The most recent quarterly Minimum Data Set (MDS) assessment, dated 11/13/24, indicated the resident had no cognitive impairment, had occurrences of feeling down, depressed, and/or hopeless, one-sided upper extremity impairment, had lower extremity impairment to both sides, was dependent while toileting, and required substantial to maximum assistance of two staff members to roll left to right in bed. A care plan, revised 1/15/25, included Resident C had specific needs related to their care. An intervention included bed mobility, resident dependent upon two-person assistance. During an observation and interview, on 1/22/25 at 3:00 P.M., Resident C was observed sitting up in bed in her room. She was wearing a gown. The resident spoke coherently but did not answer direct questions. A male entered the resident's room and identified himself as Resident C's boyfriend. The male indicated a staff member had touched Resident C inappropriately. During an interview on 1/24/25 at 2:30 P.M., the SSD indicated that Resident C did require reassurance that CNA 13 would not be returning to the facility. On 1/21/25 at 2:00 P.M., The Facility Administrator 2 supplied a facility policy titled, Abuse, Neglect, and Misappropriation Prohibition and Prevention Policy, dated 6/4/19. The policy indicated, It is the policy of [company name] . to provide each resident with an environment that is free from verbal, sexual, physical, and mental abuse . b. Examples of Actual Abuse: .iii. Rape or inappropriate sexual touching or relationship between staff and resident . The past noncompliance Immediate Jeopardy began on 12/18/24. The Immediate Jeopardy was removed on 1/24/25 and the deficient practice corrected 12/21/24 after the facility implemented a systemic plan that included the following actions; in-services related to procedures for resident abuse and ongoing monitoring. This citation relates to complaint IN00449522. 3.1-27(a)(1)

Based on interview and record review, the facility failed to ensure a resident was free from accidents for 1 of 3 residents reviewed for the use of a mechanical lift. A resident was in the process of transferring in a mechanical lift while the lift pad was wrapped under the resident's legs rather than through the resident's legs. The resident did not possess the required stability to transfer safely with the lift pad wrapped under her legs. The resident slid feet first out of the lift pad which resulted in multiple lower extremity fractures and a laceration to the back of her head. The resident was transferred to a local Emergency Department (ED) where she expired. (Resident D) This Immediate Jeopardy began on [DATE] at approximately 7:50 A.M., when Resident D fell 3.5 to 4 feet from a mechanical lift while being transferred by Certified Nurse Aide (CNA) 6 and CNA 7. Resident D's fall resulted in a left femur fracture, left tibial fracture, right femur fracture, right ankle fracture, and a 3-centimeter (cm) laceration to the back of her head. Resident D expired at a local ED on [DATE] at 10:42 A.M. While Resident C was being transferred in the mechanical lift, CNA 6 and CNA 7 wrapped a lift pad under the resident's legs, rather than through her legs, due to the resident's rigidity in her lower extremity. The resident lacked the required good torso stability to use the under-leg method, as stated in the mechanical lift operator's instructions, and no assessment had been completed that indicated the resident was appropriate for the use of that method. Facility Administrator 2 was notified of Immediate Jeopardy on [DATE] at 3:10 P.M. The Immediate Jeopardy was removed on [DATE] at 4:48 P.M, and the deficient practice corrected, on [DATE], prior to the start of the survey and was therefore Past Noncompliance. Finding includes: An Indiana Department of Health (IDOH) Facility Reportable Incident (FRI) form dated [DATE] at 7:50 A.M., indicated that Resident D had a witnessed fall during a transfer using a lift with two staff present. The resident sustained a laceration to her head and complained of pain. Resident D was sent to Emergency Department (ED) for evaluation. An IDOH FRI follow up report dated [DATE], indicated the resident was found to have sustained a left distal femur fracture, left tibial fracture, a right distal femur fracture, and a right ankle fracture. Resident D passed while in the hospital. The facility's investigation report of Resident D's fall, on [DATE], included a typed note signed by CNA 6, dated [DATE]. CNA 6 indicated she and CNA 7 entered Resident D's room while Resident D was lying in bed. Following care and dressing the resident, a lift pad was placed under the resident. The bottom of the lift pad was crossed under Resident D's legs. The lift pad straps were hooked to the mechanical lift so that Resident D would be sitting up in a sitting position and due to the condition of the resident's legs. One of the resident's legs is stiff while the left leg hangs due to the resident having no use of her left side. CNA 6 was operating the mechanical lift. CNA 6 lifted Resident D up high enough that her legs were off the bed. CNA 7 was on the left side of the bed toward the bottom of the bed. CNA 6 pulled the lift out from her bed to place the resident in her chair when she began to fall feet first from the lift pad. As the resident's feet hit the floor, CNA 6 was trying to catch her head. Resident D's head came back and hit the battery box on the mechanical lift. The mechanical lift did not tip. Nursing was immediately notified. An untimed, typed interview conducted, dated [DATE], indicated CNA 6 did not know what went wrong during the transfer of Resident D. The report indicated CNA 6 placed the lower lift pad straps under the resident's legs, but did not place the excess sling legs over the thighs because one leg was kind of stiff and the other leg was flaccid. The report indicated CNA 6 reported the resident fell from the lift pad feet first and the pad remained attached to the mechanical lift. An untimed, typed interview with CNA 7, dated [DATE], included the question, What do you think went wrong? CNA 7 indicated, .If we would have put the pad in between (Resident D's) legs, it may have helped keep her in the pad . On [DATE] at 9:30 A.M., the mechanical lift, EZ Way Smart Lift 500, 600, & 1,000 pound (lb) Capacities Operator's Instructions, dated [DATE], was reviewed. The instructions indicated, Step 1 Position sling under resident . 6) Lift patient's left thigh and pull the left sling leg of the sling under patients' thigh. Then place excess sling leg over the top of the patient's left thigh. 7) Repeat the above step for right thigh. NOTE: If the patient's legs are extremely rigid, it may work better to bring the left sling leg under the right thigh and the right sling leg under the left thigh instead of threading between the patient's legs. The patient must have good torso stability to use this method . Assistant Director of Nursing (ADON) indicated during an interview, on [DATE] at 1:40 P.M., the facility used the EZ Way Smart Lift 600 mechanical lifts. The ADON indicated during an interview, on [DATE] at 12:30 P.M., she came to the facility on [DATE] following Resident D's fall from the mechanical lift. The ADON indicated, in an effort to understand what happened during the transfer, staff reenacted the transfer of Resident D, by transferring the ADON using the same lift and using same method . The ADON indicated that there were no issues during the reenactment, but that she possessed better body control than Resident D. A record review, on [DATE] at 11:00 A.M., indicated Resident D's diagnoses included, but were not limited to, hemiplegia (paralysis or weakness of one side of the body) and hemiparesis (paralysis or weakness on side of body) following nontraumatic intracerebral hemorrhage affecting the left non-dominant side, age-related physical debility, lack of coordination, weakness, and pain. Resident D's the most recent quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated a cognitive function assessment could not be completed due to the resident being rarely to never understood. Resident D had functional limitations to both right and left upper and lower extremities, was dependent for all transfers and mobility use of mech lift with two assistants, and utilized a wheelchair. Resident D's physician orders included, but were not limited to, physical therapy evaluation and treatment (started [DATE]). PT Evaluation & Plan of Treatment, dated [DATE], was reviewed. The evaluation indicated prior equipment used included a Broda chair (specialized chair), hospital bed, and mechanical lift. Prior level of function indicated resident was dependent for mobility and for all care. Resident D's mobility function was assessed with score of 0 out of 12 with 12 being highest or poor and 0 being the lowest. Resident D's balance assessment indicated the resident could not sit unsupported for 30 seconds, resident was unable to sit at the edge of bed, and resident was unable to stand without upper extremity support. Resident D's care plan included, but was not limited to, Resident has specific needs related to their care. Interventions included, the resident is a two person assist with mechanical lift for transfers (started [DATE]), use assistive device wheelchair (started [DATE]). Resident has self-care deficits related to left side hemiplegia/hemiparesis. An intervention included, follow guidelines of physical therapy (PT) (started [DATE]. Most recent review of plan was [DATE]. Resident D's nurse's progress notes included, but were not limited to: [DATE] at 11:03 A.M. - Resident has left lower extremity edema. Extremity elevated on pillow when in bed and when up in Broda chair. [DATE] at 8:30 A.M. - During a transfer, the resident fell on to floor while two staff were assisting with transfer. A 3 cm laceration was noted to the back of head. Bilateral legs were bent underneath resident. Resident complaining of pain all over. Ambulance at facility at 8:15 A.M. [DATE] at 11:30 A.M. - ED notified the facility that Resident D had passed away at hospital. Resident D's ED nursing progress note, dated [DATE] at 9:53 A.M., indicated Resident D was dropped from a lift operated by two CNA's and fell approximately 3.5 - 4 feet. The resident struck the back of her head on the lift. Emergency Medical Services (EMS) reported that Resident D was found in her room, on the floor, under the lift pad when they arrived at the facility. Hospital records included: Resident D's ED physician's progress note, dated [DATE] at 11:09 A.M., indicated Resident D fell out of a mechanical lift that morning. The resident hit the back of her head and her legs were bent under her. Resident D's physical examination indicated obvious deformity at left upper leg with bruising to the left knee. Resident D presented with trauma from fall with a concern of multiple injuries. At 10:35 A.M., Resident with extensive orthopedic trauma that included bilateral femur fractures and a right ankle fracture. At 10:45 A.M., Resident became apneic (temporary loss of breathing) and asystole(cardiac arrest). No heart sounds were heard. Resident D's time of death was 10:42 A.M. Final radiology results included a left femur fracture, left tibial fracture, right femur fracture, and a right ankle fracture. The Physical Therapy (PT) Director indicated during an interview, on [DATE] at 11:40 A.M., there was not a specific assessment to be completed for residents who required transfer with a mechanical lift using the under-leg method with the lift pad. The PT Director indicated that a balance test would be a good indicator of a resident's torso stability or if the resident was able to sit up at their bedside. The PT Director indicated during an interview, on [DATE] at 12:15 P.M., Resident D's balance assessment likely was not fully completed due to the resident being unable to perform any of the needed exercises to assess her balance. The PT Director indicated the resident had been using a Broda chair and that Broda chairs were generally used for residents who are unable support themselves in a regular wheelchair. The facility mechanical lift training documentation, dated [DATE], indicated CNA 6 completed a mechanical lift skills checklist, but did not include documentation to indicate CNA 6 was trained and competent to perform transfer with the EZ Way Smart Lift prior to [DATE]. During an interview, on [DATE] at 11:55 A.M., the ADON indicated that all staff completed the facility validations skills checklist for mechanical lifts. The facility had not initially provided the EZ Way Smart Lift competency checklist for new hires but did provide the training and ensure competency to all nursing staff immediately following the incident on [DATE]. On [DATE] at 3:30 P.M., Facility Administrator 2 and RN 4 indicated prior to Resident D's fall, on [DATE], no specific assessments were in place to determine which transfer methods were best suited for each resident that required a mechanical lift. Resident C had fallen as CNA 6 was pulling the mechanical lift out from under Resident D's bed. CNA 7 was at the foot of the bed and could not reach the resident as she slid from the sling until her feet hit the floor. CNA 7 could not support the resident as she continued to fall next to the bed. On [DATE] at 3:50 P.M., CNA 16 indicated that she had received training regarding the use of mechanical lifts for transfers following Resident D's fall on [DATE]. CNA 16 indicated that she was initially trained to place the mechanical lift pad straps through a resident's legs when transferring but had seen other staff use the under-leg method when using the mechanical lift. CNA 16 indicated that prior to recent in-services and trainings, CNA's that who provided assistance with mechanical lift transfers were able to determine which method to use and different staff used different methods. The EZ Way Smart lift Operator's Instructions provided by Facility Administrator on [DATE] at 9:30 A.M. indicated, For safe operation of the EZ Way Smart Lift, operators should watch the training video, read through this manual, complete the competency checklist, and practice on fell ow staff members before use with patients. On [DATE] at 10:00 A.M., the Facility Administrator supplied a current facility policy titled, Safe Use of a Mechanical Lift, dated [DATE]. The policy indicated, [Company name] . are committed to taking steps to ensure the resident environment remains free of accident hazards as is possible and that each resident receives adequate supervision and assistive devices to prevent accidents . if facility training and instructions shall always be reviewed and followed . At least 2 [two] trained staff members are needed to safely move a resident using a mechanical lift . Lift design and operation varies across manufactures. Staff will be trained and demonstrate competencies using the lifts utilized in their community. Attached to the facility policy was a copy of the Transferring a Resident with a Hoyer/Mechanical Lift Skills Validations checklist. The checklist indicated, .9. One staff member will man the lift while the other staff member stabilizes the resident's head and feet during the transfer . 11. Raise sling/resident . 12. Have a staff member support the resident's legs while the other monitors the movement of the lift . 13. Raise the lift high enough to clear the bed and unlock the wheels of the lift . 14. One staff member moves the lift in position and lines the lift up to the chair, while the other staff member supports the legs and feet during the move. The past noncompliance Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was removed and the deficient practice corrected by [DATE] after the facility implemented a systemic plan which included the following actions: in-services related to procedures for the use of mechanical lifts and ongoing monitoring. This citation relates to complaint IN00450157. 3XXX,d+[DATE](a)(1) 3XXX,d+[DATE](a)(2)

Based on interview and record review, the facility failed to completely and accurately report an allegation of sexual abuse to the state agency for 1 of 3 allegations of abuse reviewed. (Resident C) Finding includes: During a review of facility reported incidents on 1/21/25 at 11:45 A.M., an Indiana Department of Health (IDOH) Reportable Incident form, dated 12/18/24 at 4:15 P.M., indicated, [Resident C] stated that a Certified Nurses Aide [CNA] made contact with her chest area during care last week. She stated she had not reported to staff until now, but that she had told her roommate. One should note that resident does not have a roommate. A follow up to the incident, dated 12/26/24, indicated, Resident [C] continues to receive psychosocial monitoring and support as necessary. (Psychiatrist name) continues to follow resident. The facility investigation did not conclude any witnesses to any type of inappropriate actions from the alleged employee or any other employee. The alleged employee remained suspended during the investigation then was terminated. A police report was made by the facility. The police department started their investigation. The police department did notify the facility that the alleged employee was detained and that their investigation is ongoing. During review on 1/21/25 at 2:00 P.M., the facility's investigation of Resident C's allegation included a typed note signed by the Assistant Director of Nursing (ADON). The note indicated on 12/18/24 at approximately 4:00 P.M. the ADON was present in Resident C's room when Resident C indicated CNA 13 licked my nipples. A review of the local police department investigation report indicated that a police officer arrived at the facility on 12/20/24 and spoke with Facility Administrator 1 and the Social Service Director (SSD). Staff informed the police officer that Resident C had alleged that CNA 13 had sucked on her nipples . for a while. CNA 13 had told her not to tell anyone. On 1/21/24, CNA 13 was placed under arrest for an offense of sexual battery after indicating to a police detective that, .she asked me to do it, so I done it . During an interview on 1/22/25 at 10:25 A.M., RN 4 indicated that the facility was notified by the local police department on 1/21/24 that CNA 13 had admitted to Resident C's allegation. On 1/21/25 at 2:00 P.M., Facility Administrator 2 supplied a facility policy titled, Abuse, Neglect, and Misappropriation Prohibition and Prevention Policy, dated 6/4/19. The policy indicated, .C. Reporting to State Agencies and Local Law Enforcement 1. Allegations of abuse . will be reported immediately to the State licensing/certification agency . 4. Information reported to the agencies will include, as a minimum: .c. The type of allegation (abuse .) involved . 5. If a thorough investigation supports a conclusion that an associate of our Community is licensed or registered with the professional licensing agency or nurse aide registry and has abused . or mistreated a resident . the Administrator or designee shall ensure the allegation is reported to the appropriate board, agency or registry . This citation relates to complaint IN00449522. 3.1-28(b)(2) 3.1-28(c)

Based on observation, interview, and record review, the facility failed to ensure the plan of care was implemented for 1 of 3 residents reviewed for resident abuse. A resident was not assisted by two staff members during a transfer according to the resident's plan of care. (Resident C) Finding includes: During a review of facility reported incidents on 6/10/24 at 12:30 P.M., a reported incident dated, 6/6/24 included that Resident C state that QMA was rough with her when positioning leg during a transfer. During record review on 6/11/24 at 10:30 A.M., Resident C's diagnoses included, but were not limited to, age-related physical debility, contracture of left knee, infection and inflammatory reaction due to internal left hip prosthesis, and unspecified displaced fracture of fourth cervical vertebra. Resident C's most recent Admission MDS (Minimal Data Set) assessment, dated 4/21/24, included that Resident C had no cognitive impairment, had one-sided impairment to upper and lower extremities, and was dependent for transfers. Resident C's physician orders included, but were not limited to, up as tolerated per plan of care (initiated 4/18/24). Resident C's care plan included, but was not limited to; Resident requires assistance with ADLs including bed mobility and transfers. Interventions included, follow physical therapy/occupational therapy recommendations, provide assistance for transfers as needed, and provide assistive device as needed (started 4/25/24). During a review of CNA POC (Point of Care) documentation from 6/1/24 to 6/10/24, Resident C required total dependence daily for transfers. The facility's investigation of the reported incident from 6/6/24 included an undated handwritten note signed by PT 4 and included, .when I got to [Resident C's] room and observed [CNA 6] attempting to put [Resident C] in (wheelchair) with Hoyer lift alone. [CNA 6] had Hoyer lift control in her right hand and was pulling on [Resident C's] left leg, which made [Resident C] yell out in pain. I went into [Resident C's] room to assist and also noticed that the arm of the Hoyer (lift) was very close to [Resident C's] face . During an observation on 6/11/24 at 11:15 A.M., Resident C was lying in bed. Her left knee was bent and she appeared to have difficulty rolling over in bed without assistance. During an interview on 6/11/24 at 1:45 P.M., PT 2 indicated that Resident C was assessed to be dependent for transfers and required a mechanical lift such as a Hoyer lift for transfers and that two staff members are required to assist with a mechanical lift. During an interview on 6/11/24 at 2:00 P.M., PT 4 indicated that they had observed Resident C being transferred in a Hoyer lift by one staff member and that two staff should always be present during a Hoyer lift transfer to ensure resident and staff safety as well as proper positioning. On 6/11/24 at 3:40 P.M., the DON supplied a facility policy titled Safe Use of a Mechanical Lift, and dated 2/1/23. The policy included, .At least 2 trained staff members are needed to safely move a resident using a mechanical lift. This citation relates to complaint IN00432682. 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident's right to privacy was protected for 1 of 3 residents reviewed for privacy. Two photographs of a resident, taken by facility staff, were shared to the facility's social media website without the resident's consent. (Resident F) Finding includes: During an interview and observation on 4/15/24 at 10:50 A.M., Resident F indicated that staff had shared photographs of her on the facility's social media website after she had refused consent to do so. Resident F indicated that a friend had contacted her after seeing the photographs on the facility's social media website. Resident F indicated that one of the photographs was taken during the solar eclipse (4/8/24) and the other was taken around Easter (2024). Resident F had saved the photographs to her personal phone. An observation of the images showed Resident F sitting in a wheelchair in what appeared to be the facility parking lot, and another image showed Resident F posing with an Easter bunny. During record review on 4/15/24 at 1:30 P.M., Resident F's diagnoses included, but were not limited to, intestinal obstruction, Sigmoid colostomy, abnormal posture, and age-related physical debility. Resident F's most recent Annual MDS (Minimum Data Set) assessment, dated 2/22/24, indicated that Resident F had no cognitive impairment, used a wheelchair for mobility, and required partial to moderate assistance with transfers. A Photography and Videography Consent Form/Release signed by Resident F and dated 1/30/24 included a checked box next to the statement, I do not grant permission to Community and its affiliates to take photographs, video footage and/or digital images of myself or grant the unrestricted right to permission to use, copyright and publish such video footage & photographs of me in print and/or electronically. My refusal will not affect my ability to obtain treatment or residency at Community. During an interview on 4/15/24 at 2:30 P.M., the Activity Director indicated that Resident F had previously consented to photographs, but had recently withdrawn permission to use her image. The Activities Director indicated that facility staff had shared images of Resident F on the facility's social media website, but had removed the photographs after being made aware that Resident F had withdrawn permission. On 4/16/24 at 12:15 P.M., the Director of Nursing supplied a facility policy titled, Compliance - Social Media Policy, dated 08/2016. The policy included, .Procedure for Institutional Posting .III. What Not to Post .C.Photographs of residents may be posted on Institutional Social Media in accordance with Community Policies and Procedures and always with the resident's knowledge and consent. This deficiency relates to complaint IN00430034. 3.1-3(o)

Based on interview and record review, the facility failed to ensure services of an RN (Registered Nurse) were available at least 8 consecutive hours a day, 7 days a week for 1 of 27 days reviewed from the PBJ (Payroll Based Journal) Staffing Data Report during Quarter 4 of 2023 (weekends from July 1, 2023 through September 30, 2023). Finding includes: On 2/13/24 at 9:30 A.M., the Time Card Report from 7/1/23 through 9/30/23 was reviewed. Review of the Time Card Report indicated there was not any RN coverage on 9/29/23. During an interview on 2/7/24 at 1:46 P.M., the Administrator indicated the facility utilized Qualified Medication Aides (QMA) which may make their staffing ratio low. Corporate submits their staffing to the PBJ. On 2/14/24 at 12:33 P.M., a policy was requested, but not received during the survey period. 3.1-17(b)(3)

Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident in order to meet medical needs that were identified in the comprehensive assessment. Staff did not follow orders and implement care plan interventions for 6 of 8 residents reviewed for falls and nutrition. (Resident 38, Resident 53, Resident 68, Resident 2, Resident 64, Resident 80) Findings include: 1. On 2/5/24 at 10:00 A.M., Resident 38 was observed sitting in a wheelchair beside the bed. She was leaning over with her arms and head resting on the bed, her butt still in the wheelchair, and wearing socks that were not non-skid. On 2/7/24 at 1:57 P.M., Resident 38 was observed sitting in a wheelchair in her room with a bedside table in front of her. Resident 38 was wearing socks that were not non-skid. On 2/8/24 at 8:01 A.M., Resident 38's clinical record was reviewed. Diagnosis included, but were not limited to, dementia, anxiety, and right femur fracture. The most recent Admission MDS (Minimum Data Set) Assessment, dated 1/17/24, indicated cognition status could not be determined. Resident 38 was dependent on staff with toileting and bathing, and had experienced a fall with fracture prior to admission. A current risk for falls care plan, dated 1/12/24, included, but was not limited to, the following intervention: Resident to have non skid socks while out of bed, dated 1/23/24. On 2/12/24 at 9:51 A.M., Licensed Practical Nurse (LPN) 7 indicated Resident 38 was supposed to have on non-skid socks at all times as a fall intervention. 45933 2. During an observation on 2/8/24 at 5:21 A.M., Resident 53 was observed sitting in a wheelchair in the common area with plain white socks on both feet. During an observation on 2/8/24 at 7:24 A.M., Resident 53 was observed in a wheelchair in the common area with plain white socks on both feet. On 2/7/24 at 10:56 A.M., Resident 53's clinical record was reviewed. Resident 53's current diagnoses included, but was not limited to, Alzheimer's disease and anxiety disorder. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 11/21/23, indicated Resident 23 required extensive assistance of 2 people for bed mobility and transfers. Resident 53's current Physician Orders included, but was not limited to, Resident uses the following mobility devices: Wheelchair, dated 11/14/23. Resident 53's care plan included, but was not limited to, .at risk for falling and fall related injuries due to cognitive deficits secondary to dementia, auditory hallucinations, and a history of falls before admission, last revised 12/13/23. Current interventions included, but was not limited to, .Resident to wear non-skid socks at all times . start date 11/14/23. 3. During an observation on 2/5/24 at 2:21 P.M., Resident 68 was observed sleeping in bed. A padded mat was folded up and placed underneath the bed. During an observation on 2/8/24 at 5:20 A.M., Resident 68 was observed sleeping in bed. A padded mat was leaning sideways on the air conditioner system. On 2/8/24 at 9:50 A.M., Resident 68's clinical record was reviewed. Current diagnoses included, but was not limited to, Parkinson's disease, anxiety disorder, and ataxic [without coordination] gait. The most recent Significant Change MDS, dated [DATE], indicated the resident had a fall in the last month prior to admission or reentry. Resident 68's current Physician's Orders included, but was not limited to, .up as tolerated per plan of care, dated 1/25/24 Resident 68's care plan included, but was not limited to, .Resident at risk for falling and fall related injuries related to Parkinsons, revised 2/2/24. Current interventions included, but was not limited to, .padded mat at bedside . start date 7/13/23. During an interview on 2/12/24 at 10:06 A.M., Licensed Practical Nurse (LPN) 33 indicated Resident 53 should have non-skid socks on at all times and Resident 68 should have a fall mat placed on the floor beside his bed when he is in bed. 46416 4. On 2/7/24 at 12:14 P.M., Resident 2's clinical record was reviewed. Diagnoses included, but were not limited to, traumatic brain dysfunction, seizures, and persistent vegetative state. The most recent MDS Assessment, dated 12/5/23, indicated the resident's cognition was not able to be assessed, had weight loss, height was 6 foot, weight was 149 lbs (pounds), and he was totally dependent on 2 staff for bed mobility, transfers, and toileting. Physician's orders included, but were not limited to, the following: Obtain and record daily weight upon rising before am feeding, ordered 7/24/23 and discontinued 8/24/23 Jevity 1.5 per pump. Rate: 55 ml/hr continuous. 50 ml of flush three times a day, ordered 5/2/23 and discontinued 10/30/23 Jevity 1.5 per pump. Rate: 65 ml/hr continuous. 150 ml of flush every 6 hours, ordered 10/30/2023 The clinical record lacked a current order for weights to be completed on Resident 2. A current Feeding Care plan, revised 11/27/23, included, but was not limited to, the following intervention: Monitor and record weight per MD (Medical Doctor) order, initiated 5/16/17 Progress Notes included, but were not limited to, the following: On 6/14/23-Resident weight: 157.7 lbs, Registered Dietician (RD) recommended weekly weights x 4 to be done On 6/19/23-Order for weekly weight from RD were put in (5 days later) On 7/18/23-Resident weight 145.4 lbs, RD recommended daily weights On 7/24/23-Order for daily weight was put in from RD (6 days later) On 8/15/23-Resident weight 141.2 lbs, RD recommended to increase Jevity tube feed from 55 to 65 ml/h (milliliter per hour) with 150 ml flush every 6 hours and continue with weight monitoring On 9/20/23-Resident weight on 9/4/23 was 146.7 lbs, RD recommended increase Jevity tube feed from 55 to 65 ml/h (milliliter per hour) with 150 ml flush every 6 hours On 10/23/23-Resident weight on 10/5/23 was 145.2 lbs, RD recommended increase Jevity tube feed from 55 to 65 ml/h and with 150 ml flush every 6 hours On 10/30/23-Order for Jevity tube feed from 55 to 65 ml/h was entered (2.5 months later) Review of resident weights from 6/1/23 to 8/24/23 when the daily weight order was discontinued were reviewed. The order for daily weights was entered on 7/24/23 but not started until 8/2/23 and the following days were missing: 8/8/23 8/10/23 8/11/23 8/17/23 8/20/23 5. On 2/9/24 at 2:46 P.M., Resident 64's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's, dementia, dysphagia. The most recent Quarterly MDS Assessment, dated 11/6/23, indicated Resident 64's cognition was severely impaired and he was an extensive assist of 2 staff for bed mobility, transfers, and toileting. Physician's Orders included, but were not limited to the following: Obtain and record weekly weigh, ordered 2/6/24 A current Nutrition/Weight Loss Care plan, revised 1/23/24, included, but was not limited to, the following interventions: Monitor/record weight routinely, notify MD/RD of significant weight changes, initiated 12/4/20 Progress notes included, but were not limited to the following: On 11/17/23 9:33 A.M.-Wt [weight] record showing 13# [pound] loss in one month. Recommend to reweigh to verify accuracy. On 12/14/23 3:12 P.M.-Resident has a noted significant weight loss of 6.1% in 30 days . will be followed by IDT [interdisciplinary team and weight monitor weekly x 4 weeks. Plan of care in place and appropriate . On 1/23/24 11:29 A.M.- . nsg [nursing] noted prior edema which has resolved, and daily weights ordered to monitor changes . Resident 64's weights were reviewed from 9/4/23 to 2/5/24 and included, but were not limited to, the following weights: 10/6/23 220.1 lbs 11/6/23 206.6 lbs 12/6/23 204 lbs 12/10/23 203 lbs 12/17/23 204.2 lbs 12/24/23 200.4 lbs 12/31/23 196.4 lbs 1/4/24 196.4 lbs 1/7/24 197.8 lbs 1/14/24 196.9 lbs 1/21/24 195.7 lbs 1/28/24 187 lbs 2/5/24 197 lbs The clinical record lacked a reweigh for 11/17/23 and 1/28/24. During an interview on 2/9/24 at 3:45 P.M., Clinical Support 5 indicated the weight for 1/28/24 must have been an error but there was not a reweigh. During an interview on 2/12/24 at 3:34 P.M., the DON indicated she was not sure why Resident 64 was not weighed as recommended by the dietician. 6. On 2/8/24 at 9:31 A.M., Resident 80's clinical record was reviewed. Diagnoses included, but was not limited to, pressure ulcer of sacral region, unstageable and seizures The most recent Quarterly MDS Assessment, dated 1/22/24, indicated Resident 80 was cognitively intact and an extensive assist of 2 staff for bed mobility, transfers, and toileting. Physician's Orders included, but were not limited to, the following: Offer 240 ML Med-Pass Three Times A Day, ordered 12/4/23 Offer 30 ml pro heal liquid protein Once A Day Upon Rising, ordered 9/5/23 Obtain and record daily weight upon rising before breakfast, ordered 11/08/2023 and discontinued 12/13/2023 Weekly weight Once A Day on Mon, ordered 12/18/23 A current Nutrition Care Plan, revised 1/29/24, included, but was not limited to, the following interventions: Monitor/record weight routinely, notify MD/RD of significant weight changes, initiated 8/29/23 Progress notes included, but were not limited to, the following: On 11/17/23 10:32 A.M.-RD review . She has orders for daily weights to monitor changes . increase med pass from BID [twice daily] to TID [three times daily]. Continue with weight monitoring per order . On 12/4/23- Order from RD to increase Med pass to TID entered (17 days later) Resident 80's weights were reviewed from 11/6/23 to 1/15/24 and included, but were not limited to the following weights: 11/6/23 120 lbs 11/16/23 112.2 lbs 12/7/23 114.1 lbs During an interview on 2/12/24 at 1:59 P.M., the DON indicated she was responsible for getting the dietician's recommendations, asking the MD, and putting the orders into the resident's clinical record. She said the RD usually sends recommendations to her within 1 week of her visiting and she put orders in when she was able. During an interview on 2/12/24 at 3:34 P.M., Clinical Support 1 indicated the RD notes prior to October 2023 were before they started working at the facility and they weren't sure why the orders were missed. During an interview on 2/12/24 at 3:57 P.M., Clinical Support 1 indicated there was not a policy for the time frame orders should be put into the clinical record or for following MD orders but it was standard of Care to follow physician's orders. On 2/12/24 at 10:00 A.M., the Director of Nursing (DON) provided the Fall Prevention Policy and Procedure, dated May 2016, that indicated, .Care plans are a vital part of the nursing process and serve as an individualized pathway used by all care givers .Individualized interventions on the fall care plan will be duplicated onto care sheets to ensure care plan strategies are integrated into the health system . 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to ensure the physician was notified timely, and a thorough assessment was completed, for a resident's change in her leg circulation, resulting in hospitalization for the leg (Resident D); and failed to document assessments of a diabetic wound, keep the wound covered and a protective boot on as ordered, or notify the physician of noncompliance (Resident B), for 2 of 3 residents reviewed for quality of care regarding skin integrity and circulation. Findings include: 1. The closed clinical record of Resident D was reviewed on 2/12/20 at 10:40 A.M. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 10/30/19, indicated Resident D was cognitively impaired, and required extensive assistance of one staff for bed mobility, transfer, and dressing. The resident had no impairment in skin integrity. She was on a scheduled pain medication regimen in the previous 5 days, and also received PRN (as needed) pain medication. She had pain occasionally, and rated it a 4 on a scale of 1-10. A Care Plan regarding altered circulation was not found in the clinical record. Nursing Progress Notes included the following notations: 1/14/20 at 5:16 A.M.: Resident lethargic, difficult to arouse. Coughing green phlegm .N.O. (new order) received and noted. [MEDICATION NAME] (antibiotic) 1 gm IM (intramuscular) x 2 days. [MEDICATION NAME] 100 mg (antibiotic), CXR (chest x-ray) .Will continue to monitor. 1/14/20 at 5:24 A.M.: .Ordered CXR 1/14/20 at 9:26 A.M.: (Name of physician) will be coming in to see resident. 1/14/20 at 10:58 A.M.: This nurse noted right leg discolored to groin, foot dark purple in color. Cap (capillary) refill extremely sluggish. MD Notified order received to send to (name of hospital) for evaluation and treatment Resident D was transferred to the emergency roiagnom on [DATE] at 11:00 A.M. An Emergency Department (ED) note, dated 1/14/20 at 11:10 A.M., indicated: Patient presents to the emergency room from extended care facility due to right leg pain and the right lower extremity being cold to touch. Nursing home staff said the patient also has pneumonia per the doctor .The doctor was concerned at the nursing home about the patient's right leg and sent her to the emergency room for evaluation. Per the patient's daughter the discoloration of the right lower extremity was reported to the extended care facility on Saturday, January 11 .Physical Exam .RLE (right lower extremity) cool, dusky from the knee distally; no pulse detected by palpation or Doppler .Assessment/Plan: 1. Pneumonia, 2.[MEDICAL CONDITION], 3. Peripheral vascular occlusive disease The resident was transferred to another hospital as a direct admission on 1/14/20 at 2:15 P.M. That hospital's physician's history and physical, dated 1/14/20 at 6:15 P.M., indicated: Sent to ED for pneumonia and right leg pulses lost. Hx (history) taken from ED physician and family. Apparently, her right leg began to turn color and pulses were low to absent for as long as 4 days prior to arrival in ED .Appears in significant pain localized to right hip .Right leg cold and mottled (bluish color) up to above the knee. Tenderness in right groin .Assessment/Plan: Ischemic (reduced blood flow) leg Facility nursing Progress Notes included the following notations as late entries: 1/11/20 at 6:15 P.M.: (Recorded as Late Entry on 1/14/2020 11:18 AM) Res (resident) up in wc (wheelchair), rle (right lower extremity) noted to be discolored and cool to touch, denies pain. Res assisted to bed with legs extended and heels floating .able to make needs known, call light within reach. 1/11/20 at 8:19 P.M.: (Recorded as Late Entry on 1/14/2020 11:28 AM) res abed (sic) with no c/o (complaints) or distress noted. repositioned (sic) per staff, tolerated well. rle noted to be improving in color and temp with no c/o pain or distress noted. Call light within reach. Will monitor. 1/11/20 at 9:29 P.M.: (Recorded as Late Entry on 1/14/2020 11:36 AM) res remains abed (sic) at this time, appears to be resting comfortably. rle warm and dry with no pain noted with repositioning of leg and foot. res denies any needs at this time. Will cont (continue) to monitor. Documentation that the physician was notified of the resident's alteration in her leg circulation was not found at that time. Nursing Progress Notes continued: 1/12/20 at 4:35 A.M.: Resident has been restless a couple of times this shift, but has remains (sic) abed (sic), and was able to drift back to sleep each time. Bed is in low position, with PSA (personal safety alarm) in place, on and working. Will continue to monitor. A nursing Progress Note, dated 1/12/20 at 4:38 A.M., and edited on 1/16/20 at 8:03 A.M. due to more data available, indicated: .Resident has been c/o pain to hands, knees, legs, aching in elbows, and generalized stiffness. Checked rt (right) leg/advise (sic) of second shift nurse; resident has 3 second cap refill (with) faint pedal pulses, leg is tepid when palpated, pale in color Further documentation regarding assessment of the resident's leg, or that the physician was notified of the leg, was not found in the clinical record until 1/14/20, when the resident was transferred to the hospital. A Physician's note, dated 1/15/20 at 2:18 P.M., indicated, seen 1/14/20. In the early AM she had a turn for the worse. At 5AM [MEDICATION NAME] was ordered .pneumonia was worse. So as I was readying to come to see her I was called about her leg purple. I (sic) had been mottled and this AM was a lot worse .The problem has become serious. The new worry is that pneumonia has [MEDICAL CONDITION] and drop in BP (blood pressure) with [MEDICAL CONDITIONS] has resulted in potential deviatalization (sic) (deprive of vital properties, weakness) .Ambulance called On 2/13/20 at 9:50 A.M., RN 1 was interviewed. RN 1 indicated she was working on 1/11/20 and was informed Resident D's right leg was discolored. The resident was leaning over in her wheelchair, and so RN 1 instructed the staff to lay the resident down in bed. The staff put her to bed, she checked on the resident, and felt like the discoloration went away eventually. She told the night shift RN to keep an eye on it. RN 1 indicated she did not notify the physician, or create an event, or alert charting, because the resident's leg seemed to improve. She did not respond when questioned why she didn't chart her notes until after the resident was seen in the ER. On 2/13/20 at 10:00 A.M., RN 2 was interviewed. RN 2 indicated she worked day shift on 1/11/20 and 1/12/20. RN 2 indicated she did not notice anything different about the Resident D's leg, and couldn't believe it when she heard the resident went to the ER. She indicated the CNA staff never reported anything abnormal to her. 2. On 2/12/20 at 9:10 A.M., during the initial tour, the Unit Manager indicated Resident B had 2 pressure areas; 1 on her coccyx, and 1 on her ischial tuberosity (lower hip bone). Resident B was observed lying in a bed on an air mattress. The clinical record of Resident B was reviewed on 2/12/20 at 12:00 P.M. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Off every 2 hrs. for skin checks. A physician's orders [REDACTED]. Change every day. A Care Plan, initially dated 8/1/19 and edited 10/22/19, indicated: Problem: Resident has diabetic ulcer to right foot. The Approaches included: Administer treatment as ordered. A Wound Management document indicated, Wound Type: Diabetic Ulcer, Wound Location: Right heel .Date/Time Identified: 05/29/2019 .Date/Time Observed: 11/14/2019, 11:09 AM, Length - head to toe direction (centimeters): 0.4, Width - side to side direction (centimeters): 0.4, Can depth be measured: No .Tissue Type: Closed/Resurfaced, Wound edges/margins: small scab noted The most recent documentation regarding the appearance of the right heel wound, dated 11/18/19, indicated, Healed .area noted to be healed. dry skin noted. Md and family aware order to proceed with dry dressing for protection. Documentation that the resident refused to wear the multi podus boots, or that the physician was notified of the resident's refusal, was not found in the clinical record. On 2/12/20 at 10:30 A.M., 1:15 P.M., and 2:30 P.M., Resident B was observed lying in bed. She had her legs drawn up, with her heels flat on the bed. She did not have a sheet over her, and was bare-legged. She was not wearing any protective boots, and did not have a dressing on her right heel. On 2/12/20 at 2:55 P.M., the Unit Manager performed a wound assessment on Resident B. Resident B had an open area on her right outer heel, which had a hard reddened wound base. Redness surrounded the area. The Unit Manager indicated the area was a diabetic ulcer which had healed. The area opens and closes. The Unit Manager indicated Resident B was supposed to have a protective dressing on her right heel, because of the redness and the potential of it opening again, and did not like to wear her boots. A dressing was not observed on the resident or in her bed. On 2/12/20 at 2:55 P.M., LPN 2 was interviewed. LPN 2 indicated she had put a dressing on Resident B's right foot that morning at approximately 8:30 A.M. or 9:00 A.M., and that the resident must have kicked the dressing off. On 2/13/20 at 11:45 A.M., the Unit Manager measured the wound on Resident B's right outer heel as 1.8 cm x 1 cm. The wound bed was dry, and less red that day. The heels were on a pillow, and a foam boot was lying on the bed. The Unit Manager indicated she had placed a dressing on the resident herself that morning, and that the resident had already taken it off. The Unit Manager had notified the physician regarding the resident's refusal to wear the boots that morning, and was going to attempt a foam boot and to keep the resident's heels off loaded on a pillow. LPN 1 indicated the resident's wound was probably less red that day due to the resident not rubbing it on the bed. On 2/13/20 at 12:15 P.M., the Unit Manager provided the current facility policy, Acute Condition Changes, revised December 2012. The policy included: .Before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the Physician .The nursing staff will contact the Physician based on the urgency of the situation .The Nurse and Physician will discuss and evaluate the situation On 2/13/20 at 12:15 P.M., the Unit Manager provided the current facility policy, Skin Assessment Policy, undated. The policy included: Residents .will have a head-to-toe assessment completed by a licensed nurse upon admission and weekly thereafter .If a new skin condition is identified by a licensed nurse while completing a skin assessment, the nurse will open the appropriate 'Skin Integrity Event' in Matrix (electronic record) The licensed nurse that discovers a new open area will perform the following actions: 1. Notify the MD, obtain and enter a treatment order. 2. Apply the initial treatment .4. Inform other caregivers to ensure preventative interventions actions are put into place to promote healing and inhibit development of additional areas. 5. Document these items in the medical record. This Federal tag relates to Complaint IN 291. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and/or effective interventions were provided, in that, a resident was left unattended in the shower room and experienced a fall (Resident #55) and/or safety equipment did not activate and the resident experienced 2 falls. (Resident #17). This deficient practice resulted in Resident #17 experiencing fractures to the left shoulder, right first metacarpal, and right patella. Findings include: 1. During an observation on 8/18/14 Resident #17 was observed sitting in her recliner with her walker in front of her. The Clinical Record of Resident #17 was reviewed on 8/18/14 at 3:38 P.M. The record indicated Resident #17 was admitted on [DATE] with [DIAGNOSES REDACTED]. Fall 1. A Progress Noted dated 1/3/14 at 1:00 A.M. read as follows: Called to res (resident) room 301, found res lying supine on floor. Res had L shaped lac (laceration) to upper lip, with bleeding controlled. Nose sl (slight) swollen with blood at bil (bilateral) nares. Bil patellae with hematomas. Post right hand ecchymotic. C/o (complains of) L (left) upper arm/shoulder pain.States 'I thought I could make it to the bathroom'.transfer res to ER (emergency room ) for evaluation. A Progress Note dated 1/3/14 5:20 A.M. read as follows: Report received from (name of hospital) ER that res has been sent to (another hospital in a different town) for admission there, with with dx: (diagnosis) Fx (fracture) L (Left) humerus, Fx R (Right) hand/thumb, and Fx R Patella. The Admission MDS (Minimum Data Set Assessment) dated 10/22/13 indicated Resident #17 had moderate cognitive impairment and required extensive assistance of two people with transfers and the assistance of 1 person when ambulating. Resident #17 was only able to stabilize with assistance for balance, transfers and walking. The Discharge MDS (Minimum Data Set Assessment) dated 1/3/14 indicated Resident #17 had moderate cognitive impairment and required the assistance of 1 person with transfers and ambulating. Resident #17 was only able to stabilize with assistance for balance, transfers and walking. A Care Plan for falls with a start date of 11/2/13 read as follows: .Up with the assist of one with walker for transfers and ambulation.Alarm to bed and chair. Check placement and function every shift. An Admission Fall Risk assessment dated [DATE] 10:10 P.M. indicated Resident #17 had experienced One or Two Falls in the last 3 months and was at risk for experiencing a fall. The (hospital name) emergency room discharge deposition dictated 1/3/14 for Resident #17 read as follows: ASSESSMENT 1. Left Shoulder fracture dislocation. 2. Right first metacarpal fracture. 3. Right patella fracture. Fall 2. A Progress Noted dated 6/14/14 at 1:10 A.M., read as follows: Walking down hall, Pt (patient) roommate hollered out and found name (Resident #17) in floor sitting upright on bottom in floor in front of sink in the bathroom.when asked why she didn't sound alarm or wait for someone she stated I couldn't and had to go to bathroom A Fall Event Report dated 6/22/14 provided by the DON indicated the following: Resident #17 was toileting at the time of the fall. The fall risk score indicated Resident #17 was at risk for falling. The interventions which were in place at the time of the fall were non-skid footwear, chair alarm and bed alarm. The new immediate interventions initiated were bed alarm and other-type of alarm changed. A Care Plan for Falls Dated 6/16/14 was provided by the DON and read as follows: Approach Date 6/16/14 - DC on: 7/1/14.RD (resident) to have bed chair alarm that can't be turned off R/T Rd (resident) history of turning alarms off. During an interview on 8/19/14 at 10:00 A.M., the Director of Nursing (DON) indicated Resident #17 had a bed alarm and a chair alarm in place at the time of the falls on 1/3/14 and 6/14/14, but the clinical record lacked documention the alarms were sounding/functioning before Resident #17 fell . The DON further indicated Resident #17 had a history of [REDACTED]. The Policy titled Fall Management Program was provided by the Regional Nurse Consultant and included, but was not limited to, .The goal of the interdisciplinary team is to identify residents with a history of and potential for falls and develop an effective individualized fall management plan. 2. On 8/14/14 at 8:25 A.M., Resident #55 was observed in bed with 1/2 side rails in place and call light in reach. Resident # 55's clinical record was reviewed on 8/14/14 at 11:13 A.M. Resident #55 had been admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her clinical record indicated she had been admitted to a hospital behavioral unit on 7/2/14 related to depression and the voicing of suicide ideation. She had returned to the facility on [DATE]. On return to the facility on [DATE] she had been placed on 15 minute checks for 72 hours to monitor behavior. Fifteen minute checks were discontinued after a visit from the psychologist on 7/17/14. Her Minimum Data Set Assessment ((MDS) dated [DATE] (before fall) indicated, a cognitive summary score of 11 (moderate cognitive impairment score of 8-12). The MDS indicated, extensive assistance of 2 or more staff were needed for bed mobility, and the extensive assistance of 1 staff was needed for transfers. The MDS also indicated limited assistance of 1 staff needed for walking in room and total dependence for bathing with 2 staff to physically assist. The MDS dated [DATE] (after fall) indicated a cognitive score of 10. The assessment indicated extensive assistance of 2 or more staff needed for bed mobility, transfers, and walking in room. The MDS indicated total dependence for bathing with 2 or more staff to physically assist. A care plan with an initiation date of 7/14/14, indicated a problem of the resident being at risk for falls related to weakness. Interventions initiated on 7/15/14 indicated, Assist with ADLs (activities of daily living) as needed, Cue/remind resident to use call lights to seek assistance as needed, Keep call light in reach at all times, Keep personal items and frequently used items within reach, and transfer independently, ambulation asst (assist) x 1 w/rw (with rolling walker). After the fall of 7/16/14, an intervention was initiated on 7/17/14, which indicated, Use emergency call light for supplies needed in shower room. A progress note dated 7/16/14 at 4:25 A.M., indicated, Staff called to shower room. Resident sitting on floor in shower room. No c/o (complaint) pain/discomfort. No injuries noted at this time. V/S (vital signs) within normal limits. Neuro (neurological) checks initiated. A Fall Event record completed on 7/16/14 at 4:11 P.M., indicated an unwitnessed fall had occurred in the shower room. The documentation indicated there had been no injury. The record indicated Resident #55 had a high fall risk score of 11(a score of 10 or higher being high risk). Interventions listed in place at time of the fall were non-skid footwear. New immediate interventions that were initiated after the fall were: offer resident food and drink, toileting, and .Assistive devices and personal care items placed within resident's reach. On 8/18/14 at 9:01 A.M., the Director of Nursing (DON) was interviewed regarding the 7/16/14 at 4:25 A.M., unsupervised fall in the shower room. The DON indicated staff had completed the resident's shower and the resident's socks were wet. The DON indicated the CNA had stepped out of the shower room to get dry socks . The DON indicated when staff had returned Resident #55 had fallen. The DON indicated at that time, the CNA should not have left the resident unsupervised in the shower room. On 8/19/14 at 7:55 A.M., the Director of Therapy was interviewed regarding Resident #55's therapy and mobility status. The Director of Therapy indicated Resident #55 had been on therapy caseload before hospitalization (5/15/14 to 6/25/14) and was picked up after hospitalization (7/15/14 to 8/11/14). He indicated Resident #55 would need assistance for transfer from a shower chair to a wheelchair. On 8/19/14 at 8:15 A.M., MDS Nurse #1 was interviewed and indicated the MDS (6/24/14) before hospitalization , indicated Resident #55 needed extensive assistance of 1 staff for transfer. She reviewed the MDS of 7/21/14 and indicated, extensive assistance of 2 or more staff were needed for bed mobility, transfer, and ambulation. The MDS Nurse #1 also indicated at that time, she was only aware of Resident #55 needing assistance to transfer since she had been a resident at the facility. She indicated at that time Resident #55 should not have been left in the shower unsupervised. She indicated there were no residents currently at the facility who shower independently. On 8/19/14 at 2:40 P.M., a hospital x-ray report of Resident #55 dated 7/6/14, was reviewed. The report indicated .pt. (patient) fell from bed onto left forearm/swelling on ulnar side. On 8/19/14 at 2:40 P.M., the Regional Nurse Consultant was made aware that Resident #55 had fallen during hospitalization before readmission to the facility. She indicated at that time she was unaware that Resident #55 had fallen during hospitalization . A hospital transfer sheet from the behavioral unit of the hospital to the nursing facility (dated 7/14/14) for readmission, included but was not limited to the following information, .ptn (patient) has difficulty with weight bearing.Needs help with Bathing, Dressing, Ambulation, Up In Chair, Wt. Bearing, Exercises. 3.1-45(a)(2)

Based on interview and record review, the facility failed to follow up on assessing a resident who exhibited signs of a urinary tract infection, resulting in admission to the hospital with urosepsis, for 1 of 3 residents sampled with Foley catheters, in a sample of 12. Resident C Findings include: 1. The closed clinical record of Resident C was reviewed on 4/1/14 at 4:00 P.M. A Minimum Data Set (MDS) assessment, dated 12/15/13, indicated the resident scored a 13 out of 15 for cognition, with 15 indicating no memory impairment. The resident required extensive assistance of one staff for personal hygiene and toilet use, and had a Foley catheter (f/c). A Care Plan, initially dated 1/25/12 and updated on 12/18/13, indicated: "Problem, Resident requires an (sic) Foley catheter R/T (related to) [MEDICAL CONDITION] and outlet obstruction." The Approaches included: "Monitor urine color characteristics q (every) shift, monitor for s/s (signs and symptoms) of urinary tract infection...Report signs of complications, such as UTI (urinary tract infection) (acute confusion, bladder spasms, pain, low back/flank pain...fever, foul odor, concentrated urine, blood in urine)...." Resident Progress Notes included the following notations: 2/28/14 at 10:11 P.M.: "F/C patent. Urine discolored, odorous. Denies urinary discomfort. Will monitor for further urine symptoms. Communicated (sic) to oncoming staff." The next progress note (three days later) was dated 3/3/14 at 1:40 A.M. The note indicated: "Order received from (name of physician) to send pt (patient) to the ER (emergency room ) for c/o (complaints of) back pain, and SOA (shortness of air). Pt was c/o back pain earlier, and [MEDICATION NAME] given w/o (without) relief. Pt also has expiratory wheezes all fields posteriorly, and rhonci (sic) right lat lobes. Pt's f/c was kinked, and pt. was incont. of fowl (sic) smelling urine. The urine in his drainage bag was dark, and turbid...." A Resident Progress Note, dated 3/3/14 at 6:30 A.M., indicated: "Er called, pt is being trx (transferred) to (another hospital) with Urosepsis, and Left Lung Infiltrate...Family # 4 notified of all at this time, and was notified of trx to ER earlier at 01:45 (1:45 A.M.). A Review of Resident C's urine output and vital signs, dated 2/26/14 through 3/3/14, indicated the resident did not have his temperature or other vital signs checked during this time. The resident's output was documented as: 2/26/14: 2675 cc, 2/27/14: 2650 cc, 2/28/14: 1050 +cc, 3/1/14: 1375 cc, 3/2/14: 200 cc. The urine output documentation included: "2/28/14 at 10:11 P.M...Characteristics: Blood-tinged; 3/1/14 at 1:29 P.M....Characteristics: Blood-tinged...Cloudy...3/2/14 at 1:45 P.M....Characteristics: Blood-tinged...Cloudy...." A hospital # 1 emergency room record, dated 3/3/14, indicated: "...Anxious...Acute respiratory distress...Scant amount of thick brown liquid noted in catheter tubing just distal to penis. Attempted to irrigate the indwelling #16 French Coude catheter...Immediate return of sterile water from around catheter with thick brown/green chunks. Terrible odor noted. Foley Catheter removed without difficulty. Unable to pass coude catheter due to obstruction...Patient is in profound distress during the exam. Patient appears to be acutely ill...Disposition decision is to transfer. Transfer to another hospital...." A hospital # 2 history and physical, dated 3/3/14, included: "...He does have a chronic indwelling Foley catheter...He was taken to the (name) emergency room for evaluation. There, the patient was noted to be febrile and hypotensive. His Foley catheter was removed, and per report, grossly gray sludge and pus taken out of his catheter...Assessment and Plan: 1.[MEDICAL CONDITION] secondary to urinary etiology...." On 4/2/14 at 2:45 P.M., during interview with the corporate nurse and interim Director of Nursing (DON), the corporate nurse reviewed the resident's clinical record to determine if there was any additional charting under "Events" or "Observations." The corporate nurse was unable to find additional documentation. 2. On 4/3/14 at 10:30 A.M., the interim DON provided the current facility policy on "Catheter Care, Urinary," revised December 2007. The policy included: "The purpose of this procedure is to prevent infection of the resident's urinary tract...Observe the resident's urine level for noticeable increases or decreases...Check the urine for unusual appearance (i.e., color, blood, etc.)...Observe the resident for signs and symptoms of urinary tract infection and [MEDICAL CONDITION]." This Federal tag relates to Complaint IN 633. 3.1-41(a)(2)

Based on observation, record review and interview, the facility failed to ensure safe positioning for feeding and the availability of functioning emergency equipment resulting in 4 of 4 residents observed at risk for aspiration and respiratory arrest. This had the potential to affect 46 residents eating in the dining areas from a population of 87. Resident #94, Resident #92, Resident #1, and Resident #71 The immediate jeopardy began on [DATE] at 11:45 A.M, when residents were observed to be fed in an unsafe position with the potential for aspiration. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on [DATE] at 5:20 P.M. The Immediate Jeopardy was removed on [DATE], but noncompliance remained at a level of a pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. The noon meal in the main dining room and the adjacent Grandma's Kitchen assisted dining area was observed on [DATE] from 11:30 A.M. until 1:15 P.M. In these areas there were 41 residents seated for dining. Resident # 94 was observed throughout the entire lunch meal. He was fed primarily by CNA #1 for the first ,[DATE] of the meal and by LPN #2 the remaining ,[DATE] of the meal. The resident was seated in a high back Broda chair. His head and neck position throughout the meal were not conducive for safe swallowing. His neck was in a position of maximum hyperextension with his eyes looking up at the ceiling. He was being fed in an assisted dining room for dependant residents. Neither the nurse or the CNA attempted to support his head toward normal alignment or cued or encouraged him to lower his chin for safer swallowing. There was no support of his head as it was not touching the head rest. He was fed by the staff each mouthful of pureed food and each straw sip of thin liquid. The meal was consistent with the [DATE] physician diet order. The resident's eyes remained looking at the ceiling, while he tried to swallow with difficulty and effort. Staff did not ask if he was ready for an additional portion, but gave one after each swallow. He did cough at one point, but was able to clear the food and liquid by himself during feeding by LPN #2. There was no visible suction equipment in the area. On ,[DATE] at 1:15 P.M., LPN #2 was interviewed regarding her feeding of Resident #94. She was asked what action she would take if aspiration occurred during feeding a resident in the Grandma's kitchen area or main dining areas. LPN #2, who had been observed unsafely feeding Resident #94, indicated she would get the suction machine. She looked around the dining room and indicated there was a suction machine usually available by the book rack and between the main dining room and Grandma's kitchen area, accessible to both areas. She indicated she did not know where it was, but would ask the Director of Nursing (DON) and find out what had happened to the suction machine since other staff in the dining room did not know either. At 1:40 P.M., she indicated the DON had pointed out the location of the suction machine, which was observed to be in the lower cabinet to the side of the sink in Grandma's kitchen. There was no visual cue of its location. On [DATE] at 1:50 P.M., the DON was interviewed and indicated the suction machine had been by the book case, but it was moved a year ago to the current location. LPN #2 had been employed in her position over 5 yrs. The DON indicated she would put up a sign to identify the location of the suction machine for emergency use and inservice nurses on the location of the equipment. The DON was informed, at that time, of the failure to attempt proper alignment of the resident's head for feeding, creating increased risk of aspiration without ready access to emergency equipment. Resident # 94 was observed on [DATE] at 8:30 A.M., and noted to be sitting in his highback Broda chair with his head and neck in normal parameters of alignment. Restorative Aide #1 was interviewed regarding the resident at that time. She indicated the resident did sometimes hold his head in hyperextension, but not always. The neck was not set in a fixed contracture, but could be positioned normally. The clinical record of Resident # 94 was reviewed on [DATE] at 9:47 A.M. The resident had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment (MDS) of [DATE] included a normal swallowing status of no problems with holding food in mouth or coughing or choking. A Speech evaluation on [DATE] indicated the resident "demonstrates some holding of pureed consistency,difficulty controlling liquid flow with cup sip, good ability with liquids from a straw sip, fair ability with pureed consistency, holding pureed consistency 4 seconds at a time. Recommend further evaluation to identify severity of deficits." The Care Plan of [DATE] addressed the resident's limited ability to eat and drink related to [MEDICAL CONDITION] and limited ability. It directed "Position resident in good body alignment before feeding and drinking." On [DATE], after being informed of the problems observed, the Speech Therapist recommended therapy 5 times weekly for 2 weeks to address staff training regarding dysphagia (difficulty swallowing) deficits. On [DATE] at the noon meal, the resident was observed to have his head supported with a small pillow behind the neck as well as a U shaped pillow to support position of the head. The head was in normal, safe eating position and the therapist was attending for further assessment. The DON was interviewed on [DATE] at 10:00 A.M., regarding any Policies and Procedures related to dysphagia management, aspiration emergencies and suctioning equipment and the facility system of ensuring staff and equipment readiness. She indicated there were no related policies at that time, but she was formulating Policies and Procedures and check lists and would be providing reinservice to staff. 2. During the same observation of the entire noon meal on [DATE], Resident #92 was observed to be brought by staff to the dining room to eat. She was seated in a high back wheel chair with her head and neck unsupported in hyperextension. The resident was very lethargic and remained so throughout the meal. Staff attempted unsuccessfully to get her to eat, but did not attempt proper positioning, alignment, or support for feeding. The clinical record of Resident #92 was reviewed on [DATE] at 10:53 A.M. [DIAGNOSES REDACTED]. The MDS of [DATE] indicated the resident did not have symptoms of swallowing disorder. The Care Plan, initiated [DATE], indicated the resident had decreased physical ability related to disease process and directed maintaining body in functional alignment when at rest. The care plan, initiated [DATE], addressed "limited in ability to eat and drink related to persistent mental disorder" with an intervention "Position resident in good body alignment before feeding and drinking." 3. On [DATE] at 11 45 A.M., the 400 unit dining room noon meal was observed. There were 5 residents utilizing the dining room. The 400 unit, is composed of a nursing station (shared by both the 400 hall and 200 hall nurse) located at the intersection of the 400 and 200 halls. The 400 hall, is not a straight hall, but has a "bend" in it. While standing at the 400 hall nursing station and looking down the hall, the portion of the hall housing residents is the section of hall farthest from the nursing station and is not visible from the nursing station. The 400 unit dining room, is located at the farthest end of the hall from the nursing station, also out of view from the nursing station. At 11:47 A.M., during the noon meal service, Resident #1 and Resident #71 were observed sitting at a table with LPN #1. Both residents were observed in high back Broda chairs. LPN #1 attempted to awaken Resident #71 as she was sleeping. The resident was repositioned in her Broda chair and took a bite of her pureed diet. At 11:51 A.M., Resident #1 was being fed by LPN #1 his pureed diet. LPN #1 was assisting the resident to drink thickened liquid from a glass without a lid on the glass. At this time, Resident #1 began coughing, but it resolved on his own without staff intervention other than encouragement to cough. At 12 P.M., Resident #1 again began coughing while being fed his pureed diet. He again was able to clear his airway without staff intervention. At this time, CNA #2 was observed feeding two residents at another table in the dining room. Neither of these residents were observed to be coughing. On [DATE] at 12:08 P.M., a small, enclosed cart with several doors on the front was observed in the dining room with a microwave sitting on top. Facing the cart, a sticker was observed on the upper right had door which read "suction." At 12:10 P.M., Resident #1 again began coughing, but cleared his airway on his own without staff intervention. At 12:12 P.M., LPN #2 was observed sitting at the 400 hall nursing station. At 12:17 P.M., CNA #2 left the dining room. At this time, LPN #1 encouraged Resident #1 to hold the uncovered glass of thickened liquid and drink it himself, which the resident did. CNA #2 returned to the dining room at 12:20 P.M. At 12:25 P.M., Resident #1 again was coughing while drinking thickened liquid from an uncovered glass but again cleared his airway on his own. At 12:26 P.M., LPN #1 indicated Resident #71 received a pureed diet but also received tube feedings. At 12:28 P.M., the right upper door to the enclosed cabinet in the dining room was opened. Two flower arrangements were observed on the top shelf and behind them was located a suction machine, covered in a clear, plastic bag. At 12:31 P.M., the call light in the 400 hall dining room was activated. The light in the hallway, over the door outside the room, did not illuminate. A beeping sound could be heard in the distance. A staff member not in view, was heard commenting the call light in the dining room had been activated. Within one minute, CNA #2 responded to the dining room to answer the call light. On [DATE] at 12:34 P.M., LPN #1 was interviewed. She indicated the closest emergency equipment to this dining room was located on a "crash cart" at the opposite end of the hall, from this dining room. This "crash cart" was located beside the 400 hall nurses station. LPN #1 indicated at this time, the closest suction unit would be located on the "crash cart" by the nurses station. LPN #1 indicated she would check with someone to make sure she wasn't missing one. LPN #1 then left the dining room. At 12:37 P.M., LPN #1 returned to the 400 hall dining room and indicated she had checked with LPN #3, who was working on the 200 unit. LPN #3 indicated to LPN #1 that the closest suction machine to the 400 hall dining room was on the "crash cart." At 12:39 P.M., LPN #1 returned to the 400 hall dining room and opened the door to the cabinet to find the suction unit. Upon interview and inquiry of LPN #1 as to how the suction equipment was assembled and functioned, LPN #1 asked if she could ask someone else. Upon request, while waiting for RN #1 Unit Manager (UM) to arrive, LPN #1 was reading the equipment packages and attempting to assemble the pieces of tubing and suction catheters to the suction machine for it to function. LPN #1 indicated she had used suction in the past but it had always been already hooked up. At 12:42 P.M., LPN #1 left the dining room without having assembled the suction unit. The individually, packaged equipment which was located in the plastic bag covering the suction machine included the following: connective tubing, suction catheter and [MEDICATION NAME] suction tip tube. At 12:47 P.M., RN #1 UM arrived to the 400 hall dining room. She looked at the packaged supplies for the suction unit. She indicated they included two types of suctions catheters ([MEDICATION NAME] and flexible tip) and 1 package of connective tubing. RN #1 UM indicated there was a piece of tubing missing to connect the [MEDICATION NAME] suction tip to the suction unit, so the only option for suctioning would be to use the straight flexible suction tip. At 12:50 P.M., RN #1 UM was requested to observe the "crash cart" located at the 400 hall/ 200 hall nursing station. This cart was observed covered and housed the following items: Heart Start unit, tank of portable oxygen and a suction machine with supplies attached in plastic bag. Supplies included: "non conductive connecting tube, [MEDICATION NAME] suction tip, flexible tip suction tip and connective tubing." This suction machine had a sticker on it which indicated the following: "Medical equipment type B: General Pt. Area, inspected ,[DATE]. Reinspect before ,[DATE]." At 12:56 P.M. after reviewing the supplies accompanying this suction machine, RN #1 UM indicated the "non conductive connecting tube" was the piece of equipment missing from the suction machine in the 400 hall dining room. She indicated she could probably have used two of the long tubes but only had one in the bag in the 400 Hall dining room. At this time, RN #1 UM indicated there was no sticker on the 400 hall dining room suction unit indicating the last time the unit had been inspected by someone to verify it function. At 1:54 P.M., the Maintenance Man (MM) was interviewed. He indicated he doesn't have the suction machines on routine checks. He indicated there was no sticker on this machine indicating it had been checked for functionality. At 1:59 P.M., the DON was interviewed. She indicated she had put this suction unit in the dining room [ROOM NUMBER] months ago, when they started using this dining room. She indicated at that time, she ensured the unit was functioning but this would be the last date she would be able to verify the unit was checked. She confirmed there was currently no sticker on the unit with the date it was last checked. At this time, the DON was asked to assemble the equipment to the suction machine in the 400 hall dining room and turn the machine on to ensure it did function. After several attempts made at various combinations of plugging the tubing into various ports on the machine, the DON was able to obtain suction when the machine was turned on at 2:03 P.M. The DON indicated it had been years since she had used this equipment. At this time, the DON was made aware of the piece of packaged tubing that had originally been missing from the 400 hall suction machine. She verified that without that piece of tubing, the unit would not have been functional. On [DATE] at 2:26 P.M., the DON was interviewed while inspecting the suction unit at the ,[DATE] hall nurses station. She indicated the unit was checked by "Respiratory Partners." The portable oxygen tank and Heart Smart Defibrillators were lacking identification of having been checked for functionality. The DON indicated at this time, she was unaware how often the units are checked or should be checked. At 3:11 P.M., the DON was again interviewed. She indicated that no one is currently checking the equipment to make sure the batteries, paddles, etc., are not expired on the Heart Smart unit. The DON indicated that she had told the MM that he should start checking this equipment to make sure that the equipment components are not expired. At this time, the DON indicated there was one emergency crash cart (housing the Heart Smart, portable oxygen and suction machine) in the facility, located on the ,[DATE] unit nurses station. She indicated there were suction machines located on the 400 unit dining room, 500 unit and the main dining room. On [DATE] at 3:50 P.M., the DON provided the job specific orientation for LPN #1. This form indicated LPN #1 had been made aware of suction equipment operation on [DATE]. The DON indicated at this time, nursing staff does not have annual training pertaining to suction machine operation. On [DATE] at 4:26 P.M., the DON was interviewed. She indicated Resident #1 and #71 did not have any episodes of aspiration within the last 6 months. She also indicated these two residents would be considered aspiration risks. On [DATE] at 11:15 A.M., the DON was interviewed. She indicated that LPN #1 had been inserviced last evening on proper suction equipment operation but prior to that the last time LPN #1 was inserviced was in 2006. 4. On [DATE] at 4:30 P.M., the clinical record of Resident #1 was reviewed. [DIAGNOSES REDACTED]. A plan of care, dated [DATE], addressed the following problem: "At risk for choking r/t (related to) [MEDICAL CONDITION], hx (history) mouth pain, swallowing diff (difficulty)." Approaches included but were not limited to, the following: "cups w/(with) lids; monitor for choking episodes, monitor s/s (signs and symptoms) of aspiration; nectar thick liquids as ordered; pureed diet;...asst (assist) with feeding, sit upright at 90 degrees for intake..." The most recent MDS (Minimum Data Set assessment), dated [DATE], was reviewed. This documentation indicated the resident had not had any symptoms of a swallowing disorder. Documentation was lacking on the clinical record of a speech therapy consultation. 5. On [DATE] at 2 P.M., the clinical record of Resident #71 was reviewed. [DIAGNOSES REDACTED]. The most recent MDS, dated [DATE], indicated the following for the resident: no signs and symptoms of swallowing disorder. Physician orders, dated [DATE], indicated the following: "Pureed with honey like consistency liquids, oral intake only when awake and alert." A care plan, dated [DATE] addressed the following problem: "Resident requires tube feeding r/t poor po (per os) intake." Interventions included but were not limited to the following: "Administer tube feeding per order." A care plan, dated [DATE], addressed the following problem: "Resident leaves...food uneaten most meals. Requires a mechanically altered diet with thickened liquids." Approaches included but were not limited to, the following: "...Diet PO (by mouth) diet and tube feeding per order..." On [DATE], a "Lifespan Therapy" form was completed. This form indicated the following: "Would like to request speech therapy evaluation and treatment orders for the above resident due to: Difficulty Swallowing/Increased difficulty noted in swallowing noted by staff." This form indicated therapy may evaluate and treat. On [DATE] at 1:15 P.M., LPN #5 was interviewed. She indicated this resident received [MEDICATION NAME] and Med Pass via the gastrostomy tube and also ate foods orally. The Immediate Jeopardy that began on [DATE] at 11:45 A.M., was removed on [DATE] when the facility implemented a system to ensure residents were positioned safely for eating and staff were familiar with protocols and emergency equipment to deal with potential aspiration. The Director of Nursing will continue to audit dining areas for resident positioning and safety equipment availability with the assistance of the Speech Therapist and report results weekly to the Administrator to ensure continued safe dining practices. The ongoing system of assessment and formulation of appropriate interventions for specific residents at risk was being guided and audited by the Director of Nursing. The noncompliance remained at the lowered scope and severity level of a pattern,with no actual harm with potential for more than minimal harm that is not immediate jeopardy. 3XXX,[DATE](a)