Aviata At The Palms

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure a resident with contractures received care and services to prevent on-going decline in physical abilities and deconditioning for one (Resident # 1) of one resident observed. Findings include:On 02/23/2026 at 9:45 AM Resident #1 was observed lying in bed right hand was observed with fingers touching palm, no splint or support. On 02/23/2026 at 12:14 PM Resident #1 was observed lying in bed. He was unable to verbally communicate but able to shake his head when asked questions. His right hand was observed with fingers touching palm, with no splint or support.On 02/23/2026 at 2:00 PM Resident #1 was observed lying in bed. His neck pillow was observed lying on top of the sheet over the stomach. The right hand was observed with fingers touching palm with no splint or support.Review of Resident #1's admission Record revealed an admission to the facility initially on 10/09/2025 and readmitted on [DATE] with diagnoses to included but not limited to unspecified displaced fracture of surgical neck of right humerus, subsequent encounter fracture with routine healing, Type 2 Diabetes Mellitus without complications, affecting right dominant side, functional quadriplegia.Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed Resident #1 has impairments on one side of his upper and lower extremity and has no mobility devices.Review of Resident #1's Therapy Funding Verification Form, dated 2/23/2026, revealed Resident #1 was approved minutes for Physical and Occupational Therapy, per discipline for 30 minutes times, three visit for four weeks.On 02/23/2026 at 2:15 PM an interview was conducted with Staff A, License Practical Nurse, (LPN), Staff A stated Resident #1 is not receiving range of motion or routine care from nursing for his contracted hand, therapy is usually responsible for contractures. Staff A stated to her knowledge when a resident has any kind of contracture therapy screens the residents first. Then therapy will either continue the resident on therapy services or refer them to restorative therapy.On 02/23/2026 at 2:30 PM an interview was conducted with Staff B, Restorative Therapy. Staff B stated Resident #1 is not on her case load for restorative therapy. Staff B stated when therapy refers a resident for restorative, therapy will put the information in the electronic medical record. Staff B, Restorative Therapy stated checking the system daily for any changes to the schedule. Staff B stated Resident #1 was never referred to restorative therapy.On 2/23/2026 at 2:40 PM an interview was conducted with the Rehab Director. The Rehab Director stated he has not screened resident #1 for his contracted hand. The Rehab Director stated nursing is responsible for managing Resident #1 contracted hand.On 02/23/2026 at 4:04 PM an interview was conducted with the Director of Nurses, (DON). The DON said Resident #1 was admitted with right hand contracture. The DON stated nursing cannot do anything for a resident's contracted hand. Nursing would only take over splint management once therapy has done an evaluation and provides education to nurses on how to safely manage the resident's hand.Review of the facility policy titled, Contractures, Prevention dated 11/30/2014, revealed: Policy: Each resident must be evaluated for need of contracture prevention procedures on admission, readmission and as needed. Procedure. RANGE of Motion: Resident with inactive extremities should have range of motion done to those extremities as part of their daily care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the physician was notified of blood sugar levels (BSLs) that were outside parameters for one (Resident #2) of two residents sampled.Findings included:Resident #2 was readmitted to the facility on [DATE] with diagnoses to include type 2 diabetes mellitus with hyperglycemia, and type 2 diabetes with diabetic peripheral angiopathy without gangrene and long-term use of insulin.Review of Resident #2's Medication Administration Record (MAR) for January 2026 revealed Novolog FlexPen subcutaneous solution pen-injector 100 UNIT/ML (milliliters) (insulin Aspart). Inject per sliding scale: 150-200 + 4 Units; 201-250 = 6 units; 251-300 = 8 units; 301-350 = 10 units; 351-400 units = 12 units. Notify MD (medical doctor) if BS (blood sugar) less than 70 or greater than 400; 401-450 = 14 units subcutaneously before meals and at bedtime related to type 2 diabetes mellitus with hyperglycemia. Start date 10/29/25. D/C (discontinued) date 1/26/26.The order revealed the physician was to be notified for any BS readings above 400.Review of Resident #2's MAR for January 2026 revealed the following BS readings:On 1/1 at 9:00 p.m. = 420On 1/ 2 at 9:00 p.m. = 423On 1/4 at 9:00 p.m. = 409On 1/6 at 4:30 p.m. = 440On 1/8 at 9:00 p.m. = 450On 1/11 at 9:00 p.m. = 412On 1/18 at 9:00 p.m. = 408On 1/21 at 11:30 a.m. = 413On 1/23 at 4:30 p.m. = 436Review of Resident #2's MAR for December 2025 revealed Resident #2 had BS readings above 400 19 out of 120 tested times.Review of Resident #2's MAR for November 2025 revealed Resident #2 had BS readings above 400 32 out of 120 tested times.Review of Resident #2's medical record from November 2025 to January 2026 did not revealed documentation the physician being notified of BS readings above 400 per orders.On 2/23/2026 at 5:20 p.m. an interview was conducted with the Director of Nursing (DON). The DON reviewed the MARs for Resident #2 and stated the nurses should have been documenting notification of the BS levels that were above 400. She stated sometime in October the physician changed the sliding scale to include higher numbers because the resident was at baseline with the higher numbers. She stated when they changed the order to increase the sliding scale to 450, he did not change the instructions. The DON stated given the way the current orders read, They should have documentation. The DON stated if the numbers were above or below parameters, the physician should be notified.Review of a facility policy titled, Notification of Change, revised 12/16/2020, showed, policy - The Center to promptly notify the Patient/Resident, the attending physician, and the Resident Representative when there is a change in the status or condition.Procedure: The nurse to notify the attending physician and Resident Representative when there is a(n):o Accidentso Significant change in the patient/resident's physical, mental, or psychosocial statuso Need to alter treatment significantly New treatment Discontinuation of a current treatment due to but not limited to: Adverse consequences, Acute condition, Exacerbation of a chronic condition.o A transfer or discharge of the Patient/Resident from the Centero Patient/Resident consecutively refuses medication and/or treatment ( i.e. two or more times)o Patient/Resident is discharged without proper medical authority In the event of an emergency situation, 911 to be called and the attending physician and the Resident Representative to be notified as soon as possible. The nurse to complete an evaluation of the Patient/Resident. Document evaluation in the medical record. The nurse will contact the physician. In the event that the attending physician does not respond in a reasonable amount of time, the Medical Director may be contacted. If the Medical Director does not respond, call 911 and document in the medical record. Notify the patient/resident and the resident representative of the change in condition. Document notification in the medical record. Document resident/patient change in condition on 24 Hour Report Complete SBAR as indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure licensed nursing staff were knowledgeable and competent to provide care and services for three residents (#3, #11, and #2) out of eleven residents sampled related to: 1) failure to prevent accidents resulting in a choking and a fall incident; 2) failure to follow physician orders and care plan for therapeutic diets and positioning; and 3) failure to follow speech therapy recommendations for positioning and assistance when eating. The facility failed to provide Resident #3 with the correct physician ordered diet and resulted in the resident choking, which required staff to execute the Heimlich maneuver. Resident #3's care plan and speech therapy evaluation showed the resident needed assistance with dining and one to one supervision. Observations of the resident during the lunch dining on 11/17/25 and 11/18/25 revealed he was not in the upright position when eating, which increased the risk of choking, and one to one supervision was not observed. These failures created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #3 and resulted in the determination of Immediate Jeopardy on 11/18/25. The findings of Immediate Jeopardy were determined to be removed on 11/20/25 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings Included: 1. On 11/17/25 at 11:39 a.m., an observation of the main dining room during lunch revealed Resident #3 was seated at the table in a Geri-chair positioned at approximately 60-65 degrees. An observation of the food tray and meal provided revealed a pureed consistency. Further observations of Resident #3 revealed he ate his meal without assistance from staff. On 11/18/25 at 11:50 a.m., an observation of the main dining room during lunch revealed Resident #3 was seated at the table in a Geri-chair positioned at approximately 60 degrees. An observation of the food tray and meal provided revealed a pureed consistency. Staff were observed setting up the meal tray in front of him. Resident #3 began consuming his meal unassisted by staff. He was observed having difficulty getting food onto the fork. After four attempts, Resident #3 was able to get a dime-sized amount of food on the fork. Staff E, Certified Nursing Assistant (CNA) stated to Staff F, CNA, He [Resident #3] keeps doing that because he can't see his food. Staff F, CNA was observed looking at Resident #3's meal tray and stated, Well, he's almost done.A review of Resident #3's admission record revealed he was admitted on [DATE] with diagnoses to include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, need for assistance with personal care, muscle weakness (generalized), muscle wasting and atrophy, anxiety disorder, major depressive disorder, unspecified convulsions, persistent mood [affective] disorder, and constipation.A review of Resident #3's quarterly Minimum Data Set (MDS), dated [DATE], revealed the following: - Section C - Cognitive Patterns, Brief Interview for Mental Status (BIMS) . BIMS Summary Score 03, indicating severe impairment.- Section GG - Functional Abilities, . A. Eating: . 05. Setup or clean-up assistance .- Section K - Swallowing/Nutritional Status, . C. Mechanically altered diet - require change in texture of food or liquids (e.g. [example], pureed food, thickened liquids) Yes . D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol) Yes .A review of Resident #3's current diet orders revealed the following: - Consistent Carbohydrates (CCD) diet, Pureed texture, Regular / Thin consistency. Directions: no salt packets, with a start date of 11/11/25 and revised on 11/11/25.A review of Resident #3's discontinued diet orders revealed the following:- CCHO [consistent/constant carbohydrate diet], Low Fat, Low Chol [cholesterol], NAS [no added salt] diet, Regular texture, Regular / Thin consistency. Status: Discontinued., with a start date of 4/10/24 and an end date on 4/11/24.- CCHO, Low Fat, Low Chol, NAS diet, Mechanical Soft texture, Regular / Thin consistency. Status: Discontinued., with a start date of 4/11/24 and an end date on 4/11/24.- CCHO (Controlled Carbohydrates) diet, Mechanical Soft texture, Regular / Thin consistency. Directions: NAS; fortified foods TID [three times a day]. Status: Discontinued, with a start date of 4/11/24, revised date of 5/7/24, and an end date on 6/2/24.- CCHO (Controlled Carbohydrates) diet, Pureed texture, Regular / Thin consistency. Directions NAS., with a start date of 6/2/24, revised date of 7/9/25, and an end date on 11/11/25.A review of Resident #3's care plan revealed the following:- [Resident name] is at risk for Malnutrition r/t [related to] psychotropics, therapeutic diet, T2DM [type 2 diabetes mellitus], dementia, metabolic encephalopathy, HTN [hypertension], CKD [chronic kidney disease] stage 3, mechanically altered diet, needs assist with meals MNA[malnutrition assessment]=10 Date Initiated: 04/11/2024 Revision on: 09/16/2025., with interventions to include the following, Monitor and report to the physician: . Chewing/swallowing problems Date Initiated: 04/11/2024 . or for signs and symptoms of aspiration such as coughing, choking, pocketing, runny nose, watery eyes spitting food out, wet vocal quality, wet lungs. Notify SLP [speech language pathologist] if any symptoms are present Date Initiated: 04/11/2024 . Provide diet as ordered, monitor and record intake- Dysphagia Puree Texture/thin liquids Date Initiated: 04/11/2024 Revision on: 11/11/2025. Set up trays/supervise/cue/assist as needed with meals and allow adequate time to consume food/fluids provided Date Initiated: 04/11/2024 .- [Resident name] has a communication problem due to: Brain injury, Cognitive impairment, Expressive Aphasia, Receptive Aphasia Date Initiated: 04/23/2024 Revision on: 04/23/2024.A review of Resident #3's progress notes revealed the following:- 11/9/25 health status note 12:15, Patient in dining room for lunch, patient observed eating and choking on food. Patient assessed and vitals stable at this time. Patient skin warm and dry, no respiratory distress noted, and patient removed from dining room and back in room, created by Staff B, Licensed Practical Nurse (LPN).- 11/10/25 physician progress note, . DOS [date of service]: 11/10/2025 Effective Time: 10:30 AM CC [chief complaint]: Dysphagia / Choking Episode . HPI [history of present illness]: Nursing reports that yesterday the patient was in the dining room eating and had an episode where he was unable to swallow food. He reportedly did not get the correct food consistency for his meal. Staff performed the Heimlich maneuver on him and the food was abruptly dislodged. He did not experience any observed respiratory distress after the incident. Nursing reports after the incident he has been at his baseline cognitively and functionally. He denies any shortness of breath, coughing, fevers/chills/night sweats, sputum production, n/v/d [nausea, vomiting, diarrhea], sore throat, acute pain, dizziness, lightheadedness, headaches, vision changes, increased weakness. CXR [chest x-ray] reviewed: Early changes of intrapillar atelectasis or pneumonia. Findings favor atelectasis in the absence of leukocytosis. Perihilar inflammation, acute or chronic. Correlate risk factors for infection. CBC/CMP [complete blood count/comprehensive metabolic panel] in AM [morning] to check for leukocytosis ST [speech therapy] eval [evaluation] Continue Diet: CCHO (Controlled Carbohydrates) diet, Pureed texture, Regular / Thin consistency Upright 90 degrees for all PO [by mouth] intake Staff to ensure pt. [patient] receives correct food consistency Monitor Atelectasis CXR indicative of probable atelectasis in the absence of fevers/leukocytosis ., created by Staff C, Nurse Practitioner (NP).- 11/10/25 health status note 12:05, Note Text: Late Entry: At time of assessing the resident after chocking his bilateral lungs were clear, Resp [respiratory] even and nonlabored, O2 [oxygen] sat [saturation] at 98% on r.a. [room air] Res. [resident] was taken back to his room and was sitting up in chair without s/s [signs and symptoms] of distress, created by Staff D, Nurse Supervisor.- 11/10/25 health status note 13:04, Note Text: At the time of assessment of patient, vitals taken: B/P [blood pressure] 126/80, pulse 98, temp 97.9, respirations 18, and O2 95 on room air. Patient alert and in no apparent distress. Lung sounds clear and patient observed to have normal respiratory effort, created by Staff B, Licensed Practical Nurse (LPN).- 11/10/25 health status note 13:32, CXR reviewed: IMPRESSION: Early changes of intrapillar atelectasis or pneumonia. Findings favor atelectasis in the absence of leukocytosis. Perihilar inflammation, acute or chronic. Correlate risk factors for infection. Slightly worse compared to 4/21/2025. 1) Vitals every shift for 3 days 2) CBC/CMP in AM.- 11/11/25 health status note, Labs reviewed, stable without any leukocytosis. Stable anemia and DM II [diabetes mellitus two] are noted. No new orders.- 11/11/25 health status note 21:12, LATE ENTRY Note Text: Resident is alert with confusion and is assisted totally with ADL's [activities of daily living]. Transfers to and from Geri chair with Hoyer lift and 2 assist [two person assist]. Resident is assisted with meals, encouraged to eat meal. Incontinent of B&B [bladder and bowel]. No s/s of acute distress and no c/o [complaints of] pain voiced at this time.- 11/12/25 health status note, Note Text: IDT [interdisciplinary] reviewed for s/p [status post] choking incident. IDT reviewed chart along with labs and chest xray all noted to be unremarkable. Resident is alert with confusion, total care for ADL's incontinent of b/b mechanical lift for transfers. Sits in a Geri-chair for proper positioning. Resident was eating in MDR [main dining room] where he consumes his food independently. Pt [patient] choked on a piece of ham, Heimlich was successfully preformed and ham was expelled. Skin assessment completed today to assess for any discoloration r/t Heimlich. Skin was clear without redness or discoloration. NO s/s of discomfort or pain was noted. Lungs clear today and no cough noted. Ate in MDR with no s/s of difficulty eating or consuming fluids. MD [medical doctor] and family continue to be aware of all changes.- 11/13/25 health status note, V/S [vital signs] taken on 11/9/2025 s/p [status post] incident in MDR 126/89, 98, 18, 97.9 with O2 sat 95 on RA, created by the Director of Nursing (DON).A review of Resident #3's assessments revealed the following:- 11/9/25 17:50 [5:50 p.m.] situation, background, assessment, recommendation (SBAR) summary for providers, . 31. Other change in condition . 1a. List the other change: Res. [resident] was choking on his lunch tray . 2. This started on: 11/9/25 3. What time of day did this start? 2. Afternoon . Mental Status Evaluation 7. No changes observed Functional Status Evaluation 6. No changes observed. Since the change in condition occurred have the symptoms or signs gotten: 2. Better . Res. coughed up food that was chocking him . Res. was observed chocking on his lunch tray, Heimlich maneuver performed and res. expelled food. Res. assessed and vitals stable at this time. Res. skin warm and dry, no respiratory distress noted, and patient removed from dining room and back in room. Family notified- [family member name] Date: 11/09/2025 Time: 6:00 PM . Date and time of clinician notification: 11/9/2025 13:30 [1:30 p.m.] . New orders for 2 view CXR per [Staff C, NP], created by Staff D, Nurse Supervisor. Further review of the SBAR communication form revealed the vital signs documented were from 10/7/25.- 9/16/25 nutrition assessment form, . B. Dietary Intake 1. Current Diet Order/Enteral orders/Supplement Order: CCHO (Controlled Carbohydrates) diet, Pureed texture, Regular / Thin consistency, NAS Med Pass 2.0 120ml [milliliters] TID . Ability to Chew/Swallow: 5. None of the above . E. Neuropsychological problems 0. Severe dementia or depression . Comment/Summary: [NAME] is at risk for Malnutrition r/t psychotropics, therapeutic diet, T2DM, dementia, metabolic encephalopathy, HTN, CKD stage 3, mechanically altered diet, needs assist with meals MNA=10 .Review of Resident #3's x-ray results revealed the following:- 4/21/25 chest, single view, Clinical Information: follow up left infiltrate Test Procedure: . CHEST, SINGLE VIEW Findings: Comparison: 03/15/2025 The cardiac silhouette and mediastinal contours are normal. The lungs are free of infiltrates and focal consolidations. No pleural fluid or masses are noted. No pneumothorax is present. Impressions: No acute intrathoracic disease process.- 11/10/25 chest, 2 views, Date of Service: 11/10/2025 Clinical Information: . Pneumonitis due to inhalation of food and vomit possible aspiration Test Procedure: . CHEST, 2 VIEWS Findings: . No acute osseous or soft tissue abnormality. Cardiac and mediastinal contours are within normal limits. Normal pulmonary vasculature. No pneumothorax. Bilateral intrapillar airspace opacity is present. Peribranchial distention with peribranchial cuffing is present. This nonspecific finding indicates chronic or acute perihilar inflammation. IMPRESSION: Early changes of intrapillar atelectasis or pneumonia. Findings favor atelectasis in the absence of leukocytosis. Perihilar inflammation, acute or chronic. Correlate risk factors for infection. Slightly worse compared to 4/21/2025.A review of a resource from the American Lung Association revealed the following, Atelectasis happens when the tiny air sacs or alveoli in your lungs are blocked, and it causes a partial or full collapse of one or more lobes or sections of the lungs. Other causes may include A small object blocking the airways (like food or toy) . Lung infection like pneumonia . Your healthcare provider will discuss treatment options if atelectasis is caused by a tumor, an aspirated foreign body, or other chronic lung conditions. Serious complications may occur if atelectasis remains untreated. Complications can include low oxygen levels, pneumonia, or lung failure. The reference was reviewed on the following website https://www.lung.org/lung-health-diseases/lung-disease-lookup/atelectasis.A review of Resident #3's speech therapy (ST) notes revealed the following:- SLP evaluation and plan of treatment, dated 11/11/25, Diagnoses Nontraumatic subacute subdural hemorrhage onset 11/11/25 Dysphagia, oropharyngeal phase onset 11/11/25 . Reason for Referral/ Current Illness: Patient is a 91 year LTC [long term care] resident of this facility referred to ST due to reported aspiration episode. Patient is currently on a puree diet with thin liquids. Prior Level of Function Intake/Diet Level = Puree consistencies, Thin liquids, Successive Swallows; Swallowing Abilities = Severe; Self Feeding = Total Dependence without attempts to initiate . Oral Exam Oral Motor Structure and Function = Impaired . Cognition Cognitive-Communicative Skills = Impaired . Cognition Follows Directions = Max(A) [Assistance], responsive to cues . Clinical Bedside Assessment of Swallowing Overall Abilities = Severe . Solids Assessed During Eval = Puree consistencies . Assessment Summary Clinical Impression: Patient seen for dysphagia evaluation at bedside. Per nursing and chart review, patient has known history of advanced dementia with limited cognitive-linguistic function. Spontaneous oral movements appear functional for current diet level. No overt signs/symptoms of aspiration (no coughing, throat clearing, or wet vocal quality) observed during limited trials. Deficits include impaired cognition impacting ability to follow commands, implement swallow strategies, or adjust to texture changes. Current diet of puree solids and thin liquids appears appropriate and safe at this time based on bedside observation and nursing report. Provide 1:1 feeding assistance and slow rate of intake. Ensure upright positioning at 90 degrees during and 30 minutes after meals. No further swallow study indicated due to advanced dementia and inability to participate in treatment. Supervision for Oral Intake = Close supervision .On 11/17/25 at 10:10 a.m., an interview was conducted with Resident #10. He confirmed he witnessed the incident with Resident #3 on 11/9/25. He stated, He [Resident #3] choked. Resident #10 said the meal tickets are on the food trays. He said the CNAs passed the trays and double checked the meal ticket matched the food. Resident #10 stated that day, A new person was helping. Resident #10 said the new staff member gave Resident #3 a tray with a regular diet. He said Resident #3 was in a recliner chair. Resident #10 said the staff were patting his back, but it was not helping. Resident #10 described the staff present as, Frantic. He said Resident #9 wheeled himself to the hallway outside of the dining room stating, Help, Help and putting his hands up. Resident #10 said he recalled the staff present saying, What do we do, what do we do, I will call for the nurse. He confirmed there was no nurse present in the dining room during the lunch meal on 11/9/25. Resident #10 said a nurse never came to assess Resident #3. He said staff took Resident #3 to his room after the lunch meal was completed. Resident #10 confirmed he stayed for the duration of the lunch. He said other departments are now helping in the dining room and a nurse is present. A review of Resident #10 quarterly MDS, dated [DATE], under section C - cognitive patterns revealed a BIMS score of 15, indicating cognitively intact. On 11/17/25 at 1:29 p.m., an interview was conducted with the Food Service Director. He said he had been in this position since August 2025. He said Staff G, Dietary Aide was at the end of the tray line and the last one to touch the tray in the kitchen on 11/9/25 during lunch. The Food Service Director said he was not present for the incident, but he learned Resident #3 choked in the dining room on 11/9/25. He said two other staff members, Staff H, [NAME] and Staff I, Dietary Aide were also on the tray line. He said Staff I, Dietary Aide was at the beginning of the tray line and called the ticket out to include the diet, such as mechanical or regular. The Food Service Director said Staff G, Dietary Aide was at the end of the line and repeated back what was provided to her by the cook. He said Staff I, Dietary Aide was telling Staff H, [NAME] what she needed to plate, and Staff G, Dietary Aide double checked the meal on the tray was correct. He said Staff G, Dietary Aide called him on 11/9/25 and told him what happened. The Food Service Director stated he talked to Staff G, Dietary Aide the following day and asked for more information about what happened. He said she told him, I [Staff G, Dietary Aide] don't remember, there were people coming in, when you're not here they come in and do whatever they want and not sure what happened. The Food Service Director said Resident #3's diet on 11/9/25 was dysphagia, mechanical soft which meant ground consistency for the protein, pureed vegetables, and a pureed starch. He said he could not provide the residents meal ticket for that day, as he did not have access to do that, but he could provide an example meal ticket of a dysphagia, mechanical texture for the meal that day. He said the mechanical and pureed diets are the same consistency, except for the protein. He said he changed Resident #3's diet to pureed consistency on 11/10/25 in the meal tracker system. The Food Service Director said he did not have documentation of in-services or training regarding meal ticket accuracy for dietary staff prior to August 2025. He said since he has been at the facility he has not needed to provide an in-service on meal ticket accuracy. The Food Service Director said he completed audits and an in-service on meal ticket accuracy to all the dietary staff on 11/10/25. On 11/17/25 at 1:49 p.m., an interview was conducted with Staff G, Dietary Aide. She said on 11/9/25, during lunch, Staff I, Dietary Aide and Staff H, cook were on the tray line. Staff G, Dietary Aide stated she was at the end of the tray line as the, The double checker. She said she called out every ticket and made sure it is the correct food. Staff G, Dietary Aide said the cook knows the diets because of the first person on tray line who tells them. She said the first person called out the diet, the cook puts the food on the plate, and she puts the plate on the resident's tray. Staff G, Dietary Aide said the meal ticket is already on the tray, and she made sure it had the correct beverage, condiments, diet, and the meal matches. She said she did not remember Resident #3 getting a regular diet and believed he received pureed consistency. Staff G, Dietary Aide stated, It's possible it could have happened, and said she had taken accountability if the resident received the wrong diet. She said staff kept interrupting them during the tray line for lunch that day. She said she recalled being told the nurses aids were short staffed on 11/9/25. She said she recalled the dining room cart went out, then the first cart for the south unit went out, then she left the kitchen, came back and when she returned there were two staff members in the kitchen. Staff G, Dietary Aide said one staff member had a tray with a plate and the other staff had the meal ticket in their hand. She said they told her the resident had choked and something serious could have happened. Staff G, Dietary Aide said she recalled walking in the dining room between 11:45 a.m. and 12:00 p.m. and had not seen any resident choking. She said she recalled seeing the two staff members sitting down in the dining room. Staff G, Dietary Aide said when the tray line was almost done is when the two staff members approached her about the choking incident. She said after the two staff approached her, she immediately called the Food Service Director and told him the resident choked and staff were blaming her for the incident. Staff G, Dietary Aide stated the Food Service Director told her no one had called him and, They would see about it on Monday when he comes in. She confirmed that the Nursing Home Administrator (NHA) asked her what happened and she provided a statement. She confirmed she had meal ticket accuracy education, before 11/9/25, from the Food Service Director. On 11/17/25 at 2:29 p.m., a phone interview was conducted with Staff I, Dietary Aide. She said she was typically the first person working on the tray line. She described the, A2 and A1, roles. She stated the person as A1 is preparing the tray with items such as milk and juice, then the tray goes to the person as A2. She stated, A2 putting plate with food exactly what is required with ticket is talking about. Regarding the incident on 11/9/25 she stated, I remember person who was A2 making mistake . that person [Resident #3] has mechanical. Mechanically it is supposed to be bread and meat ground. She [A2] exchanged for regular diet. She said the person in the A2 role did not pay attention and gave Resident #3 the wrong meal. Staff I, Dietary Aide said when she starts the line she puts the ticket on the tray, looks at the diet and says loudly if the meal ticket says mechanical or pureed. She said when she first started, at the end of June 2025, she was educated on the tray line and meal ticket accuracy process by the former food service director and one of the dietary aides. A follow-up interview was conducted with the Food Service Director on 11/17/25 at 2:44 p.m. He said there's been no change to the process on the tray line after the choking incident on 11/9/25. He said the only change made was to the dining meal times. The Food Service Director stated they haven't implemented anything new but, Thought about extra set of eyes to help the tray line process. He said he wanted to put an extra dietary staff in the middle of the tray line, so the last person could focus on checking the trays. The Food Service Director said the nurses and CNAs are supposed to check the tray when meal passing. He stated, It's supposed to be happening, but it fluctuates.A review of a meal ticket on 11/9/25 revealed the following, Dys [Dysphagia] Mech [Mechanical] . Ground Glazed Baked Ham, [NAME] Gravy, Black-Eyed Peas, Fortified Mashed Potatoes, Chopped Greens, Chop, Pureed Dinner Roll/Bread . Vanilla Ice Cream . The Food Service Director confirmed the meal ticket reflected what Resident #3 would have received. An interview was conducted on 11/17/25 at 1:40 p.m. with Staff J, CNA. Staff J, CNA said there was never a nurse in the dining room for meals. She said she typically was the only person in the dining room for lunch and often times at dinner as well. Staff J, CNA said she had complained multiple times about being the only person in the dining room and asked for more assistance, but no one ever came to help. She said the day Resident #3 choked she was in the dining room for lunch time. She said Staff K, receptionist came to the dining room to help pass trays. Staff J, CNA said she knew the residents and their diets well. She said Resident #3 received a meal tray with a regular diet, and he should have received a pureed diet. She said the day of the incident, Resident #3 was feeding himself and she heard him gasping for air. Staff J, CNA said she looked over and saw he was choking. She said his eyes were watering and demonstrated he had his hands on the chest/neck area while gasping. Staff J, CNA and Staff K, receptionist both went to assist him and yelled out for reception to get a nurse. Staff J, CNA said she leaned him forward to pat him on the back. She said it was difficult because he was reclined and leaning back in a Geri chair. She confirmed Staff K, receptionist performed the Heimlich maneuver on Resident #3. She said she assisted with twisting the resident to the side that way Staff K, receptionist could get behind him. Staff J, CNA said she is not cardiopulmonary resuscitation (CPR) certified. She said by the time Staff D, Nurse Supervisor arrived the food had been dislodged, and the resident was breathing. Staff J, CNA said Staff D, Nurse Supervisor asked what happened and said they should not have done anything because only a nurse should do the Heimlich. She said Staff D, Nurse Supervisor asked them if the resident was ok and said she had to go back to the unit to finish what she was doing, then left. Staff J, CNA said she did not observe an assessment completed on Resident #3 in the dining room and no vital signs were taken at that time. She said Resident #3 stayed in the dining room for another hour and ate some ice cream. She said meals in the dining room started around 11:15 a.m. to 11:30 a.m., and Resident #3 choked around 11:45 a.m. Staff J, CNA said he did not leave the dining room until after 12:45 p.m.On 11/18/25 at 1:50 p.m., an interview was conducted with Staff K, receptionist. She said she typically worked as a receptionist, but she picked up a shift for activities on 11/9/25. She said she helped pass the meal trays out sometimes. She said she went to help Staff J, CNA in the dining room because she was the only staff member there. She said she did not know she had to check the diets on the meal tickets when passing the trays. Staff K, receptionist confirmed she gave Resident #3 his tray and he started to eat the meal. She said she heard Resident #3 gasping and they tried to pat his back. She confirmed there was no nurse present, so they called out for reception to get a nurse. She said while all this was happening, Resident #9 was scared, and he wheeled down the hall yelling for a nurse to help. She said Resident #3's gasping was getting worse therefore, she did five abdominal thrusts from the front while he was in the Geri-chair. She said the thrusts did not do anything. Staff K, receptionist said herself and Staff J, CNA were able to twist the resident to the side, that way she could get her arms around the resident to perform the Heimlich maneuver. Staff K, receptionist said she did three abdominal thrusts and the lodged food came out of the resident's throat. She stated what came out of the resident's throat was a, Thick piece of ham. Staff K, receptionist said she is not a clinical staff member at the facility, but she is CPR certified.On 11/18/25 at 2:03 p.m., a phone interview was conducted with Staff D, Nurse Supervisor. She stated, That day [11/9/25] I was the only supervisor in building, which is normal. Staff D, Nurse Supervisor said she was on the south wing assessing a patient who was complaining of chest pain. She stated while she was, Getting that under control, she heard yelling that a nurse was needed for an assessment. She said she ran to the dining room and confirmed the incident happened during lunch time. Staff D, Nurse Supervisor said Resident #3 was sitting up in the chair, there were approximately four staff members there, and she heard he choked. She stated, Whatever they did it was already taken care of, by the time she got to the dining room. Staff D, Nurse Supervisor confirmed the staff present said they did the Heimlich. She stated, He was calm, peaceful, nothing wrong with him. Staff D, Nurse Supervisor confirmed she assessed Resident #3 to include listening to his lungs and looking at him. She stated it was a Quick look, listen, and go, as she had another emergency she was handling. She said she saw he was okay; then went to the kitchen and asked what and how the incident happened. Staff D, Nurse Supervisor said, The head person in the kitchen stated someone was on their phone while fixing the tray. She said she told the kitchen staff they needed to be careful, and Resident #3 could have died. She did not recall the names of the kitchen staff present. She said the resident went back to his room but could not confirm who took him there. She said she called and let her manager know about the incident. Staff D, Nurse Supervisor confirmed Staff B, LPN was his assigned nurse. She stated, She [Staff B, LPN] was on the floor, not in the dining room. She said she does not know Resident #3 well but knows he was on a pureed diet and assumed he had a swallowing difficulty. She confirmed she assisted with educating staff after the incident. She said immediately after the incident, they started making sure a nurse and/or management is in the dining room during mealtimes. When asked which residents in the dining room needed assistance with eating, she stated, Nobody in the dining room needs assistance with eating. Not even Resident #3 needs assistance with eating. Staff D, Nurse Supervisor said staff know their residents and are aware if they needed assistance when eating. She stated, If they don't know, the nurse knows. She said she is not sure where to find information about a resident who needed assistance with eating. Staff D, Nurse Supervisor stated, I'm thinking, that's a good question, never thought of the process. She stated she has been at the facility since March 2025 and it, Never crossed my mind to ask that question about where to look. At 2:46 p.m., a follow-up interview with Staff D, Nurse Supervisor was conducted by phone. She said it was the Kardex where they find information about residents who need assistance with eating. She stated, I stick by my answer of staff knowing their residents, if they need assistance with eating.On 11/18/25 at 2:31 p.m., a phone interview was conducted with Staff B, LPN. She said on 11/9/25, Resident #3 went to the dining room for lunch and came back to his room. She said she assessed him to include vitals and lung sounds. She confirmed she documented her assessment in the electronic health record. Staff B, LPN stated, He was perfectly fine back in the room and breathing with no difficulty. She said she was told he received the wrong meal or got the wrong tray, he choked, and the Heimlich was performed. Staff B, LPN said Resident #3 was on a pureed diet. She said when he got back to his room that is when she was told about what happened. She confirmed she would have expected to be notified and w

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents were provided the correct physician ordered therapeutic diet for one resident (#3) out of twenty-three residents sampled with texture-modified diets. The facility failed to provide Resident #3 with the correct physician ordered diet which resulted in the resident choking, and required staff to execute the Heimlich maneuver. Resident #3's physician ordered diet on 11/9/25 was a controlled carbohydrates (CCHO) diet, pureed texture, and regular/thin consistency due to advanced dementia and swallowing difficulties. The resident was provided a regular consistency meal for lunch. These failures created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #3 and resulted in the determination of Immediate Jeopardy on 11/18/25. The findings of Immediate Jeopardy were determined to be removed on 11/20/25 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings Included: 1. A review of Resident #3's admission record revealed he was admitted on [DATE] with diagnoses to include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, need for assistance with personal care, muscle weakness (generalized), muscle wasting and atrophy, anxiety disorder, major depressive disorder, unspecified convulsions, persistent mood [affective] disorder, and constipation.A review of Resident #3's quarterly Minimum Data Set (MDS), dated [DATE], revealed the following: - Section C - Cognitive Patterns, Brief Interview for Mental Status (BIMS) . BIMS Summary Score 03, indicating severe impairment.- Section K - Swallowing/Nutritional Status, . C. Mechanically altered diet - require change in texture of food or liquids (e.g. [example], pureed food, thickened liquids) Yes . D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol) Yes .A review of Resident #3's current diet orders revealed the following: - Consistent Carbohydrates (CCD) diet, Pureed texture, Regular / Thin consistency. Directions: no salt packets, with a start date of 11/11/25 and revised on 11/11/25.A review of Resident #3's discontinued diet orders revealed the following:- CCHO [consistent/constant carbohydrate diet], Low Fat, Low Chol [cholesterol], NAS [no added salt] diet, Regular texture, Regular / Thin consistency. Status: Discontinued., with a start date of 4/10/24 and an end date on 4/11/24.- CCHO, Low Fat, Low Chol, NAS diet, Mechanical Soft texture, Regular / Thin consistency. Status: Discontinued., with a start date of 4/11/24 and an end date on 4/11/24.- CCHO (Controlled Carbohydrates) diet, Mechanical Soft texture, Regular / Thin consistency. Directions: NAS; fortified foods TID [three times a day]. Status: Discontinued, with a start date of 4/11/24, revised date of 5/7/24, and an end date on 6/2/24.- CCHO (Controlled Carbohydrates) diet, Pureed texture, Regular / Thin consistency. Directions NAS., with a start date of 6/2/24, revised date of 7/9/25, and an end date on 11/11/25.A review of Resident #3's care plan revealed the following:- [Resident name] is at risk for Malnutrition r/t [related to] psychotropics, therapeutic diet, T2DM [type 2 diabetes mellitus], dementia, metabolic encephalopathy, HTN [hypertension], CKD [chronic kidney disease] stage 3, mechanically altered diet, needs assist with meals MNA[malnutrition assessment]=10 Date Initiated: 04/11/2024 Revision on: 09/16/2025., with interventions to include the following, Monitor and report to the physician: . Chewing/swallowing problems Date Initiated: 04/11/2024 . or for signs and symptoms of aspiration such as coughing, choking, pocketing, runny nose, watery eyes spitting food out, wet vocal quality, wet lungs. Notify SLP [speech language pathologist] if any symptoms are present Date Initiated: 04/11/2024 . Provide diet as ordered, monitor and record intake- Dysphagia Puree Texture/thin liquids Date Initiated: 04/11/2024 Revision on: 11/11/2025. Set up trays/supervise/cue/assist as needed with meals and allow adequate time to consume food/fluids provided Date Initiated: 04/11/2024 .- [Resident name] has a communication problem due to: Brain injury, Cognitive impairment, Expressive Aphasia, Receptive Aphasia Date Initiated: 04/23/2024 Revision on: 04/23/2024.A review of Resident #3's progress notes revealed the following:- 11/9/25 health status note 12:15, Patient in dining room for lunch, patient observed eating and choking on food. Patient assessed and vitals stable at this time. Patient skin warm and dry, no respiratory distress noted, and patient removed from dining room and back in room, created by Staff B, Licensed Practical Nurse (LPN).- 11/10/25 physician progress note, . DOS [date of service]: 11/10/2025 Effective Time: 10:30 AM CC [chief complaint]: Dysphagia / Choking Episode . HPI [history of present illness]: Nursing reports that yesterday the patient was in the dining room eating and had an episode where he was unable to swallow food. He reportedly did not get the correct food consistency for his meal. Staff performed the Heimlich maneuver on him and the food was abruptly dislodged. He did not experience any observed respiratory distress after the incident. Nursing reports after the incident he has been at his baseline cognitively and functionally. He denies any shortness of breath, coughing, fevers/chills/night sweats, sputum production, n/v/d [nausea, vomiting, diarrhea], sore throat, acute pain, dizziness, lightheadedness, headaches, vision changes, increased weakness. CXR [chest x-ray] reviewed: Early changes of intrapillar atelectasis or pneumonia. Findings favor atelectasis in the absence of leukocytosis. Perihilar inflammation, acute or chronic. Correlate risk factors for infection. CBC/CMP [complete blood count/comprehensive metabolic panel] in AM [morning] to check for leukocytosis ST [speech therapy] eval [evaluation] Continue Diet: CCHO (Controlled Carbohydrates) diet, Pureed texture, Regular / Thin consistency Upright 90 degrees for all PO [by mouth] intake Staff to ensure pt. [patient] receives correct food consistency Monitor Atelectasis CXR indicative of probable atelectasis in the absence of fevers/leukocytosis ., created by Staff C, Nurse Practitioner (NP).- 11/12/25 health status note, Note Text: IDT [interdisciplinary] reviewed for s/p [status post] choking incident. IDT reviewed chart along with labs and chest xray all noted to be unremarkable. Resident is alert with confusion, total care for ADL's incontinent of b/b mechanical lift for transfers. Sits in a Geri-chair for proper positioning. Resident was eating in MDR [main dining room] where he consumes his food independently. Pt [patient] choked on a piece of ham, Heimlich was successfully preformed and ham was expelled. Skin assessment completed today to assess for any discoloration r/t Heimlich. Skin was clear without redness or discoloration. NO s/s of discomfort or pain was noted. Lungs clear today and no cough noted. Ate in MDR with no s/s of difficulty eating or consuming fluids. MD [medical doctor] and family continue to be aware of all changes.A review of Resident #3's assessments revealed the following:- 11/9/25 17:50 [5:50 p.m.] situation, background, assessment, recommendation (SBAR) summary for providers, . 31. Other change in condition . 1a. List the other change: Res. [resident] was choking on his lunch tray . 2. This started on: 11/9/25 3. What time of day did this start? 2. Afternoon . Mental Status Evaluation 7. No changes observed Functional Status Evaluation 6. No changes observed. Since the change in condition occurred have the symptoms or signs gotten: 2. Better . Res. coughed up food that was chocking him . Res. was observed chocking on his lunch tray, Heimlich maneuver performed and res. expelled food. Res. assessed and vitals stable at this time. Res. skin warm and dry, no respiratory distress noted, and patient removed from dining room and back in room. Family notified- [family member name] Date: 11/09/2025 Time: 6:00 PM . Date and time of clinician notification: 11/9/2025 13:30 [1:30 p.m.] . New orders for 2 view CXR per [Staff C, NP], created by Staff D, Nurse Supervisor. Further review of the SBAR communication form revealed the vital signs documented were from 10/7/25.- 9/16/25 nutrition assessment form, . B. Dietary Intake 1. Current Diet Order/Enteral orders/Supplement Order: CCHO (Controlled Carbohydrates) diet, Pureed texture, Regular / Thin consistency, NAS Med Pass 2.0 120ml [milliliters] TID . Ability to Chew/Swallow: 5. None of the above . E. Neuropsychological problems 0. Severe dementia or depression . Comment/Summary: [NAME] is at risk for Malnutrition r/t psychotropics, therapeutic diet, T2DM, dementia, metabolic encephalopathy, HTN, CKD stage 3, mechanically altered diet, needs assist with meals MNA=10 .A review of Resident #3's speech therapy (ST) notes revealed the following:- SLP evaluation and plan of treatment, dated 11/11/25, Diagnoses Nontraumatic subacute subdural hemorrhage onset 11/11/25 Dysphagia, oropharyngeal phase onset 11/11/25 . Reason for Referral/ Current Illness: Patient is a 91 year LTC [long term care] resident of this facility referred to ST due to reported aspiration episode. Patient is currently on a puree diet with thin liquids. Prior Level of Function Intake/Diet Level = Puree consistencies, Thin liquids, Successive Swallows; Swallowing Abilities = Severe; Self Feeding = Total Dependence without attempts to initiate . Oral Exam Oral Motor Structure and Function = Impaired . Cognition Cognitive-Communicative Skills = Impaired . Cognition Follows Directions = Max(A) [Assistance], responsive to cues . Clinical Bedside Assessment of Swallowing Overall Abilities = Severe . Solids Assessed During Eval = Puree consistencies . Assessment Summary Clinical Impression: Patient seen for dysphagia evaluation at bedside. Per nursing and chart review, patient has known history of advanced dementia with limited cognitive-linguistic function. Spontaneous oral movements appear functional for current diet level. No overt signs/symptoms of aspiration (no coughing, throat clearing, or wet vocal quality) observed during limited trials. Deficits include impaired cognition impacting ability to follow commands, implement swallow strategies, or adjust to texture changes. Current diet of puree solids and thin liquids appears appropriate and safe at this time based on bedside observation and nursing report. Provide 1:1 feeding assistance and slow rate of intake. Ensure upright positioning at 90 degrees during and 30 minutes after meals. No further swallow study indicated due to advanced dementia and inability to participate in treatment. Supervision for Oral Intake = Close supervision .On 11/17/25 at 10:10 a.m., an interview was conducted with Resident #10. He confirmed he witnessed the incident with Resident #3 on 11/9/25. He stated, He [Resident #3] choked. Resident #10 said the meal tickets are on the food trays. He said the CNAs passed the trays and double checked the meal ticket matched the food. Resident #10 stated that day, A new person was helping. Resident #10 said the new staff member gave Resident #3 a tray with a regular diet. He said Resident #3 was in a recliner chair. Resident #10 said the staff were patting his back, but it was not helping. Resident #10 described the staff present as, Frantic. He said Resident #9 wheeled himself to the hallway outside of the dining room stating, Help, Help and putting his hands up. Resident #10 said he recalled the staff present saying, What do we do, what do we do, I will call for the nurse. A review of Resident #10 quarterly MDS, dated [DATE], under section C - cognitive patterns revealed a BIMS score of 15, indicating cognitively intact. On 11/17/25 at 1:29 p.m., an interview was conducted with the Food Service Director. He said he had been in this position since August 2025. He said Staff G, Dietary Aide was at the end of the tray line and the last one to touch the tray in the kitchen on 11/9/25 during lunch. The Food Service Director said he was not present for the incident, but he learned Resident #3 choked in the dining room on 11/9/25. He said two other staff members, Staff H, [NAME] and Staff I, Dietary Aide were also on the tray line. He said Staff I, Dietary Aide was at the beginning of the tray line and called the ticket out to include the diet, such as mechanical or regular. The Food Service Director said Staff G, Dietary Aide was at the end of the line and repeated back what was provided to her by the cook. He said Staff I, Dietary Aide was telling Staff H, [NAME] what she needed to plate, and Staff G, Dietary Aide double checked the meal on the tray was correct. He said Staff G, Dietary Aide called him on 11/9/25 and told him what happened. The Food Service Director stated he talked to Staff G, Dietary Aide the following day and asked for more information about what happened. He said she told him, I [Staff G, Dietary Aide] don't remember, there were people coming in, when you're not here they come in and do whatever they want and not sure what happened. The Food Service Director said Resident #3's diet on 11/9/25 was dysphagia, mechanical soft which meant ground consistency for the protein, pureed vegetables, and a pureed starch. He said he could not provide the residents meal ticket for that day, as he did not have access to do that, but he could provide an example meal ticket of a dysphagia, mechanical texture for the meal that day. He said the mechanical and pureed diets are the same consistency, except for the protein. He said he changed Resident #3's diet to pureed consistency on 11/10/25 in the meal tracker system. The Food Service Director said he did not have documentation of in-services or training regarding meal ticket accuracy for dietary staff prior to August 2025. He said since he has been at the facility he has not needed to provide an in-service on meal ticket accuracy. The Food Service Director said he completed audits and an in-service on meal ticket accuracy to all the dietary staff on 11/10/25. On 11/17/25 at 1:49 p.m., an interview was conducted with Staff G, Dietary Aide. She said on 11/9/25, during lunch, Staff I, Dietary Aide and Staff H, cook were on the tray line. Staff G, Dietary Aide stated she was at the end of the tray line as the, The double checker. She said she called out every ticket and made sure it is the correct food. Staff G, Dietary Aide said the cook knows the diets because of the first person on tray line who tells them. She said the first person called out the diet, the cook puts the food on the plate, and she puts the plate on the resident's tray. Staff G, Dietary Aide said the meal ticket is already on the tray, and she made sure it had the correct beverage, condiments, diet, and the meal matches. She said she did not remember Resident #3 getting a regular diet and believed he received pureed consistency. Staff G, Dietary Aide stated, It's possible it could have happened, and said she had taken accountability if the resident received the wrong diet. She said staff kept interrupting them during the tray line for lunch that day. She said she recalled being told the nurses aids were short staffed on 11/9/25. She said she recalled the dining room cart went out, then the first cart for the south unit went out, then she left the kitchen, came back and when she returned there were two staff members in the kitchen. Staff G, Dietary Aide said one staff member had a tray with a plate and the other staff had the meal ticket in their hand. She said they told her the resident had choked and something serious could have happened. Staff G, Dietary Aide said she recalled walking in the dining room between 11:45 a.m. and 12:00 p.m. and had not seen any resident choking. She said she recalled seeing the two staff members sitting down in the dining room. Staff G, Dietary Aide said when the tray line was almost done is when the two staff members approached her about the choking incident. She said after the two staff approached her, she immediately called the Food Service Director and told him the resident choked and staff were blaming her for the incident. Staff G, Dietary Aide stated the Food Service Director told her no one had called him and, They would see about it on Monday when he comes in. She confirmed that the Nursing Home Administrator (NHA) asked her what happened and she provided a statement. She confirmed she had meal ticket accuracy education, before 11/9/25, from the Food Service Director. On 11/17/25 at 2:29 p.m., a phone interview was conducted with Staff I, Dietary Aide. She said she was typically the first person working on the tray line. She described the, A2 and A1, roles. She stated the person as A1 is preparing the tray with items such as milk and juice, then the tray goes to the person as A2. She stated, A2 putting plate with food exactly what is required with ticket is talking about. Regarding the incident on 11/9/25 she stated, I remember person who was A2 making mistake . that person [Resident #3] has mechanical. Mechanically it is supposed to be bread and meat ground. She [A2] exchanged for regular diet. She said the person in the A2 role did not pay attention and gave Resident #3 the wrong meal. Staff I, Dietary Aide said when she starts the line she puts the ticket on the tray, looks at the diet and says loudly if the meal ticket says mechanical or pureed. She said when she first started, at the end of June 2025, she was educated on the tray line and meal ticket accuracy process by the former food service director and one of the dietary aides. A follow-up interview was conducted with the Food Service Director on 11/17/25 at 2:44 p.m. He said there's been no change to the process on the tray line after the choking incident on 11/9/25. He said the only change made was to the dining meal times. The Food Service Director stated they haven't implemented anything new but, Thought about extra set of eyes to help the tray line process. He said he wanted to put an extra dietary staff in the middle of the tray line, so the last person could focus on checking the trays. The Food Service Director said the nurses and CNAs are supposed to check the tray when meal passing. He stated, It's supposed to be happening, but it fluctuates.A review of a meal ticket on 11/9/25 revealed the following, Dys [Dysphagia] Mech [Mechanical] . Ground Glazed Baked Ham, [NAME] Gravy, Black-Eyed Peas, Fortified Mashed Potatoes, Chopped Greens, Chop, Pureed Dinner Roll/Bread . Vanilla Ice Cream . The Food Service Director confirmed the meal ticket reflected what Resident #3 would have received. An interview was conducted on 11/17/25 at 1:40 p.m. with Staff J, CNA. Staff J, CNA said there was never a nurse in the dining room for meals. She said she typically was the only person in the dining room for lunch and often times at dinner as well. Staff J, CNA said she had complained multiple times about being the only person in the dining room and asked for more assistance, but no one ever came to help. She said the day Resident #3 choked she was in the dining room for lunch time. She said Staff K, receptionist came to the dining room to help pass trays. Staff J, CNA said she knew the residents and their diets well. She said Resident #3 received a meal tray with a regular diet, and he should have received a pureed diet. She said Resident #3 stayed in the dining room for another hour and ate some ice cream. She said meals in the dining room started around 11:15 a.m. to 11:30 a.m., and Resident #3 choked around 11:45 a.m. Staff J, CNA said he did not leave the dining room until after 12:45 p.m.On 11/18/25 at 1:50 p.m., an interview was conducted with Staff K, receptionist. She said she typically worked as a receptionist, but she picked up a shift for activities on 11/9/25. She said she helped pass the meal trays out sometimes. She said she went to help Staff J, CNA in the dining room because she was the only staff member there. She said she did not know she had to check the diets on the meal tickets when passing the trays. Staff K, receptionist confirmed she gave Resident #3 his tray and he started to eat the meal. She said she heard Resident #3 gasping and they tried to pat his back. She confirmed there was no nurse present, so they called out for reception to get a nurse. She said while all this was happening, Resident #9 was scared, and he wheeled down the hall yelling for a nurse to help. She said Resident #3's gasping was getting worse therefore, she did five abdominal thrusts from the front while he was in the Geri-chair. She said the thrusts did not do anything. Staff K, receptionist said herself and Staff J, CNA were able to twist the resident to the side, that way she could get her arms around the resident to perform the Heimlich maneuver. Staff K, receptionist said she did three abdominal thrusts and the lodged food came out of the resident's throat. She stated what came out of the resident's throat was a, Thick piece of ham. Staff K, receptionist said she is not a clinical staff member at the facility, but she is CPR certified.On 11/18/25 at 3:45 p.m., an interview was conducted with the DON and NHA to review their response to the incident with Resident #3. The NHA said the incident happened on 11/9/25. She said she was made aware during the morning meeting on 11/10/25 that Resident #3 choked in the dining room. The NHA said Staff D, Nurse Supervisor notified her Resident #3 had the wrong lunch tray and choked on a small piece of ham. She said Staff D, Nurse Supervisor obtained statements from the dietary staff, CNA and receptionist who were in the dining area at the time of the incident. The NHA said Resident #3 was fine, he had no change in condition, was at baseline, and the physician was notified who ordered a chest x-ray. She said Staff K, receptionist who was assisting with passing meal trays gave the resident the tray. The NHA said Staff D, Nurse Supervisor told her she did not see the tray provided to Resident #3 due to her being with two other resident emergencies. The NHA said she asked the dietary team about Resident #3's meal ticket that day and she was advised it was the right ticket on the tray. The NHA said the dietary staff confirmed what meals went out to the dining room and what Resident #3 received, which was a pureed diet. She said the dietary staff confirmed they provided the right tray, meal, and verified the meal before the tray exited the kitchen area. She said through her interview with Staff K, receptionist she confirmed she did not verify the meal before giving it to Resident #3. The NHA said after the Heimlich was performed, Resident #3's tray was taken back to the kitchen and confirmed he had the wrong tray. She said the tray ticket showed he had a pureed diet to include puree ham, mashed potato and puree black eyed peas. The NHA said he was provided a regular diet to include regular consistency of ham, black eyed peas, and greens. She said through their investigation they are not sure if it was the dietary staff or the staff passing trays that provided the wrong meal to Resident #3. The NHA stated it is, Still unknown where the error and confusion happened. When asked who can change a diet order, the NHA and DON said a nurse can downgrade, the speech therapist is the only one who can upgrade, the dietitian can upgrade and downgrade the diet, and kitchen managers cannot change the diets. The DON stated, They [kitchen managers] cannot touch the diets. The NHA and DON said there were no changes made to the tray line process. They said the kitchen staff will not provide the dining room trays unless a nurse is in the dining room. A review of the food consistency audits conducted in the dining room revealed the following:- On 11/10/25, an audit was completed for one meal, however, the meal time was not documented.- On 11/12/25, an audit was completed for two meals, however, the meal times were not documented.- On 11/14/25, a meal audit was not completed for dinner.- On 11/15/25, a meal audit was not completed for breakfast.- On 11/17/25, a meal audit was not completed for lunch.A review of Resident #3's Kardex revealed the following:- As of 11/18/25, .Eating/Nutrition Arrange meals in patients visual field, Offer food substitutions when meal is refused or an alternate is requested, Offer snacks prn, Offer/encourage fluids of choice, Provide diet as ordered, monitor and record intake - Dysphagia Puree Texture/thin liquids, Set up trays/supervise/cue/assist as needed with meals and allow adequate time to consume food/fluids provided.- As of 11/19/25, .Eating/Nutrition Arrange meals in patients visual field, Offer food substitutions when meal is refused or an alternate is requested, Offer snacks prn Offer/encourage fluids of choice, Provide diet as ordered, monitor and record intake - Dysphagia Puree Texture/thin liquids, Set up meal tray allow to eat independently assist if needed, Set up trays adequate time to consume food/fluids provided.On 11/19/25 at 10:18 a.m., a phone interview was conducted with Staff L, SLP. Staff L, SLP said Resident #3 was referred to her because he had an episode of aspiration. She said he had been on a pureed diet due to advanced dementia and determined that was the safest consistency for him. Staff L, SLP said she was told Resident #3 was given a piece of ham and choked but did not know he was provided a regular tray in the dining room. She said she did not know Resident #3 until he was referred to her. Staff L, SLP said when she looked in the electronic health record she saw he was on a pureed diet and might have been on a mechanical texture at some point. She stated, Pureed is least restrictive and safer for him and because of his cognition. Staff L, SLP said when she made recommendations, she immediately lets the nurse on duty know what they are.On 11/19/25 at 11:20 a.m., an interview with Resident #9 was conducted. He was observed wheeling himself from the dining room, down the hall, and to his room. He said he was scared after the incident with Resident #3 and confirmed he was in the dining room when it happened. Resident #9 said there was no nurse that day, but now there is.A review of Resident #9's quarterly MDS, dated [DATE], under section C - cognitive patterns revealed a BIMS score of 12, indicating moderately impaired. On 11/19/25 at 11:33 a.m., a follow-up phone interview was conducted with Staff K, receptionist. She said she had no training on passing meal trays or reading meal tickets prior to 11/9/25. She confirmed it was not the first time she had helped in the dining room.On 11/19/25 at 11:44 a.m., an interview was conducted with Staff C, NP. He said Resident #3 was in the dining room and staff gave him the wrong tray or food consistency. Staff C, NP said to his understanding the resident is supposed to be on a mechanical soft, dysphagia diet. He stated, Mechanical soft dysphagia is basically puree consistency. He said staff did the Heimlich maneuver and the food dislodged. He confirmed he saw Resident #3 on 11/10/25. Staff C, NP said he presumed Resident #3 may have, Fear of choking, as it was an unpleasant experience, but he had no medical consequences. He said he looked at Resident #3's speech therapy evaluation and could not find diagnostic proof of dysphagia. Staff C, NP said the risks and concerns with receiving a regular diet is choking and aspiration. He said his expectation is for the right diet to be served to residents.On 11/19/25 at 2:53 p.m., a follow-up interview was conducted with Staff J, CNA. She said she knows the residents' diets because they provide food in activities. She said the kitchen manager provides her with the diet slip and allergy list. Staff J, CNA said she had no training or education prior to 11/9/25 to check the resident's food tray for meal ticket accuracy. She said the facility is now training staff about reviewing the food and checking the meal ticket before leaving the food tray, as well as a nurse being present during dining to check the meal tickets. She stated, Everything they should have been doing, they are doing now. On 11/20/25 at 10:03 a.m., an interview was conducted with Staff O, Cook, Staff G, Dietary Aide, and Staff P, Dietary Aide. They confirmed staff come to the kitchen door requesting something right away which interrupts them on the tray line. Staff O, [NAME] and Staff P, Dietary Aide said they tell staff to give them time as the residents need to receive their meals first. Staff P, Dietary Aide said staff sometimes stop them when they are taking the meal carts to the floor. Staff G, Dietary Aide confirmed there were distractions when she was on the lunch tray line on 11/9/25. Staff P, Dietary Aide said staff also call by phone requesting things. She stated, We can't step off the line to answer the phone. Staff O, Cook, Staff G, Dietary Aide and Staff P, Dietary Aide said there are less distractions now, but staff are still coming in or calling the kitchen during the meal service. (Photographic evidence obtained)A review of the facility's procedure and in-service documentation titled, Texture Modification Inservice, revealed the following: .Purpose: To educate all new hires and current employees on the importance of and guidelines for proper texture modification. Importance of Texture Modification . Proper preparation and delivery of texture-modified diets is critical for resident safety and wellness. Dysphagia Puree Consistency All foods (ex. meats, breads, starches, fruits, vegetables, and desserts) must be pureed to a mousse-like texture. Cannot receive hard, dry meats . or foods that cannot be pureed into a smooth mousse-like texture. A review of the facility's policy titled, Meal Distribution, with an original date of 5/2014 and a revised date of 2/2023, revealed the following: Procedures1. All meals will be assembled in accordance with the individualized diet order, plan of care, and preferences. 4. The nursing staff will be responsible for verifying meal accuracy and the timely delivery of meals to residents/patients. 5. For point-of-service dining, the Dining Services Department staff, under the supervision of the licensed nurse, will assemble the meal in accordance with the individual meal card and present it to the resident/patient or care staff for delivery to the resident/patient. The facility's immediate actions to remove the Immediate Jeopardy included:- On 11/10/2025, the Nursing Home Administrator, educated unlicensed staff that served the wrong diet consistency tray was suspended and educated on abuse and neglect.- On 11/10/25 dietary employee that prepared the wrong diet consistency tray was suspended and educated on abuse and neglect as well as tray accuracy by the CDM district dietary manager.- On 11/10/25 an ADHOC Quality Improvement Performance Committee meeting was held to review the recommendations made from the root cause analysis. The following team members were in attendance: Medical Director (via telephone), Executive Director, Director of Nursing (via telephone), and management staff.- On 11/10/25, a Performance Improvement Plan was developed and initiated based upon Root Cause Analysis (RCA) as determined by Quality Assurance Performance Improvement committee (QAPI). Root cause analysis identified as dietary staff prepared the incorrect diet consistency for Resident #3 and an unlicensed staff member served the incorrect meal tray.- On 11/10/25 The ADHOC QAPI Committee approved the following recommendations:1. Resident was assessed, MD was notified & chest x-ray was ordered.2. Current residents in the facility diet orders in [electronic health record vendor] were checked against meal tickets in the kitchen to ensure all were accurate.3. Education was completed for dietary employees on following the correct diet when preparing resident meal trays.4. Nursing staff were educated on checking the meal tickets with diet being served.5. Nursing staff completed competencies on meal tray serving.6. Current facility staff were

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents were free from avoidable accidents for two residents (#3 and #2) out of three residents reviewed for accidents.The facility failed to provide Resident #3 with the correct physician ordered diet and resulted in the resident choking, which required staff to execute the Heimlich maneuver. Resident #3's care plan and speech therapy evaluation showed the resident needed assistance with dining and one to one supervision. Observations of the resident during the lunch dining on 11/17/25 and 11/18/25 revealed he was not in the upright position when eating, which increased the risk of choking, and one to one supervision was not observed. These failures created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #3 and resulted in the determination of Immediate Jeopardy on 11/18/25. The findings of Immediate Jeopardy were determined to be removed on 11/20/25 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings Included: 1. On 11/17/25 at 11:39 a.m., an observation of the main dining room during lunch revealed Resident #3 was seated at the table in a Geri-chair positioned at approximately 60-65 degrees. An observation of the food tray and meal provided revealed a pureed consistency. Further observations of Resident #3 revealed he ate his meal without assistance from staff.On 11/18/25 at 11:50 a.m., an observation of the main dining room during lunch revealed Resident #3 was seated at the table in a Geri-chair positioned at approximately 60 degrees. An observation of the food tray and meal provided revealed a pureed consistency. Staff were observed setting up the meal tray in front of him. Resident #3 began consuming his meal unassisted by staff. He was observed having difficulty getting food onto the fork. After four attempts, Resident #3 was able to get a dime-sized amount of food on the fork. Staff E, Certified Nursing Assistant (CNA) stated to Staff F, CNA, He [Resident #3] keeps doing that because he can't see his food. Staff F, CNA was observed looking at Resident #3's meal tray and stated, Well, he's almost done.A review of Resident #3's admission record revealed he was admitted on [DATE] with diagnoses to include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, need for assistance with personal care, muscle weakness (generalized), muscle wasting and atrophy, anxiety disorder, major depressive disorder, unspecified convulsions, persistent mood [affective] disorder, and constipation. A review of Resident #3's quarterly Minimum Data Set (MDS), dated [DATE], revealed the following:- Section C - Cognitive Patterns, Brief Interview for Mental Status (BIMS) . BIMS Summary Score 03, indicating severe impairment.- Section GG - Functional Abilities, . A. Eating: . 05. Setup or clean-up assistance .- Section K - Swallowing/Nutritional Status, . C. Mechanically altered diet - require change in texture of food or liquids (e.g. [example], pureed food, thickened liquids) Yes . D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol) Yes . A review of Resident #3's current diet orders revealed the following:- Consistent Carbohydrates (CCD) diet, Pureed texture, Regular / Thin consistency. Directions: no salt packets, with a start date of 11/11/25 and revised on 11/11/25. A review of Resident #3's discontinued diet orders revealed the following:- CCHO [consistent/constant carbohydrate diet], Low Fat, Low Chol [cholesterol], NAS [no added salt] diet, Regular texture, Regular / Thin consistency. Status: Discontinued., with a start date of 4/10/24 and an end date on 4/11/24.- CCHO, Low Fat, Low Chol, NAS diet, Mechanical Soft texture, Regular / Thin consistency. Status: Discontinued., with a start date of 4/11/24 and an end date on 4/11/24.- CCHO (Controlled Carbohydrates) diet, Mechanical Soft texture, Regular / Thin consistency. Directions: NAS; fortified foods TID [three times a day]. Status: Discontinued, with a start date of 4/11/24, revised date of 5/7/24, and an end date on 6/2/24.- CCHO (Controlled Carbohydrates) diet, Pureed texture, Regular / Thin consistency. Directions NAS., with a start date of 6/2/24, revised date of 7/9/25, and an end date on 11/11/25.A review of Resident #3's care plan revealed the following:- [Resident name] is at risk for Malnutrition r/t [related to] psychotropics, therapeutic diet, T2DM [type 2 diabetes mellitus], dementia, metabolic encephalopathy, HTN [hypertension], CKD [chronic kidney disease] stage 3, mechanically altered diet, needs assist with meals MNA[malnutrition assessment]=10 Date Initiated: 04/11/2024 Revision on: 09/16/2025., with interventions to include the following, Monitor and report to the physician: . Chewing/swallowing problems Date Initiated: 04/11/2024 . or for signs and symptoms of aspiration such as coughing, choking, pocketing, runny nose, watery eyes spitting food out, wet vocal quality, wet lungs. Notify SLP [speech language pathologist] if any symptoms are present Date Initiated: 04/11/2024 . Provide diet as ordered, monitor and record intake- Dysphagia Puree Texture/thin liquids Date Initiated: 04/11/2024 Revision on: 11/11/2025. Set up trays/supervise/cue/assist as needed with meals and allow adequate time to consume food/fluids provided Date Initiated: 04/11/2024 .- [Resident name] has a communication problem due to: Brain injury, Cognitive impairment, Expressive Aphasia, Receptive Aphasia Date Initiated: 04/23/2024 Revision on: 04/23/2024.A review of Resident #3's progress notes revealed the following:- 11/9/25 health status note 12:15, Patient in dining room for lunch, patient observed eating and choking on food. Patient assessed and vitals stable at this time. Patient skin warm and dry, no respiratory distress noted, and patient removed from dining room and back in room, created by Staff B, Licensed Practical Nurse (LPN).- 11/10/25 physician progress note, . DOS [date of service]: 11/10/2025 Effective Time: 10:30 AM CC [chief complaint]: Dysphagia / Choking Episode . HPI [history of present illness]: Nursing reports that yesterday the patient was in the dining room eating and had an episode where he was unable to swallow food. He reportedly did not get the correct food consistency for his meal. Staff performed the Heimlich maneuver on him and the food was abruptly dislodged. He did not experience any observed respiratory distress after the incident. Nursing reports after the incident he has been at his baseline cognitively and functionally. He denies any shortness of breath, coughing, fevers/chills/night sweats, sputum production, n/v/d [nausea, vomiting, diarrhea], sore throat, acute pain, dizziness, lightheadedness, headaches, vision changes, increased weakness. CXR [chest x-ray] reviewed: Early changes of intrapillar atelectasis or pneumonia. Findings favor atelectasis in the absence of leukocytosis. Perihilar inflammation, acute or chronic. Correlate risk factors for infection. CBC/CMP [complete blood count/comprehensive metabolic panel] in AM [morning] to check for leukocytosis ST [speech therapy] eval [evaluation] Continue Diet: CCHO (Controlled Carbohydrates) diet, Pureed texture, Regular / Thin consistency Upright 90 degrees for all PO [by mouth] intake Staff to ensure pt. [patient] receives correct food consistency Monitor Atelectasis CXR indicative of probable atelectasis in the absence of fevers/leukocytosis ., created by Staff C, Nurse Practitioner (NP).- 11/10/25 health status note 12:05, Note Text: Late Entry: At time of assessing the resident after chocking his bilateral lungs were clear, Resp [respiratory] even and nonlabored, O2 [oxygen] sat [saturation] at 98% on r.a. [room air] Res. [resident] was taken back to his room and was sitting up in chair without s/s [signs and symptoms] of distress, created by Staff D, Nurse Supervisor.- 11/10/25 health status note 13:04, Note Text: At the time of assessment of patient, vitals taken: B/P [blood pressure] 126/80, pulse 98, temp 97.9, respirations 18, and O2 95 on room air. Patient alert and in no apparent distress. Lung sounds clear and patient observed to have normal respiratory effort, created by Staff B, Licensed Practical Nurse (LPN).- 11/10/25 health status note 13:32, CXR reviewed: IMPRESSION: Early changes of intrapillar atelectasis or pneumonia. Findings favor atelectasis in the absence of leukocytosis. Perihilar inflammation, acute or chronic. Correlate risk factors for infection. Slightly worse compared to 4/21/2025. 1) Vitals every shift for 3 days 2) CBC/CMP in AM.- 11/11/25 health status note, Labs reviewed, stable without any leukocytosis. Stable anemia and DM II [diabetes mellitus two] are noted. No new orders.- 11/11/25 health status note 21:12, LATE ENTRY Note Text: Resident is alert with confusion and is assisted totally with ADL's [activities of daily living]. Transfers to and from Geri chair with Hoyer lift and 2 assist [two person assist]. Resident is assisted with meals, encouraged to eat meal. Incontinent of B&B [bladder and bowel]. No s/s of acute distress and no c/o [complaints of] pain voiced at this time.- 11/12/25 health status note, Note Text: IDT [interdisciplinary] reviewed for s/p [status post] choking incident. IDT reviewed chart along with labs and chest xray all noted to be unremarkable. Resident is alert with confusion, total care for ADL's incontinent of b/b mechanical lift for transfers. Sits in a Geri-chair for proper positioning. Resident was eating in MDR [main dining room] where he consumes his food independently. Pt [patient] choked on a piece of ham, Heimlich was successfully preformed and ham was expelled. Skin assessment completed today to assess for any discoloration r/t Heimlich. Skin was clear without redness or discoloration. NO s/s of discomfort or pain was noted. Lungs clear today and no cough noted. Ate in MDR with no s/s of difficulty eating or consuming fluids. MD [medical doctor] and family continue to be aware of all changes.- 11/13/25 health status note, V/S [vital signs] taken on 11/9/2025 s/p [status post] incident in MDR 126/89, 98, 18, 97.9 with O2 sat 95 on RA, created by the Director of Nursing (DON).A review of Resident #3's assessments revealed the following:- 11/9/25 17:50 [5:50 p.m.] situation, background, assessment, recommendation (SBAR) summary for providers, . 31. Other change in condition . 1a. List the other change: Res. [resident] was choking on his lunch tray . 2. This started on: 11/9/25 3. What time of day did this start? 2. Afternoon . Mental Status Evaluation 7. No changes observed Functional Status Evaluation 6. No changes observed. Since the change in condition occurred have the symptoms or signs gotten: 2. Better . Res. coughed up food that was chocking him . Res. was observed chocking on his lunch tray, Heimlich maneuver performed and res. expelled food. Res. assessed and vitals stable at this time. Res. skin warm and dry, no respiratory distress noted, and patient removed from dining room and back in room. Family notified- [family member name] Date: 11/09/2025 Time: 6:00 PM . Date and time of clinician notification: 11/9/2025 13:30 [1:30 p.m.] . New orders for 2 view CXR per [Staff C, NP], created by Staff D, Nurse Supervisor. Further review of the SBAR communication form revealed the vital signs documented were from 10/7/25.- 9/16/25 nutrition assessment form, . B. Dietary Intake 1. Current Diet Order/Enteral orders/Supplement Order: CCHO (Controlled Carbohydrates) diet, Pureed texture, Regular / Thin consistency, NAS Med Pass 2.0 120ml [milliliters] TID . Ability to Chew/Swallow: 5. None of the above . E. Neuropsychological problems 0. Severe dementia or depression . Comment/Summary: [NAME] is at risk for Malnutrition r/t psychotropics, therapeutic diet, T2DM, dementia, metabolic encephalopathy, HTN, CKD stage 3, mechanically altered diet, needs assist with meals MNA=10 .Review of Resident #3's x-ray results revealed the following:- 4/21/25 chest, single view, Clinical Information: follow up left infiltrate Test Procedure: . CHEST, SINGLE VIEW Findings: Comparison: 03/15/2025 The cardiac silhouette and mediastinal contours are normal. The lungs are free of infiltrates and focal consolidations. No pleural fluid or masses are noted. No pneumothorax is present. Impressions: No acute intrathoracic disease process.- 11/10/25 chest, 2 views, Date of Service: 11/10/2025 Clinical Information: . Pneumonitis due to inhalation of food and vomit possible aspiration Test Procedure: . CHEST, 2 VIEWS Findings: . No acute osseous or soft tissue abnormality. Cardiac and mediastinal contours are within normal limits. Normal pulmonary vasculature. No pneumothorax. Bilateral intrapillar airspace opacity is present. Peribranchial distention with peribranchial cuffing is present. This nonspecific finding indicates chronic or acute perihilar inflammation. IMPRESSION: Early changes of intrapillar atelectasis or pneumonia. Findings favor atelectasis in the absence of leukocytosis. Perihilar inflammation, acute or chronic. Correlate risk factors for infection. Slightly worse compared to 4/21/2025.A review of a resource from the American Lung Association revealed the following, Atelectasis happens when the tiny air sacs or alveoli in your lungs are blocked, and it causes a partial or full collapse of one or more lobes or sections of the lungs. Other causes may include A small object blocking the airways (like food or toy) . Lung infection like pneumonia . Your healthcare provider will discuss treatment options if atelectasis is caused by a tumor, an aspirated foreign body, or other chronic lung conditions. Serious complications may occur if atelectasis remains untreated. Complications can include low oxygen levels, pneumonia, or lung failure. The reference was reviewed on the following website https://www.lung.org/lung-health-diseases/lung-disease-lookup/atelectasis. A review of Resident #3's speech therapy (ST) notes revealed the following:- SLP evaluation and plan of treatment, dated 11/11/25, Diagnoses Nontraumatic subacute subdural hemorrhage onset 11/11/25 Dysphagia, oropharyngeal phase onset 11/11/25 . Reason for Referral/ Current Illness: Patient is a 91 year LTC [long term care] resident of this facility referred to ST due to reported aspiration episode. Patient is currently on a puree diet with thin liquids. Prior Level of Function Intake/Diet Level = Puree consistencies, Thin liquids, Successive Swallows; Swallowing Abilities = Severe; Self Feeding = Total Dependence without attempts to initiate . Oral Exam Oral Motor Structure and Function = Impaired . Cognition Cognitive-Communicative Skills = Impaired . Cognition Follows Directions = Max(A) [Assistance], responsive to cues . Clinical Bedside Assessment of Swallowing Overall Abilities = Severe . Solids Assessed During Eval = Puree consistencies . Assessment Summary Clinical Impression: Patient seen for dysphagia evaluation at bedside. Per nursing and chart review, patient has known history of advanced dementia with limited cognitive-linguistic function. Spontaneous oral movements appear functional for current diet level. No overt signs/symptoms of aspiration (no coughing, throat clearing, or wet vocal quality) observed during limited trials. Deficits include impaired cognition impacting ability to follow commands, implement swallow strategies, or adjust to texture changes. Current diet of puree solids and thin liquids appears appropriate and safe at this time based on bedside observation and nursing report. Provide 1:1 feeding assistance and slow rate of intake. Ensure upright positioning at 90 degrees during and 30 minutes after meals. No further swallow study indicated due to advanced dementia and inability to participate in treatment. Supervision for Oral Intake = Close supervision .On 11/17/25 at 10:10 a.m., an interview was conducted with Resident #10. He confirmed he witnessed the incident with Resident #3 on 11/9/25. He stated, He [Resident #3] choked. Resident #10 said the meal tickets are on the food trays. He said the CNAs passed the trays and double checked the meal ticket matched the food. Resident #10 stated that day, A new person was helping. Resident #10 said the new staff member gave Resident #3 a tray with a regular diet. He said Resident #3 was in a recliner chair. Resident #10 said the staff were patting his back, but it was not helping. Resident #10 described the staff present as, Frantic. He said Resident #9 wheeled himself to the hallway outside of the dining room stating, Help, Help and putting his hands up. Resident #10 said he recalled the staff present saying, What do we do, what do we do, I will call for the nurse. He confirmed there was no nurse present in the dining room during the lunch meal on 11/9/25. Resident #10 said a nurse never came to assess Resident #3. He said staff took Resident #3 to his room after the lunch meal was completed. Resident #10 confirmed he stayed for the duration of the lunch. He said other departments are now helping in the dining room and a nurse is present. A review of Resident #10 quarterly MDS, dated [DATE], under section C - cognitive patterns revealed a BIMS score of 15, indicating cognitively intact. On 11/17/25 at 1:29 p.m., an interview was conducted with the Food Service Director. He said Staff G, Dietary Aide was at the end of the tray line and the last one to touch the tray for Resident #3 in the kitchen on 11/9/25 during lunch. The Food Service Director said he was not present for the incident and he learned Resident #3 choked in the dining room on 11/9/25. He said two other staff members, Staff H, [NAME] and Staff I, Dietary Aide were also on the tray line. He said Staff I, Dietary Aide was at the beginning of the tray line and called the ticket out to include the diet. The Food Service Director said Staff G, Dietary Aide was at the end of the line and repeated back what was provided to her by the cook. He said Staff I, Dietary Aide was telling Staff H, [NAME] what she needed to plate, and Staff G, Dietary Aide double checked the meal on the tray to assure it was correct. He said Staff G, Dietary Aide called him on 11/9/25 and told him what happened. The Food Service Director stated he talked to Staff G, Dietary Aide the following day and asked for more information about what happened. He said she told him, I [Staff G, Dietary Aide] don't remember, there were people coming in, when you're not here they come in and do whatever they want and not sure what happened. The Food Service Director said Resident #3's diet on 11/9/25 was dysphagia, mechanical soft which meant ground consistency for the protein, pureed vegetables, and a pureed starch. He said the mechanical and pureed diets are the same consistency, except for the protein. He said he changed Resident #3's diet to pureed consistency on 11/10/25 in the meal tracker system. On 11/17/25 at 1:49 p.m., an interview was conducted with Staff G, Dietary Aide. She said on 11/9/25, during lunch, Staff I, Dietary Aide and Staff H, cook were on the tray line. Staff G, Dietary Aide stated she was at the end of the tray line as The double checker. She said she called out every ticket and made sure it was the correct food. Staff G, Dietary Aide said the cook knows the diets because of the first person on tray line who tells them. She said the first person called out the diet, the cook puts the food on the plate, and she puts the plate on the resident's tray. Staff G, Dietary Aide said the meal ticket is already on the tray. She said she did not remember Resident #3 getting a regular diet and believed he received pureed consistency. Staff G, Dietary Aide stated, It's possible it could have happened, and said she had taken accountability if the resident received the wrong diet. She said staff kept interrupting them during the tray line for lunch that day. She said she recalled being told the nurses aides were short staffed on 11/9/25. She said she recalled the dining room cart went out, then the first cart for the south unit went out, then she left the kitchen, came back and when she returned there were two staff members in the kitchen. Staff G, Dietary Aide said one staff member had a tray with a plate and the other staff had the meal ticket in their hand. She said they told her the resident had choked and something serious could have happened. Staff G, Dietary Aide said she recalled walking in the dining room between 11:45 a.m. and 12:00 p.m. and had not seen any resident choking. She said she recalled seeing the two staff members sitting down in the dining room. Staff G, Dietary Aide said when the tray line was almost done is when the two staff members approached her about the choking incident. She said after the two staff approached her she immediately called the Food Service Director. Staff G, Dietary Aide stated the Food Service Director told her, They would see about it on Monday when he comes in. On 11/17/25 at 2:29 p.m., a phone interview was conducted with Staff I, Dietary Aide. She said she was typically the first person working on the tray line. She described the, A2 and A1, roles. She stated the person as A1 is preparing the tray with items such as milk and juice, then the tray goes to the person as A2. She stated, A2 putting plate with food exactly what is required with ticket is talking about. Regarding the incident on 11/9/25 she stated, I remember the person who was A2 making mistake . that person [Resident #3] has mechanical. Mechanically it is supposed to be bread and meat ground. She [A2] exchanged for regular diet. She said the person in the A2 role did not pay attention and gave Resident #3 the wrong meal. Staff I, Dietary Aide said when she starts the line she puts the ticket on the tray, looks at the diet and says loudly if the meal ticket says mechanical or pureed. A follow-up interview was conducted with the Food Service Director on 11/17/25 at 2:44 p.m. He said there's been no change to the process on the tray line after the choking incident on 11/9/25. He said the only change made was to the dining meal times. The Food Service Director stated they haven't implemented anything new but, Thought about extra set of eyes to help the tray line process. He said he wanted to put an extra dietary staff in the middle of the tray line, so the last person could focus on checking the trays. The Food Service Director said the nurses and CNAs are supposed to check the tray when meal passing. He stated, It's supposed to be happening, but it fluctuates.A review of a meal ticket on 11/9/25 revealed the following, Dys [Dysphagia] Mech [Mechanical] . Ground Glazed Baked Ham, [NAME] Gravy, Black-Eyed Peas, Fortified Mashed Potatoes, Chopped Greens, Chop, Pureed Dinner Roll/Bread . Vanilla Ice Cream . The Food Service Director confirmed the meal ticket reflected what Resident #3 would have received. An interview was conducted on 11/17/25 at 1:40 p.m. with Staff J, CNA. Staff J, CNA said there was never a nurse in the dining room for meals. She said she typically was the only person in the dining room for lunch and often times at dinner as well. Staff J, CNA said she had complained multiple times about being the only person in the dining room and asked for more assistance, but no one ever came to help. She said the day Resident #3 choked she was in the dining room for lunch time. She said Staff K, receptionist came to the dining room to help pass trays. Staff J, CNA said she knew the residents and their diets well. She said Resident #3 received a meal tray with a regular diet, and he should have received a pureed diet. She said the day of the incident, Resident #3 was feeding himself and she heard him gasping for air. Staff J, CNA said she looked over and saw he was choking. She said his eyes were watering and demonstrated he had his hands on the chest/neck area while gasping. Staff J, CNA and Staff K, receptionist both went to assist him and yelled out for reception to get a nurse. Staff J, CNA said she leaned him forward to pat him on the back. She said it was difficult because he was reclined and leaning back in a Geri chair. She confirmed Staff K, receptionist performed the Heimlich maneuver on Resident #3. She said she assisted with twisting the resident to the side that way Staff K, receptionist could get behind him. Staff J, CNA said she is not cardiopulmonary resuscitation (CPR) certified. She said by the time Staff D, Nurse Supervisor arrived the food had been dislodged, and the resident was breathing. Staff J, CNA said Staff D, Nurse Supervisor asked what happened and said they should not have done anything because only a nurse should do the Heimlich. She said Staff D, Nurse Supervisor asked them if the resident was ok and said she had to go back to the unit to finish what she was doing, then left. She said Resident #3 stayed in the dining room for another hour and ate some ice cream. On 11/18/25 at 1:50 p.m., an interview was conducted with Staff K, receptionist. She said she typically worked as a receptionist, but she picked up a shift for activities on 11/9/25. She said she helped pass the meal trays out sometimes. She said she went to help Staff J, CNA in the dining room because she was the only staff member there. She said she did not know she had to check the diets on the meal tickets when passing the trays. Staff K, receptionist confirmed she gave Resident #3 his tray and he started to eat the meal. She said she heard Resident #3 gasping and they tried to pat his back. She confirmed there was no nurse present, so they called out for reception to get a nurse. She said while all this was happening, Resident #9 was scared, and he wheeled down the hall yelling for a nurse to help. She said Resident #3's gasping was getting worse therefore, she did five abdominal thrusts from the front while he was in the Geri-chair. She said the thrusts did not do anything. Staff K, receptionist said herself and Staff J, CNA were able to twist the resident to the side, that way she could get her arms around the resident to perform the Heimlich maneuver. Staff K, receptionist said she did three abdominal thrusts and the lodged food came out of the resident's throat. She stated what came out of the resident's throat was a, Thick piece of ham. Staff K, receptionist said she is not a clinical staff member at the facility, but she is CPR certified.On 11/18/25 at 2:03 p.m., a phone interview was conducted with Staff D, Nurse Supervisor. She stated, That day [11/9/25] I was the only supervisor in building, which is normal. Staff D, Nurse Supervisor said she was on the south wing assessing a patient who was complaining of chest pain. She stated while she was, Getting that under control, she heard yelling that a nurse was needed for an assessment. She said she ran to the dining room and confirmed the incident happened during lunch time. Staff D, Nurse Supervisor said Resident #3 was sitting up in the chair, there were approximately four staff members there, and she heard he choked. She stated, Whatever they did it was already taken care of, by the time she got to the dining room. Staff D, Nurse Supervisor confirmed the staff present said they did the Heimlich. She stated, He was calm, peaceful, nothing wrong with him. Staff D, Nurse Supervisor confirmed she assessed Resident #3 to include listening to his lungs and looking at him. She stated it was a, Quick look, listen, and go, as she had another emergency she was handling. She said she saw he was okay; then went to the kitchen and asked what and how the incident happened. Staff D, Nurse Supervisor said, The head person in the kitchen stated someone was on their phone while fixing the tray. She said she told the kitchen staff they needed to be careful, and Resident #3 could have died. She did not recall the names of the kitchen staff present. She said the resident went back to his room but could not confirm who took him there. She said she called and let her manager know about the incident. Staff D, Nurse Supervisor confirmed Staff B, LPN was his assigned nurse. She stated, She [Staff B, LPN] was on the floor, not in the dining room. She said she does not know Resident #3 well but knows he was on a pureed diet and assumed he had a swallowing difficulty. She said immediately after the incident, they started making sure a nurse and/or management is in the dining room during mealtimes. When asked which residents in the dining room needed assistance with eating, she stated, Nobody in the dining room needs assistance with eating. Not even Resident #3 needs assistance with eating. Staff D, Nurse Supervisor said staff know their residents and are aware if they needed assistance when eating. She stated, If they don't know, the nurse knows. She said she is not sure where to find information about a resident who needed assistance with eating. Staff D, Nurse Supervisor stated, I'm thinking, that's a good question, never thought of the process. She stated she has been at the facility since March 2025 and it, Never crossed my mind to ask that question about where to look. At 2:46 p.m., a follow-up interview with Staff D, Nurse Supervisor was conducted by phone. She said it was the Kardex where they find information about residents who need assistance with eating. She stated, I stick by my answer of staff knowing their residents, if they need assistance with eating. On 11/18/25 at 2:31 p.m., a phone interview was conducted with Staff B, LPN. She said on 11/9/25, Resident #3 went to the dining room for lunch and came back to his room. She said she assessed him to include vitals and lung sounds. Staff B, LPN stated, He was perfectly fine back in the room and breathing with no difficulty. She said she was told he received the wrong meal or got the wrong tray, he choked, and the Heimlich was performed. Staff B, LPN said Resident #3 was on a pureed diet. She said when he got back to his room that is when she was told about what happened. She confirmed she would have expected to be notified and would have evaluated him sooner since she was his assigned nurse. Staff B, LPN said nurses are checking meal tickets to make sure they match with the meal on the tray. She stated, They are stricter now, but the process was the same before. On 11/18/25 at 3:45 p.m., an interview was conducted with the DON and NHA to review their response to the incident with Resident #3. The NHA said the incident happened on 11/9/25. She said she was made aware during the morning meeting on 11/10/25 that Resident #3 choked in the dining room. The NHA said Staff D, Nurse Supervisor notified her Resident #3 had the wrong lunch tray and choked on a small piece of ham. The NHA said Resident #3 was fine, he had no change in condition, was at baseline, and the physician was notified who ordered a chest x-ray. She said Staff K, receptionist who was assisting with passing meal trays gave the resident the tray. The NHA said Staff D, Nurse Supervisor told her she did not see the tray provided to Resident #3 due to her being with two other resident emergencies. The NHA said she asked the dietary team about Resident #3's meal ticket that day and she was advised it was the right ticket on the tray. She said the dietary staff confirmed they provided the right tray, meal, and verified the meal before the tray exited the kitchen area. She said through her interview with Staff K, receptionist she confirmed she did not verify the meal before giving it to Resident #3. The NHA said after the Heimlich was performed, Resident #3's tray was taken back to the kitchen and confirmed he had the wrong tray. The NHA said he was provided a regular diet to include regular consistency of ham, black eyed peas, and greens. She said through their investigation they are not sure if it was the dietary staff or the staff passing trays that provided the wrong meal to Resident #3. The NHA stated it is, Still unknown where the error and confusion happened. She said Resident #3 was assessed again on 11/10/25 and had no signs of distress and labs completed showed he did n

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the resident's right to be free from neglect for one resident (#3) out of two residents reviewed for neglect and abuse. The facility neglected to provide Resident #3 with the correct physician ordered diet and resulted in the resident choking, which required staff to execute the Heimlich maneuver. Resident #3's care plan and speech therapy evaluation showed the resident needed assistance with dining and supervision as needed. Observations of the resident during the lunch dining on 11/17/25 and 11/18/25 revealed he was not in the upright position when eating, which increased the risk of choking, and one to one supervision was not observed. These failures created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #3 and resulted in the determination of Immediate Jeopardy on 11/18/25. The findings of Immediate Jeopardy were determined to be removed on 11/20/25 and the severity and scope was reduced to a D after verification of removal of immediacy of harm.Findings Included: 1. On 11/17/25 at 11:39 a.m., an observation of the main dining room during lunch revealed Resident #3 was seated at the table in a Geri-chair positioned at approximately 60-65 degrees. An observation of the food tray and meal provided revealed a pureed consistency. Further observations of Resident #3 revealed he ate his meal without assistance from staff. On 11/18/25 at 11:50 a.m., an observation of the main dining room during lunch revealed Resident #3 was seated at the table in a Geri-chair positioned at approximately 60 degrees. An observation of the food tray and meal provided revealed a pureed consistency. Staff were observed setting up the meal tray in front of him. Resident #3 began consuming his meal unassisted by staff. He was observed having difficulty getting food onto the fork. After four attempts, Resident #3 was able to get a dime-sized amount of food on the fork. Staff E, Certified Nursing Assistant (CNA) stated to Staff F, CNA, He [Resident #3] keeps doing that because he can't see his food. Staff F, CNA was observed looking at Resident #3's meal tray and stated, Well, he's almost done.A review of Resident #3's admission record revealed he was admitted on [DATE] with diagnoses to include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, need for assistance with personal care, muscle weakness (generalized), muscle wasting and atrophy, anxiety disorder, major depressive disorder, unspecified convulsions, persistent mood [affective] disorder, and constipation.A review of Resident #3's quarterly Minimum Data Set (MDS), dated [DATE], revealed the following: - Section C - Cognitive Patterns, Brief Interview for Mental Status (BIMS) . BIMS Summary Score 03, indicating severe impairment.- Section GG - Functional Abilities, . A. Eating: . 05. Setup or clean-up assistance .- Section K - Swallowing/Nutritional Status, . C. Mechanically altered diet - require change in texture of food or liquids (e.g. [example], pureed food, thickened liquids) Yes . D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol) Yes .A review of Resident #3's current diet orders revealed the following: - Consistent Carbohydrates (CCD) diet, Pureed texture, Regular / Thin consistency. Directions: no salt packets, with a start date of 11/11/25 and revised on 11/11/25.A review of Resident #3's discontinued diet orders revealed the following:- CCHO [consistent/constant carbohydrate diet], Low Fat, Low Chol [cholesterol], NAS [no added salt] diet, Regular texture, Regular / Thin consistency. Status: Discontinued., with a start date of 4/10/24 and an end date on 4/11/24. - CCHO, Low Fat, Low Chol, NAS diet, Mechanical Soft texture, Regular / Thin consistency. Status: Discontinued., with a start date of 4/11/24 and an end date on 4/11/24. - CCHO (Controlled Carbohydrates) diet, Mechanical Soft texture, Regular / Thin consistency. Directions: NAS; fortified foods TID [three times a day]. Status: Discontinued, with a start date of 4/11/24, revised date of 5/7/24, and an end date on 6/2/24. - CCHO (Controlled Carbohydrates) diet, Pureed texture, Regular / Thin consistency. Directions NAS., with a start date of 6/2/24, revised date of 7/9/25, and an end date on 11/11/25.A review of Resident #3's care plan revealed the following: - [Resident name] is at risk for Malnutrition r/t [related to] psychotropics, therapeutic diet, T2DM [type 2 diabetes mellitus], dementia, metabolic encephalopathy, HTN [hypertension], CKD [chronic kidney disease] stage 3, mechanically altered diet, needs assist with meals MNA[malnutrition assessment]=10 Date Initiated: 04/11/2024 Revision on: 09/16/2025., with interventions to include the following, Monitor and report to the physician: . Chewing/swallowing problems Date Initiated: 04/11/2024 . or for signs and symptoms of aspiration such as coughing, choking, pocketing, runny nose, watery eyes spitting food out, wet vocal quality, wet lungs. Notify SLP [speech language pathologist] if any symptoms are present Date Initiated: 04/11/2024 . Provide diet as ordered, monitor and record intake- Dysphagia Puree Texture/thin liquids Date Initiated: 04/11/2024 Revision on: 11/11/2025. Set up trays/supervise/cue/assist as needed with meals and allow adequate time to consume food/fluids provided Date Initiated: 04/11/2024 .- [Resident name] has a communication problem due to: Brain injury, Cognitive impairment, Expressive Aphasia, Receptive Aphasia Date Initiated: 04/23/2024 Revision on: 04/23/2024.A review of Resident #3's progress notes revealed the following:- 11/9/25 health status note 12:15, Patient in dining room for lunch, patient observed eating and choking on food. Patient assessed and vitals stable at this time. Patient skin warm and dry, no respiratory distress noted, and patient removed from dining room and back in room, created by Staff B, Licensed Practical Nurse (LPN).- 11/10/25 physician progress note, . DOS [date of service]: 11/10/2025 Effective Time: 10:30 AM CC [chief complaint]: Dysphagia / Choking Episode . HPI [history of present illness]: Nursing reports that yesterday the patient was in the dining room eating and had an episode where he was unable to swallow food. He reportedly did not get the correct food consistency for his meal. Staff performed the Heimlich maneuver on him and the food was abruptly dislodged. He did not experience any observed respiratory distress after the incident. Nursing reports after the incident he has been at his baseline cognitively and functionally. He denies any shortness of breath, coughing, fevers/chills/night sweats, sputum production, n/v/d [nausea, vomiting, diarrhea], sore throat, acute pain, dizziness, lightheadedness, headaches, vision changes, increased weakness. CXR [chest x-ray] reviewed: Early changes of intrapillar atelectasis or pneumonia. Findings favor atelectasis in the absence of leukocytosis. Perihilar inflammation, acute or chronic. Correlate risk factors for infection. CBC/CMP [complete blood count/comprehensive metabolic panel] in AM [morning] to check for leukocytosis ST [speech therapy] eval [evaluation] Continue Diet: CCHO (Controlled Carbohydrates) diet, Pureed texture, Regular / Thin consistency Upright 90 degrees for all PO [by mouth] intake Staff to ensure pt. [patient] receives correct food consistency Monitor Atelectasis CXR indicative of probable atelectasis in the absence of fevers/leukocytosis ., created by Staff C, Nurse Practitioner (NP). - 11/10/25 health status note 12:05, Note Text: Late Entry: At time of assessing the resident after chocking his bilateral lungs were clear, Resp [respiratory] even and nonlabored, O2 [oxygen] sat [saturation] at 98% on r.a. [room air] Res. [resident] was taken back to his room and was sitting up in chair without s/s [signs and symptoms] of distress, created by Staff D, Nurse Supervisor. - 11/10/25 health status note 13:04, Note Text: At the time of assessment of patient, vitals taken: B/P [blood pressure] 126/80, pulse 98, temp 97.9, respirations 18, and O2 95 on room air. Patient alert and in no apparent distress. Lung sounds clear and patient observed to have normal respiratory effort, created by Staff B, Licensed Practical Nurse (LPN).- 11/10/25 health status note 13:32, CXR reviewed: IMPRESSION: Early changes of intrapillar atelectasis or pneumonia. Findings favor atelectasis in the absence of leukocytosis. Perihilar inflammation, acute or chronic. Correlate risk factors for infection. Slightly worse compared to 4/21/2025. 1) Vitals every shift for 3 days 2) CBC/CMP in AM.- 11/11/25 health status note, Labs reviewed, stable without any leukocytosis. Stable anemia and DM II [diabetes mellitus two] are noted. No new orders.- 11/11/25 health status note 21:12, LATE ENTRY Note Text: Resident is alert with confusion and is assisted totally with ADL's [activities of daily living]. Transfers to and from Geri chair with Hoyer lift and 2 assist [two person assist]. Resident is assisted with meals, encouraged to eat meal. Incontinent of B&B [bladder and bowel]. No s/s of acute distress and no c/o [complaints of] pain voiced at this time. - 11/12/25 health status note, Note Text: IDT [interdisciplinary] reviewed for s/p [status post] choking incident. IDT reviewed chart along with labs and chest xray all noted to be unremarkable. Resident is alert with confusion, total care for ADL's incontinent of b/b mechanical lift for transfers. Sits in a Geri-chair for proper positioning. Resident was eating in MDR [main dining room] where he consumes his food independently. Pt [patient] choked on a piece of ham, Heimlich was successfully preformed and ham was expelled. Skin assessment completed today to assess for any discoloration r/t Heimlich. Skin was clear without redness or discoloration. NO s/s of discomfort or pain was noted. Lungs clear today and no cough noted. Ate in MDR with no s/s of difficulty eating or consuming fluids. MD [medical doctor] and family continue to be aware of all changes.- 11/13/25 health status note, V/S [vital signs] taken on 11/9/2025 s/p [status post] incident in MDR 126/89, 98, 18, 97.9 with O2 sat 95 on RA, created by the Director of Nursing (DON). A review of Resident #3's assessments revealed the following: - 11/9/25 17:50 [5:50 p.m.] situation, background, assessment, recommendation (SBAR) summary for providers, . 31. Other change in condition . 1a. List the other change: Res. [resident] was choking on his lunch tray . 2. This started on: 11/9/25 3. What time of day did this start? 2. Afternoon . Mental Status Evaluation 7. No changes observed Functional Status Evaluation 6. No changes observed. Since the change in condition occurred have the symptoms or signs gotten: 2. Better . Res. coughed up food that was chocking him . Res. was observed chocking on his lunch tray, Heimlich maneuver performed and res. expelled food. Res. assessed and vitals stable at this time. Res. skin warm and dry, no respiratory distress noted, and patient removed from dining room and back in room. Family notified- [family member name] Date: 11/09/2025 Time: 6:00 PM . Date and time of clinician notification: 11/9/2025 13:30 [1:30 p.m.] . New orders for 2 view CXR per [Staff C, NP], created by Staff D, Nurse Supervisor. Further review of the SBAR communication form revealed the vital signs documented were from 10/7/25. - 9/16/25 nutrition assessment form, . B. Dietary Intake 1. Current Diet Order/Enteral orders/Supplement Order: CCHO (Controlled Carbohydrates) diet, Pureed texture, Regular / Thin consistency, NAS Med Pass 2.0 120ml [milliliters] TID . Ability to Chew/Swallow: 5. None of the above . E. Neuropsychological problems 0. Severe dementia or depression . Comment/Summary: [NAME] is at risk for Malnutrition r/t psychotropics, therapeutic diet, T2DM, dementia, metabolic encephalopathy, HTN, CKD stage 3, mechanically altered diet, needs assist with meals MNA=10 . Review of Resident #3's x-ray results revealed the following:- 4/21/25 chest, single view, Clinical Information: follow up left infiltrate Test Procedure: . CHEST, SINGLE VIEW Findings: Comparison: 03/15/2025 The cardiac silhouette and mediastinal contours are normal. The lungs are free of infiltrates and focal consolidations. No pleural fluid or masses are noted. No pneumothorax is present. Impressions: No acute intrathoracic disease process. - 11/10/25 chest, 2 views, Date of Service: 11/10/2025 Clinical Information: . Pneumonitis due to inhalation of food and vomit possible aspiration Test Procedure: . CHEST, 2 VIEWS Findings: . No acute osseous or soft tissue abnormality. Cardiac and mediastinal contours are within normal limits. Normal pulmonary vasculature. No pneumothorax. Bilateral intrapillar airspace opacity is present. Peribranchial distention with peribranchial cuffing is present. This nonspecific finding indicates chronic or acute perihilar inflammation. IMPRESSION: Early changes of intrapillar atelectasis or pneumonia. Findings favor atelectasis in the absence of leukocytosis. Perihilar inflammation, acute or chronic. Correlate risk factors for infection. Slightly worse compared to 4/21/2025. A review of a resource from the American Lung Association revealed the following, Atelectasis happens when the tiny air sacs or alveoli in your lungs are blocked, and it causes a partial or full collapse of one or more lobes or sections of the lungs. Other causes may include A small object blocking the airways (like food or toy) . Lung infection like pneumonia . Your healthcare provider will discuss treatment options if atelectasis is caused by a tumor, an aspirated foreign body, or other chronic lung conditions. Serious complications may occur if atelectasis remains untreated. Complications can include low oxygen levels, pneumonia, or lung failure. The reference was reviewed on the following website https://www.lung.org/lung-health-diseases/lung-disease-lookup/atelectasis. A review of Resident #3's speech therapy (ST) notes revealed the following:- SLP evaluation and plan of treatment, dated 11/11/25, Diagnoses Nontraumatic subacute subdural hemorrhage onset 11/11/25 Dysphagia, oropharyngeal phase onset 11/11/25 . Reason for Referral/ Current Illness: Patient is a 91 year LTC [long term care] resident of this facility referred to ST due to reported aspiration episode. Patient is currently on a puree diet with thin liquids. Prior Level of Function Intake/Diet Level = Puree consistencies, Thin liquids, Successive Swallows; Swallowing Abilities = Severe; Self Feeding = Total Dependence without attempts to initiate . Oral Exam Oral Motor Structure and Function = Impaired . Cognition Cognitive-Communicative Skills = Impaired . Cognition Follows Directions = Max(A) [Assistance], responsive to cues . Clinical Bedside Assessment of Swallowing Overall Abilities = Severe . Solids Assessed During Eval = Puree consistencies . Assessment Summary Clinical Impression: Patient seen for dysphagia evaluation at bedside. Per nursing and chart review, patient has known history of advanced dementia with limited cognitive-linguistic function. Spontaneous oral movements appear functional for current diet level. No overt signs/symptoms of aspiration (no coughing, throat clearing, or wet vocal quality) observed during limited trials. Deficits include impaired cognition impacting ability to follow commands, implement swallow strategies, or adjust to texture changes. Current diet of puree solids and thin liquids appears appropriate and safe at this time based on bedside observation and nursing report. Provide 1:1 feeding assistance and slow rate of intake. Ensure upright positioning of 90 degrees during and 30 minutes after meals. No further swallow study indicated due to advanced dementia and inability to participate in treatment. Supervision for Oral Intake = Close supervision .On 11/17/25 at 10:10 a.m., an interview was conducted with Resident #10. He confirmed he witnessed the incident with Resident #3 on 11/9/25. He stated, He [Resident #3] choked. Resident #10 said the meal tickets are on the food trays. He said the CNAs passed the trays and double checked the meal ticket matched the food. Resident #10 stated that day, A new person was helping. Resident #10 said the new staff member gave Resident #3 a tray with a regular diet. He said Resident #3 was in a recliner chair. Resident #10 said the staff were patting his back, but it was not helping. Resident #10 described the staff present as, Frantic. He said Resident #9 wheeled himself to the hallway outside of the dining room stating, Help, Help and putting his hands up. Resident #10 said he recalled the staff present saying, What do we do, what do we do, I will call for the nurse. He confirmed there was no nurse present in the dining room during the lunch meal on 11/9/25. Resident #10 said a nurse never came to assess Resident #3. He said staff took Resident #3 to his room after the lunch meal was completed. Resident #10 confirmed he stayed for the duration of the lunch. He said other departments are now helping in the dining room and a nurse is present. A review of Resident #10 quarterly MDS, dated [DATE], under section C - cognitive patterns revealed a BIMS score of 15, indicating cognitively intact. On 11/17/25 at 1:29 p.m., an interview was conducted with the Food Service Director. He said he had been in this position since August 2025. He said Staff G, Dietary Aide was at the end of the tray line and the last one to touch the tray in the kitchen on 11/9/25 during lunch. The Food Service Director said he was not present for the incident, but he learned Resident #3 choked in the dining room on 11/9/25. He said two other staff members, Staff H, [NAME] and Staff I, Dietary Aide were also on the tray line. He said Staff I, Dietary Aide was at the beginning of the tray line and called the ticket out to include the diet, such as mechanical or regular. The Food Service Director said Staff G, Dietary Aide was at the end of the line and repeated back what was provided to her by the cook. He said Staff I, Dietary Aide was telling Staff H, [NAME] what she needed to plate, and Staff G, Dietary Aide double checked the meal on the tray was correct. He said Staff G, Dietary Aide called him on 11/9/25 and told him what happened. The Food Service Director stated he talked to Staff G, Dietary Aide the following day and asked for more information about what happened. He said she told him, I [Staff G, Dietary Aide] don't remember, there were people coming in, when you're not here they come in and do whatever they want and not sure what happened. The Food Service Director said Resident #3's diet on 11/9/25 was dysphagia, mechanical soft which meant ground consistency for the protein, pureed vegetables, and a pureed starch. He said he could not provide the residents meal ticket for that day, as he did not have access to do that, but he could provide an example meal ticket of a dysphagia, mechanical texture for the meal that day. He said the mechanical and pureed diets are the same consistency, except for the protein. He said he changed Resident #3's diet to pureed consistency on 11/10/25 in the meal tracker system. The Food Service Director said he did not have documentation of in-services or training regarding meal ticket accuracy for dietary staff prior to August 2025. He said since he has been at the facility he has not needed to provide an in-service on meal ticket accuracy. The Food Service Director said he completed audits and an in-service on meal ticket accuracy to all the dietary staff on 11/10/25. On 11/17/25 at 1:49 p.m., an interview was conducted with Staff G, Dietary Aide. She said on 11/9/25, during lunch, Staff I, Dietary Aide and Staff H, cook were on the tray line. Staff G, Dietary Aide stated she was at the end of the tray line as the, The double checker. She said she called out every ticket and made sure it is the correct food. Staff G, Dietary Aide said the cook knows the diets because of the first person on tray line who tells them. She said the first person called out the diet, the cook puts the food on the plate, and she puts the plate on the resident's tray. Staff G, Dietary Aide said the meal ticket is already on the tray, and she made sure it had the correct beverage, condiments, diet, and the meal matches. She said she did not remember Resident #3 getting a regular diet and believed he received pureed consistency. Staff G, Dietary Aide stated, It's possible it could have happened, and said she had taken accountability if the resident received the wrong diet. She said staff kept interrupting them during the tray line for lunch that day. She said she recalled being told the nurses aids were short staffed on 11/9/25. She said she recalled the dining room cart went out, then the first cart for the south unit went out, then she left the kitchen, came back and when she returned there were two staff members in the kitchen. Staff G, Dietary Aide said one staff member had a tray with a plate and the other staff had the meal ticket in their hand. She said they told her the resident had choked and something serious could have happened. Staff G, Dietary Aide said she recalled walking in the dining room between 11:45 a.m. and 12:00 p.m. and had not seen any resident choking. She said she recalled seeing the two staff members sitting down in the dining room. Staff G, Dietary Aide said when the tray line was almost done is when the two staff members approached her about the choking incident. She said after the two staff approached her, she immediately called the Food Service Director and told him the resident choked and staff were blaming her for the incident. Staff G, Dietary Aide stated the Food Service Director told her no one had called him and, They would see about it on Monday when he comes in. She confirmed that the Nursing Home Administrator (NHA) asked her what happened and she provided a statement. She confirmed she had meal ticket accuracy education, before 11/9/25, from the Food Service Director. On 11/17/25 at 2:29 p.m., a phone interview was conducted with Staff I, Dietary Aide. She said she was typically the first person working on the tray line. She described the, A2 and A1, roles. She stated the person as A1 is preparing the tray with items such as milk and juice, then the tray goes to the person as A2. She stated, A2 putting plate with food exactly what is required with ticket is talking about. Regarding the incident on 11/9/25 she stated, I remember person who was A2 making mistake . that person [Resident #3] has mechanical. Mechanically it is supposed to be bread and meat ground. She [A2] exchanged for regular diet. She said the person in the A2 role did not pay attention and gave Resident #3 the wrong meal. Staff I, Dietary Aide said when she starts the line she puts the ticket on the tray, looks at the diet and says loudly if the meal ticket says mechanical or pureed. She said when she first started, at the end of June 2025, she was educated on the tray line and meal ticket accuracy process by the former food service director and one of the dietary aides. A follow-up interview was conducted with the Food Service Director on 11/17/25 at 2:44 p.m. He said there's been no change to the process on the tray line after the choking incident on 11/9/25. He said the only change made was to the dining meal times. The Food Service Director stated they haven't implemented anything new but, Thought about extra set of eyes to help the tray line process. He said he wanted to put an extra dietary staff in the middle of the tray line, so the last person could focus on checking the trays. The Food Service Director said the nurses and CNAs are supposed to check the tray when meal passing. He stated, It's supposed to be happening, but it fluctuates.A review of a meal ticket on 11/9/25 revealed the following, Dys [Dysphagia] Mech [Mechanical] . Ground Glazed Baked Ham, [NAME] Gravy, Black-Eyed Peas, Fortified Mashed Potatoes, Chopped Greens, Chop, Pureed Dinner Roll/Bread . Vanilla Ice Cream . The Food Service Director confirmed the meal ticket reflected what Resident #3 would have received. An interview was conducted on 11/17/25 at 1:40 p.m. with Staff J, CNA. Staff J, CNA said there was never a nurse in the dining room for meals. She said she typically was the only person in the dining room for lunch and often times at dinner as well. Staff J, CNA said she had complained multiple times about being the only person in the dining room and asked for more assistance, but no one ever came to help. She said the day Resident #3 choked she was in the dining room for lunch time. She said Staff K, receptionist came to the dining room to help pass trays. Staff J, CNA said she knew the residents and their diets well. She said Resident #3 received a meal tray with a regular diet, and he should have received a pureed diet. She said the day of the incident, Resident #3 was feeding himself and she heard him gasping for air. Staff J, CNA said she looked over and saw he was choking. She said his eyes were watering and demonstrated he had his hands on the chest/neck area while gasping. Staff J, CNA and Staff K, receptionist both went to assist him and yelled out for reception to get a nurse. Staff J, CNA said she leaned him forward to pat him on the back. She said it was difficult because he was reclined and leaning back in a Geri chair. She confirmed Staff K, receptionist performed the Heimlich maneuver on Resident #3. She said she assisted with twisting the resident to the side that way Staff K, receptionist could get behind him. Staff J, CNA said she is not cardiopulmonary resuscitation (CPR) certified. She said by the time Staff D, Nurse Supervisor arrived the food had been dislodged, and the resident was breathing. Staff J, CNA said Staff D, Nurse Supervisor asked what happened and said they should not have done anything because only a nurse should do the Heimlich. She said Staff D, Nurse Supervisor asked them if the resident was ok and said she had to go back to the unit to finish what she was doing, then left. Staff J, CNA said she did not observe an assessment completed on Resident #3 in the dining room and no vital signs were taken at that time. She said Resident #3 stayed in the dining room for another hour and ate some ice cream. She said meals in the dining room started around 11:15 a.m. to 11:30 a.m., and Resident #3 choked around 11:45 a.m. Staff J, CNA said he did not leave the dining room until after 12:45 p.m.On 11/18/25 at 1:50 p.m., an interview was conducted with Staff K, receptionist. She said she typically worked as a receptionist, but she picked up a shift for activities on 11/9/25. She said she helped pass the meal trays out sometimes. She said she went to help Staff J, CNA in the dining room because she was the only staff member there. She said she did not know she had to check the diets on the meal tickets when passing the trays. Staff K, receptionist confirmed she gave Resident #3 his tray and he started to eat the meal. She said she heard Resident #3 gasping and they tried to pat his back. She confirmed there was no nurse present, so they called out for reception to get a nurse. She said while all this was happening, Resident #9 was scared, and he wheeled down the hall yelling for a nurse to help. She said Resident #3's gasping was getting worse therefore, she did five abdominal thrusts from the front while he was in the Geri-chair. She said the thrusts did not do anything. Staff K, receptionist said herself and Staff J, CNA were able to twist the resident to the side, that way she could get her arms around the resident to perform the Heimlich maneuver. Staff K, receptionist said she did three abdominal thrusts and the lodged food came out of the resident's throat. She stated what came out of the resident's throat was a, Thick piece of ham. Staff K, receptionist said she is not a clinical staff member at the facility, but she is CPR certified.On 11/18/25 at 2:03 p.m., a phone interview was conducted with Staff D, Nurse Supervisor. She stated, That day [11/9/25] I was the only supervisor in building, which is normal. Staff D, Nurse Supervisor said she was on the south wing assessing a patient who was complaining of chest pain. She stated while she was, Getting that under control, she heard yelling that a nurse was needed for an assessment. She said she ran to the dining room and confirmed the incident happened during lunch time. Staff D, Nurse Supervisor said Resident #3 was sitting up in the chair, there were approximately four staff members there, and she heard he choked. She stated, Whatever they did it was already taken care of, by the time she got to the dining room. Staff D, Nurse Supervisor confirmed the staff present said they did the Heimlich. She stated, He was calm, peaceful, nothing wrong with him. Staff D, Nurse Supervisor confirmed she assessed Resident #3 to include listening to his lungs and looking at him. She stated it was a Quick look, listen, and go, as she had another emergency she was handling. She said she saw he was okay; then went to the kitchen and asked what and how the incident happened. Staff D, Nurse Supervisor said, The head person in the kitchen stated someone was on their phone while fixing the tray. She said she told the kitchen staff they needed to be careful, and Resident #3 could have died. She did not recall the names of the kitchen staff present. She said the resident went back to his room but could not confirm who took him there. She said she called and let her manager know about the incident. Staff D, Nurse Supervisor confirmed Staff B, LPN was his assigned nurse. She stated, She [Staff B, LPN] was on the floor, not in the dining room. She said she does not know Resident #3 well but knows he was on a pureed diet and assumed he had a swallowing difficulty. She confirmed she assisted with educating staff after the incident. She said immediately after the incident, they started making sure a nurse and/or management is in the dining room during mealtimes. When asked which residents in the dining room needed assistance with eating, she stated, Nobody in the dining room needs assistance with eating. Not even Resident #3 needs assistance with eating. Staff D, Nurse Supervisor said staff know their residents and are aware if they needed assistance when eating. She stated, If they don't know, the nurse knows. She said she is not sure where to find information about a resident who needed assistance with eating. Staff D, Nurse Supervisor stated, I'm thinking, that's a good question, never thought of the process. She stated she has been at the facility since March 2025 and it, Never crossed my mind to ask that question about where to look. At 2:46 p.m., a follow-up interview with Staff D, Nurse Supervisor was conducted by phone. She said it was the Kardex where they find information about residents who need assistance with eating. She stated, I stick by my answer of staff knowing their residents, if they need assistance with eating. On 11/18/25 at 2:31 p.m., a phone interview was conducted with Staff B, LPN. She said on 11/9/25, Resident #3 went to the dining room for lunch and came back to his room. She said she assessed him to include vitals and lung sounds. She confirmed she documented her assessment in the electronic health record. Staff B, LPN stated, He was perfectly fine back in the room and breathing with no difficulty. She said she was told he received the wrong meal or got the wrong tray, he choked, and the Heimlich was performed. Staff B, LPN said Resident #3 was on a pureed diet. She said when he got back to his room that is when she was told about what happened. She confirmed she would have expected to be notified and would have evaluated him sooner since she was his assigned nurse. Staff B, LPN said lunch in the dining room is around 11:00 am. When asked what time she assessed Resident #3 she stated, Pretty much whatever time I documented is when I evaluated him, it was probably a few minutes before. Staff B,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a clean and home like environment in two (#311 and #405 B) of sixty-one rooms observed.
Findings included:
1. A review of the facility's work order #7384 for room [ROOM NUMBER], created on 7/27/24 at 12:42 p.m. showed ac leaking.
A review of the facility's work order #7374 for room [ROOM NUMBER] B, created on 7/25/24 at 1:29 p.m., showed air conditioner running water on the floor.
On 8/6/24 at 10:08 a.m., wet linen was observed piled under the Packaged Terminal Air Conditioner (PTAC) in room [ROOM NUMBER]. The resident in the room said the PTAC had been leaking for about a month. The room was muggy with a musty odor. (Photographic Evidence Obtained.)
On 8/7/24 at 9:45 a.m., the same observation was made in room [ROOM NUMBER] (Photographic Evidence Obtained).
On 8/8/24 at 9:52 a.m., the same observation was made in room [ROOM NUMBER] (Photographic Evidence Obtained).)
2. On 8/6/24 at 10:46 a.m., a blanket with a yellow ring and appeared dry was observed under the PTAC unit in room [ROOM NUMBER] (Photographic Evidence Obtained).
On 8/7/24 at 2:34 p.m., the same observation was made in room [ROOM NUMBER] B. (Photographic Evidence Obtained).
On 8/8/24 at 10:54 a.m., the same observation was made in room [ROOM NUMBER] B.
On 8/7/24 at 9:54 a.m., during an interview Staff K, Certified Nursing Assistant (CNA) said maintenance related issues were reported through the facility's electronic building maintenance system.
On 8/8/24 at 9:50 a.m., an interview and observation of room [ROOM NUMBER] was conducted with the Nursing Home Administrator (NHA). The NHA said he was not aware of the issue, and he would get the maintenance staff to address the issue. The NHA said all the facility's staff know how to report issues in the facility's electronic building maintenance system. He said maintenance needed to remove the unit and clean the drain. The NHA said the issue would be addressed today.
On 8/8/24 at 10:26 a.m., during an interview, Staff L, Licensed Practical Nurse (LPN) said maintenance issues were reported in the facility's electronic building maintenance system.
On 8/8/24 at 4:46 p.m., during an observation and interview in room [ROOM NUMBER] B, the NHA immediately called the maintenance director. The NHA said the maintenance director would address the issue. The NHA removed wet linen from under the PTAC and piled the linen in front of the unit.
On 8/8/24 at 5:59 p.m., the NHA said staff should be checking resident rooms daily.
A review of the facility's policy and procedure, subject Maintenance, effective date 11/30/2014 showed: Policy: The facility's physical plant and equipment will be maintained through a program of preventive maintenance and prompt action to identify/areas items in need of repair. Procedure: all items needed maintenance assistance will be reported to maintenance using the maintenance repair request form. Environmental services personnel will check for completed forms throughout the day. The requests will be prioritized and completed according to need.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure the accuracy of the Preadmission Screening and Resident Review's (PASRRs) and obtain a Level II screening when appropriate for three (#44, #11, and #46) of six residents sampled for PASRR's.
Findings included:
1. A review of Resident #44's admission Record revealed the resident was admitted on [DATE] and re-admitted on [DATE]. The record revealed the resident had the following diagnoses prior to the readmission:
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Paranoid schizophrenia, onset 4/1/22.
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Psychotic disorder with delusions due to known physiological condition, onset 4/1/22.
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Recurrent moderate Major Depressive Disorder, onset 10/1/22.
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Mild Dementia in other diseases classified elsewhere with other behavioral disturbance, onset 10/1/22.
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Unspecified hallucinations, onset 4/2/21.
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Other sexual dysfunction not due to a substance or known physiological condition, onset 10/27/23.
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Other schizoaffective disorders, onset 5/11/21.
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Delusional disorders, onset 6/10/20.
The diagnosis of Cognitive Communication Deficit (CCD) was added to Resident #44's diagnosis information on 7/14/24.
An interview was attempted with Resident #44 on 8/6/24 at 3:21 p.m., the resident way lying in bed and when spoken to, the resident turned her head away from this writer and asked the kids if the hillbillies were cute. The room contained both roommates of the resident, (both of whom were lying in bed), the resident, and this writer, there were no kids or hillbillies in the room.
A review of Resident #44's PASRR Level I Screen, dated 7/26/24, which was completed at the facility and submitted by the Director of Nursing (DON), showed the resident had mental illnesses the (MI) or suspected MI's of anxiety disorder, depressive disorder, psychotic disorder, schizoaffective disorder, schizophrenia, delusional disorder, other sexual dysfunction not due to a substance or known physiological condition, and hallucinations. The PASRR revealed the resident did not have any disorder resulting in functional limitations in major life activities that would otherwise be appropriate for the individual's developmental stage, no interpersonal functioning limitation, no issue with concentration, persistence, and/or pace, and no issue with adaptation to change. The screening revealed the resident had a secondary diagnosis of dementia with a primary diagnosis of a serious MI or ID. The PASRR revealed Resident #44 had no diagnosis or suspicion of a Serious Mental Illness or Intellectual Disability and a Level II PASRR was not required.
Review of a recent Psychiatry Note, dated 7/30/24, for Resident #44 revealed the reason for encounter was Today, I saw the patient as it was reported to me that patient is unstable requiring psychiatric assessment. The note revealed prior to the last visit the resident was doing well, and patient was unstable and hallucinating when Seroquel was decreased. The physician noted As per collected information, patient has hallucinations and delusions chronically. She sees people who are not on the room. She cries and screams due to hallucinations. The assessment revealed the resident had Impaired insight and judgement, recall/short-term memory, remote memory, attention span/concentration, language, and fund of knowledge.
2. During an observation on 08/06/2024 at 10:20 a.m., Resident #11 was observed lying in bed dressed in a hospital gown, sleeping.
During an observation on 08/07/2024 at 11:45 a.m., Resident #11 was observed sitting up in her bed with staff setting up her lunch tray. She was observed with her bedside table within reach and eating lunch.
A review of Resident #11's admission Record showed she was admitted to the facility on [DATE] with diagnoses of senile degeneration of brain, unspecified dementia, other persistent mood disorder, insomnia, and paranoid schizophrenia.
A review of the Level I PASRR, dated 07/24/2024, showed in Section I-Part A MI (Mental Illness) or suspected MI had anxiety disorder, depressive disorder, and schizophrenia were all marked. Part B. ID (Intellectual disability) or suspected ID was blank.
Section II: Other Indications for PASRR Screen Decision-Making questions 1 through 5 were marked no. Question 6, Does the individual have a secondary diagnosis of dementia, related neurocognitive disorder (including Alzheimer's disease) and the primary diagnosis is an Serious Mental Illness or intellectual Disability, was marked no.
Section III: PASRR Screen Provisional admission or Hospital Discharge Exemption Not a Provisional admission was marked no.
Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required was marked.
3. During an observation on 08/06/2024 at 9:50 a.m., Resident #46 was observed dressed for the day sitting in a wheelchair in the common room of the 100 hall.
During an observation on 08/07/2024 at 10:10 a.m., Resident #46 was observed dressed for the day sitting in a wheelchair in the common room of the 100 hall.
Review of Resident #46's admission Record showed Resident #46 was admitted to the facility on [DATE] with diagnoses of unspecified dementia, psychotic disorder with delusions due to known physiological condition, and major depressive disorder.
Review of the Level I PASRR, dated 07/24/2024, showed in Section I-Part A MI (Mental Illness) or suspected MI (Mental Illness) Depressive Disorder, and other with Dementia, Insomnia and mood disorder typed in were marked. Part B. ID (Intellectual disability) or suspected ID (Intellectual disability) was blank.
Section II: Other Indications for PASRR Screen Decision-Making questions 1 through 5 were marked no. Question 6, Does the individual have a secondary diagnosis of dementia, related neurocognitive disorder (including Alzheimer's disease) and the primary diagnosis is an Serious Mental Illness or intellectual Disability, was marked no.
Section III: PASRR Screen Provisional admission or Hospital Discharge Exemption Not a Provisional admission was marked no.
Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required was marked.
During an interview on 08/08/2024 at 12:45 p.m., the Social Services Director, reviewed the PASRR level 1 for Resident #11, #44 and #46, and stated question 6 of section II was marked incorrectly and should have been marked yes for having a secondary diagnosis of dementia for Resident #11 and #46 and question 7 for Resident #44 of section II was marked incorrectly and should have been marked yes. She reviewed the [company name] submission website and confirmed that a level 2 PASRR had not been submitted for Resident #11, #44 and #46. She stated she did not typically do the level 1 PASRR's, the DON (Director of Nursing) was the one who completed them. She [SSD] reviewed the PASRR's that came in from the hospital and was responsible for gathering the information for residents who needed a level 2 completed. She stated she was taught to look at the resident's psych notes to confirm the resident's diagnosis.
Review of the facility's Preadmission Screening and Resident Review (PASRR) Policy, dated 11/08/2021, states The center will assure that all Serious Mental Ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting. Procedure, 4. If it is learned after admission that a PASRR Level II screening is indicated, it will be the responsibility of Social Services to coordinate and or inform the appropriate agency to conduct the screening and obtain the results.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure one resident (#81) out of three residents reviewed for resident rights had their choices honored.
Findings included:
An observation on 08/06/24 at 10:26 a.m. revealed Resident #81 was in his room laying in bed with a hospital gown on.
During an interview on 08/06/24 at 10:26 a.m., Resident #81 stated, no one was assisting him out of bed when he asked to get up. Resident #81 stated he asked for assistance to get out of bed daily, but no one would assist him. Resident #81 stated staff seemed too busy and I'm getting tired of being put off with no help. Resident #81 stated he even requested to talk with the Director of Nursing (DON) and had not had that request honored .
An observation on 08/06/24 at 1:37 p.m., Resident # 81 remained in his bed with the same hospital gown.
During an interview on 08/06/24 at 3:37 p.m., Resident # 81 stated he informed his nurse earlier that he would like assistance getting out of bed and into his wheelchair today. Resident # 81 stated the nurse informed him that she would be back, and no one had come back so he continued to lay in bed.
An observation on 08/06/24 at 3:37 p.m., revealed Resident #81 remained in bed.
Review of the admission Record showed Resident #81 was admitted to the facility on [DATE] with diagnoses that included but not limited to Venous insufficiency (chronic) (peripheral), Unspecified atrial fibrillation, Chronic obstructive pulmonary disease, weakness, unsteady on feet and muscle weakness (generalized). Review of the quarterly Minimum Data Set (MDS) dated [DATE], Section C-Cognitive Patterns showed Resident #81 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition.
Review of the Care plan showed Resident #81 had a Focus- [Resident #81] is at risk for decreased ability to perform ADLS in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion and toileting related to chronic disease process, COPD, Lymphedema, recent hospitalization. Goal- Will maintain highest capable level of ADL ability throughout the next review period as evidenced by his/her ability to perform ADL'S. Interventions:
-1/4 side rails for bed mobility
-Assist of 2 or more with bed mobility.
-Assist of 2 with transfers.
- Enablers for positioning and bed mobility
-Monitor laboratory test results and report abnormal results to MD/ARNP
- Observe for decline in ADL function. Refer to rehab therapy if decline in ADL'S is noted.
- Provide cueing for safety and sequencing to maximize current level of function
- PT/OT/SP treatment as ordered by MD/ARNP
An observation on 08/07/24 at 10:28 a.m., revealed Resident # 81 was in bed.
An observation on 08/07/24 at 2:03 p.m., revealed Resident # 81 remained in bed.
During an interview on 08/07/24 at 2:18 p.m., Staff D, Unit Manager (UM), Licensed Practical Nurse (LPN) stated she talked with Resident #81 yesterday about getting up out of bed. Staff D stated she went to the therapy department and made sure he was able to get up. Staff D stated therapy informed her Resident #81 was able to get out of bed with a Hoyer lift. Staff D stated the plan was to get him out of bed today. She said Resident #81 was waiting for his wounds to heal before getting up out of bed and he only wanted out of bed an hour at a time, so it would need to be coordinated.
Review of the Weekly Non-Pressure Wound Evaluation dated 07/23/24 showed the venous wound on Resident #81's right lower extremities (RLE) was healed. An addition review of a second Weekly Non-Pressure Wound Evaluation dated 07/23/24 showed the venous wound on Resident #81's left lower extremities (LLE) was healed. Review of the Order Summary Report revealed no current wound treatment.
During an interview on 08/07/24 at 2:24 p.m., Resident #81 stated that he was not assisted out of bed yet today however the nurse came back into his room a few minutes ago and said staff were going to assist him out of bed today.
During an interview on 08/07/24 at 2:44 p.m., Staff E, Regional Director of Operations (RDO) stated I got the back story. Resident # 81 had not been getting out bed lately because the big guy with non-normal human strength [the Physical Therapy Assistant (PTA)] could assist Resident # 81 out of bed by himself but had been out for surgery. The RDO stated the nursing staff was having trouble coordinating the Hoyer lift to get Resident #81 out of bed for the 20 to 30 minutes that he tolerated, so Resident #81 had not been getting out of bed lately.
Review of the Task tab titled Transfers on 08/07/24 at 3:13 p.m., revealed Resident #81 had only been assisted out of bed on 07/31/24 with a two persons physical assist with no Resident refusals during the 14-day look back period from 07/25/24 to 08/07/24.
An observation on 08/08/24 at 10:40 a.m., revealed a Resident Rights sign posted on the hallway near the Director of Nursing (DON) Office. The sign posted stated Quality of Life .(b) Self-determination and participation The resident has the right to . (1) choose activities, schedules and healthcare consistent with his or her interests, assessments or plan of care; (3) Make choices about aspects of his or her life in the facility that are significant to the resident. Photographic evidence obtained.

Based on record review and interview the facility failed to follow the pharmacist recommendations to monitor for behaviors for two residents (#76 and #89) of two Medication Regimen Reviews (MRR) reviewed.
Findings included:
1. Review of Resident #76's admission record showed an admission date of 5/31/24, with diagnoses to include bipolar disorder.
Review of Resident #76's order summary report, active orders as of 8/7/24 showed the following: Trazadone 50 mg daily for depression
Review of Resident #76's August 2024 Medication Administration Report (MAR) showed Trazodone 50 mg was administered daily at 9:00 a.m.
Review of Resident #76's care plan showed risk for complications related to the use of psychotropic drugs, initiated on 6/3/24. Interventions included monitor for continued need of medication as related to behavior and mood. Monitor for side effects and consult the pharmacist as needed, initiated on 6/3/24.
Review of Resident #76's Pharmacist's Report to Nursing, dated 6/7/24 showed this resident was currently receiving psychotropic medication with required behavior monitoring Trazodone 50 mg for depression. Nursing recommendations: Please add behavior monitoring for .antidepressants . to ensure that behaviors being treated are being helped and adverse effects are also being tracked.
On 8/7/24 at 5:01 p.m. the facility had not initiated the pharmacist recommendations for Resident #76.
2. Review of Resident #89's admission record showed an admission date of on 5/23/24, with diagnoses to include major depressive, mood, and psychotic disorders.
Review of Resident #89's order summary report, showed active orders as of 8/7/24 included Divalproex 1250 mg two times daily for mood disorder, Trazodone 100 mg daily for depression, and Citalopram 20 mg daily for depression.
Review of Resident #89's July 2024 Medication Administration Report (MAR) showed Trazodone 50 mg two tabs were administered daily at 9:00 a.m. Citalopram 20 mg administration began on 8/16/24 at 9:00 a.m. Depakote 1250 mg (dose increased on 7/12/24), administration started on 7/12/24 at 9:00 a.m.
Review of Resident #89's care plan showed risk for complications related to the use of psychotropic drugs: antidepressant .for mood disorder, initiated on 8/6/24. Resident #89's care plan interventions include .monitor for continued need of medication as related to behavior and mood. Monitor for side affects and consult the pharmacist as needed, initiated on 8/6/24.
On 8/7/24 at 5:01 p.m. the facility had not initiated the pharmacist recommendations for Resident #89.
On 8/7/24 at 5:16 p.m. during an interview the Director of Nursing (DON) said Resident #76's and Resident #89's pharmacist recommendations did not get done, they were missed.
Review of the facility's policy titled, Consultant Pharmacist Services Provider Recommendations, dated May 2022.
Policy: Regular and reliable consultant pharmacist services are provided to residents.
Procedures:
C. The consultant pharmacists agrees to render the required service in accordance with local state and federal laws, regulations, and guidelines and professional standards of practice.
E. The consultant pharmacist provides consultation on all aspects of the provision of pharmacy services in the facility This includes but is not limited to:
-3. Assistance in the identification an evaluation of medication-related issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement an effective discharge plan for one (#449) of three residents reviewed.
During an interview on 8/8/2024 at 12:16 p.m. with Resident #449, she stated her discharge was not arranged. She said she was admitted to the facility from the hospital after a motor vehicle accident. She stated the physician stated the benefit would come from therapy. She stated, Everything was going well, then the insurance company thought I should be discharged . I had to appeal. Each time I had to be the one to follow up on if the appeal was granted etc. The Social Service Director (SSD) hardly assisted at all. The [SSD] asked when I was admitted , if I would be going home, with who and if I would need home health care at home. On 3/13/2024 the facility told me I would be discharging [the next day]. No other information was provided to me. I arranged to borrow a walker from a friend and the facility permitted me to borrow a wheelchair. At discharge the facility told me to go to the emergency room for the wound on my leg. The wound orders had changed right before discharge. I repeatedly called the facility and left messages with the [SSD] and the Nursing Home Administrator (NHA), their names were given to me at discharge. No one responded to my calls until 3/21/2024. I was already back in the hospital, the [SSD] emailed with my daughter.
A review of the Social Service Note dated 3/4/2024 at 12:36 p.m., signed by the SSD revealed Resident #449 was given a Notice of Medicare Non-Coverage (NOMNC) for last covered day for 03/06/2024. The resident did not agree with her discharge at that time. The resident made an appeal. The resident's discharge plan was home with spouse.
A review of the Social Service Note dated 3/11/2024 at 15:46 p.m., signed by the SSD revealed resident's discharge plan was to return home with her spouse when able to go upstairs to enter the home.
Review of the Discharge summary dated [DATE] at 12:28 p.m. completed by nursing revealed:
Reviewed discharge instructions page by page with Resident. Resident voiced understanding. Instructions to follow up with wound care and her follow up ortho appointment at the end of this month. Resident does not have a Primary Care Physician (PCP) in the community here in FL but Resident states family will pursue. Discharge instructions placed in folder with current med list.
Resident is discharging with facility wheelchair and will return wheelchair to facility once hers has been delivered by insurance. Resident shared how thankful for stay here, how great therapy was and how wonderful nursing has been. Resident seems to have great friends and family support in the community.
A review of the Social Service Note dated 3/21/2024 at 13:20 p.m. signed by the SSD revealed, This writer followed up with resident regarding Durable Medical Equipment (DME) and Home Health Care (HHC) after discharge. This writer followed up with [name of DME company]. This writer will contact [name of HHC company] to follow up regarding HHC.
During an interview on 8/8/2024 at 2:06 p.m., the SSD stated remembering Resident #449 had several appeals due to the insurance company wanting to stop payment. The SSD stated the resident requested to be discharged . The SSD did not know when this conversation occurred. The SSD stated not having any documentation on additional documentation regarding discharge or when setting up the HHC. The SSD wanted additional time to find the information. No information was brought back to the surveyor by the end of the survey.
Review of the facility's policy and procedures titled Interdisciplinary Discharge Planning dated 11/30/2014 revealed that Policy: discharge planning begins on the day of admission. The process involves the resident and family, care management/social services, and those members of the clinical team involved in the residence care. Procedures: 1. We discharge goal and estimated length of stay will be established upon admission and reviewed/revised at the residence 1st and subsequent team conference(s). 2. Discharge plans are adjusted, as appropriate, at subsequent team conferences. a. Care Management/Social Services monitors progress towards discharge goals. b. Care Management/Social Services responsible for coordinating necessary outside services 1) Outside services will be contacted for services 2) Home visits scheduled and completed 3. Residents discharged to home will be made aware of, understand and agree with the proposed discharge plan, discharge date and other home care needs by the Care Manager/designee. The Care Manager/designee will complete a Discharge Summary for each resident . 4. Prior to discharge home, the resident and their family will receive Resident's Discharge Summary & Guide. The Care Manager/Social Worker will complete the form with input from each discipline. When completed, this form provides a comprehensive picture of the resident's current status and recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 8/6/24 at 10:22 a.m., Resident #68 was observed sitting in a wheelchair in the hallway directly outside of doorway to the resident's room. The observation revealed the resident's right lower extremity was extremely edematous and had a bumpy rough surface. On top of the resident's right foot was a white patch of dry-looking skin. Staff J, Licensed Practical Nurse/Unit Manager (LPN/UM) asked if the resident had a shoe to put on and the resident replied that a shoe would have to be specially made. The staff member asked if the resident had a sock to be put on and the resident responded they told her to keep it off due to cutting circulation off.
During an interview on 8/6/24 at 10:40 a.m., Resident #68 revealed her right leg had an infection in it. The resident's right leg was observed without a dressing and in an area directly above the anterior ankle was a scant amount of a bright red wet-looking substance appearing to be coming from a crease in between the numerous bumpy areas. The area was mentioned to and acknowledged by Staff J, who was on other side of hallway administering medications. The staff member stated she would get to it.
An observation was made on 8/6/24 at 3:10 p.m. of Resident #68 sitting outside of her room in a wheelchair, yelling down hallway to Staff J as the staff member was walking toward the nursing station. The resident yelled that the staff member had to dress the right leg. The observation revealed a dressing had not been applied to the resident's leg.
A review of Resident #68's admission Record showed the resident had been originally admitted on [DATE] and re-admitted on [DATE]. The record included the diagnoses but was not limited to not elsewhere classified lymphedema, morbid (severe) obesity due to excess calories, need for assistance with personal care, and skin transplant status.
A review of the [name of wound care vendor] Nurse Practitioner (NP) note, dated 7/30/24, showed the right lower extremity had a partial thickness venous wound, which measured 17-centimeter (cm) x 6 cm x 0.1 cm and covered a area of 102 cm2. The wound had been acquired on 2/5/24, had reopened, and had a moderate amount of serosanguineous exudate. The treatment instructed staff to cleanse with normal saline, cover with silver alginate and rolled gauze daily.
A review of Resident #68's July 2024 Treatment Administration Record (TAR) revealed the following physician order:
- Clean anterior RLE with normal saline, pat dry, apply skin prep and abdominal (abd) pad, and wrap with (rolled gauze) every shift for weeping. The order started on 7/29/24, discontinued on 8/1/24, and the TAR documentation revealed the order had been administered during the night shift on 7/29 and both day and night shifts on 7/30 and 7/31/24.
Review of Resident #68's August TAR revealed the following physician order:
- Clean anterior RLE with normal saline, pat dry, apply skin prep and abd pad, and wrap with (rolled gauze) every night shift for weeping. The order was started on 8/1/24 at 7:00 p.m. and was discontinued on 8/8/24 at 11:57 a.m. The TAR documentation showed staff had administered this dressing during the night shift except for 8/3/24 and was Held on 8/7/24.
Review of Resident #68's July and August TAR's did not show the Wound NP's treatment order, dated 7/30/24, had been implemented.
The NP skin and wound note, date of service 8/6/24 at 9:46 a.m., revealed Resident #68 was seen due to follow up for a right lower extremity (RLE) venous ulcer. The exam showed the resident had bilateral lower extremity (BLE) edema with a thickened texture. The assessment was the wound measured 17 cm x 6 cm x 0.1 cm with a surface area of 102 square cm's and a moderate amount of serosanguineous exudate. The treatment recommendations were to cleanse with normal saline, apply collagen to base of wound, secure with rolled gauze, and change daily. The note was signed on 8/6/24 at 9:51 a.m. by the NP.
On 8/8/24 at 9:50 a.m., Resident #68 was observed sitting on her bed with lower her extremities dangling from the side of bed. The RLE was wrapped with rolled gauze and dated 8/7/24. The resident stated they don't usually wrap it.
An interview was conducted with Staff H, LPN on 8/8/24 at 11:42 a.m., the staff member reported the wound care team came in on Tuesday, the Unit Manager received the wound care orders from the provider and put them into the computer. The staff member stated if the wound was new, staff would call the primary care provider.
An interview was conducted with Staff D, LPN/North wing UM on 8/8/24 at 11:43 a.m., the staff member reported the UM's do rounds with the wound Advanced Practitioner Registered Nurse (APRN). The staff member reported the APRN type up their report and the order would come from it. Staff D stated the primary care provider deferred orders to the wound care providers. The staff member reviewed the NP Wound assessment dated [DATE] and confirmed the order was for silver alginate and cover with rolled gauze. Reviewing the TAR she confirmed the order was for skin prep to be applied. Staff D reviewed the wound care NP note on 8/6/24 and confirmed the order for Resident #68's RLE had not been changed, still read for skin prep and rolled gauze to be applied. The staff member reviewed the discontinued orders and confirmed the order for silver alginate and collagen had not been implemented.
During an interview on 8/8/24 at 12:00 p.m. Staff H reported working 3 - 12 hour shifts during the week and Resident #68 did not refuse treatments and did not remove dressings.
Review of Resident #68's August TAR showed the Wound Care NP order regarding the application of collagen and wrapping with rolled gauze had not been implemented until 8/8/24 and the resident did not have an order for an as needed (prn) dressing change from 7/30 until 8/8/24.
An interview was conducted with the Director of Nursing (DON) on 8/8/24 at 12:04 p.m., the DON stated Staff D had started in the position on Tuesday (8/6/24). The DON stated the wound report gets emailed to herself and the Assistant DON, the UM's round with the Wound APRN and any changes would be verbally communicated to the UM. The UM should have made the changes and the orders should have been implemented. The DON stated typically there should be a prn order in case the dressing got dirty or wet. The observation of Resident #68 was discussed and the DON stated the nurse should have dressed the wound and if there was not a prn order the nurse should have obtained one from the physician.
Review of the policy - Dressing Change, revised on 12/6/17, revealed A clean dressing will applied by a nurse to a wound as ordered to promote healing. The policy described the procedure for applying a dressing.
Review of the policy - Physician Orders, revised on 3/3/21, revealed The center will ensure that Physician orders are appropriately and timely documented in the medical record. The procedure for routine orders showed:
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A nurse may accept a telephone order from the Physician, Physician Assistant, or Nurse
Practitioner (as permitted by state law).
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The order will be repeated back to the physician, PA, or ARNP for his/ her verbal confirmation. The order is transcribed to all appropriate areas of the electronic health record (eMAR/eTAR).
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For pharmacy orders the nurse will notify the pharmacy per pharmacy policy by telephoning,
faxing, or completing the order electronically.
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The ordering physician or physician extender will review and confirm orders. Confirmation of
routine orders require that the physician sign and date the order as soon as practicable after it
is provided to maintain an accurate medical record.
4. On 8/6/24 at 11:31 a.m., a wrist splint was observed on the bedside dresser of Resident #37 while the resident laid in bed. The resident was non-verbal but did show staff put it on by nodding her head, the resident shook head in response to liking to wear it.
On 8/7/24 at 9:53 a.m., the wrist splint of Resident #37 was shown to be lying on the bedside dresser next to the resident's bed.
On 8/8/24 at 4:00 p.m. an observation was made of Resident #37's wrist splint lying near the front of the bedside dresser next to the resident's bed.
On 8/9/24 at 8:49 a.m. an observation was made of Resident #37's wrist splint lying near the front of the bedside dresser next to the resident's bed.
Review of Resident #37's admission Record showed the resident was originally admitted on [DATE] and re-admitted on [DATE]. The record included diagnoses not limited to left hand contracture, functional quadriplegia, and aphasia.
Review of Resident #37's physician orders revealed the resident to wear left (L) hand splint on and off daily or as tolerated by patient every day and night shift, on in a.m./off in p.m., this order was dated 8/3/24.
Review of Resident #37's June 2024 Treatment Administration Record (TAR) showed a order for Patient (Pt) to wear left (L) hand splint on and off daily or as tolerated by patient every day and night shift, on in am/off in pm. The order started on 5/7/23 and was discontinued on 8/3/24. The nursing documentation showed the resident's splint was off 21 times, on eight times, and Y one time out of 30 opportunities during the day shift. The night shift documented the resident's splint was on three times and off twenty-seven times during the night shift. The TAR did not reveal the amount of time the resident tolerated the splint being on during the eight times it had been applied. The TAR did have an area for staff to document on and off during the day and night shifts.
Review of Resident #37's July 2024 TAR showed an order for Patient (Pt) to wear L hand splint on and off daily or as tolerated by patient every day and night shift, on in am/off in pm. The order started on 5/7/23 and was discontinued on 8/3/24. The documentation showed the splint was off during the day shift 21 times out of 31 opportunities, y was documented twice during the day shift, and on 8 times during the day shift. The night shift documentation revealed the resident's splint was off twenty-nine times, on once, and no revealing documentation on 7/11/24. The TAR did not reveal the amount of time the resident tolerated the splint being on. The TAR did have an area for staff to document on and off during the day and night shifts.
Review of Resident #37's August 2024 TAR showed an order, dated 5/7/23 for Pt to wear L hand splint on and off daily or as tolerated by patient every day and night shift, ON in am/off in pm. The record had an area for staff to document whether on or off during each shift. The TAR revealed the splint was off during the three available day shifts and twice on the night shift prior to the discontinuation of the order at 9:38 p.m. on 8/3/24. An order, Pt to wear L hand splint on and off daily as tolerated by patient every day and night shift, ON in am/off in pm was started at 7:00 a.m. on 8/4/24. The order did not allow for documentation of on and/or off during either day or night shifts. The TAR revealed a checkmark had been documented on the day and night shifts of 8/4 - 8/8/24. Per the TAR chart code legend a checkmark revealed the item had been administered.
Review of Resident #37's progress notes, including eMAR notes, from 6/9/to 8/9/24 did not reveal documentation of how long the resident tolerated wearing the splint, how the resident tolerated wearing the splint or any behavior associated with the wearing of the splint.
Review of the Certified Nursing Assistant (CNA) Tasks for Applying splints device(s) per order, apply splint to left hand as pt will allow. showed Resident #37's splint was on on 7/16, 7/18, 7/27, 7/28, 7/30, 7/31, 8/3, and 8/8/24. The tasks did not reveal the resident refused application of the splint from 7/16 to 8/8/24. The task documentation did not show how long the resident tolerated wearing the splint.
Review of Resident #37's care plan showed the Registered Nurse (RN) and CNA were responsible for apply splint as tolerated as ordered related to the resident having contractures of left hand and was at risk for impaired skin integrity, pain and injuries related to cerebrovascular accident (CVA) (and) quadriplegia/paraplegia. The RN was to refer to restorative nursing and therapy as needed. The resident's goal was to remain free from complications of impaired Range of Motion (ROM) through next review date. The care plan showed the resident had a potential for pain/discomfort related to diagnosis of functional quadriplegia, left hand contracture, gout, very limited mobility, history of chronic pain syndrome, and abdominal cramps. The interventions instructed nursing to assess/monitor for non-verbal indicators of pain (pacing, agitation, anxiety, facial grimacing, tearfulness/crying, sad/distant facial expression, gasping/groaning, yelling out) and left hand splinting related to contractures as tolerated.
An interview was conducted with Staff G, Restorative Aide, on 8/9/24 at 8:40 a.m., the staff member reported responsibilities of the restorative department was assisting with showers, ROM, exercises, Walk to Dine program, and when resident's did not have a payor source for therapy we pick them up, and put splints/braces on. Staff G said she used to put Resident #37's splint on but did not anymore because it caused the resident a lot of pain. The staff member reported the last time putting the resident's splint on was last week, did not have any documentation of the application, and the resident was not on the restorative program and had not been since approximately the beginning of the year. Staff G stated it would be therapy's responsibility to put the splint/brace on. The staff member stated she had been asked by the previous Unit Manager to put splint on so it was about 2 weeks ago, from what the staff member could see the splint caused pain, the resident would yell out and only time that occurred was due to pain.
An interview was conducted with Staff I, CNA, on 8/9/4 at 8:50 a.m., the staff member reported not putting Resident #37's splint on, restorative put it on.
During the interview with Staff I, on 8/9/24 at 8:50 a.m., Staff G reported being mistaken, therapy did not put Resident #37's splint on, nursing did. The staff member clarified nursing was not the aides but the nurses.
An interview was conducted with the Director of Nursing (DON) on 8/9/24 at 9:35 a.m., the DON reported Resident #37 was not on restorative so it was on the TAR for nursing to put it on, the order was to wear as tolerated but it did cause the resident pain. The DON confirmed there were more off's then on's on the June and July TAR's and wasn't any documentation either in the progress notes or TAR of how long the resident tolerated the brace/splint. The DON stated she understood the findings.
An interview was conducted with the DON on 8/9/24 at 11:21 a.m., the DON stated per Resident #37's therapy notes, the splint had been tolerated up to 3 hours and the resident had been discharged from therapy on 6/28/24. The DON stated the facility had a communication error related to who was responsible for putting on the splint, therapy and the nursing electronic documentation systems were not integrated so they needed to work on communication.
Review of the Occupational Therapy Discharge Summary date 6/28/24, showed at the time of OT discharge Resident #37 tolerated wearing the orthotic device 3.5 hours and 5 minutes of passive ROM to left hand prior to donning the orthotic device.
Review of the policy - Prevention Contractures, revised on 8/22/17, revealed To prevent contracture of extremities where those residents who no longer have full use of their extremities. All contracture prevention devices should be removed at least daily for hygiene and observation of skin conditions. Each resident must be evaluated for need of contracture prevention procedures on admission, readmission, and as needed. Residents with inactive extermination should have range of motion exercises done to those extremities as part of their daily care. Some residents may have braces or splints to prevent or help release contractures- be sure to follow the physician's order regarding the schedule of when to put these on and when to remove them.
Based on observation, interview, and record review, the facility failed to ensure three (#147, #47 and #68 ) of four residents reviewed had dressings changed appropriately and per physician orders. The facility failed to ensure one (#37) of one resident had a splint applied and documented as ordered.
Findings included:
1. During an interview on 08/06/24 at 10:46 a.m., Resident #147 stated he had a wound on his hand and arm. Resident #147 stated the dressing was dirty because the facility had not changed it. Resident #147 stated the facility changed it when he was first admitted to the facility but then did not.
An observation on 08/06/24 at 10:46 a.m., revealed Resident #147 had dressings on his right hand/wrist area and another on the upper right arm that was visibly soiled and not dated. The dressing on his right-hand/wrist area had a brown dirty looking substance on the dressing and was not dated. Resident #147 gave (State Agency) SA Surveyor verbal permission to take a picture of the right hand/wrist and arm dressings. Photographic evidence obtained.
A review of the admission Record showed Resident #147 was admitted to the facility on [DATE] with diagnoses that included but not limited to Other specified sepsis, metabolic encephalopathy, bacteremia, thrombocytopenia and pemphigus vulgaris.
A review of the Brief Interview for Mental Status (BIMS) evaluation dated 08/06/24 showed Resident #147 had a BIMS score of 15 which indicated intact cognition. Photographic evidence obtained.
A review of the Order Summary Report showed the following physician orders related to dressing changes:
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A physician order dated 08/02/24 showed, cleanse 3 small open areas on Left lower back with NS, apply Triamcinolone/bacitracin mixture to all open areas and leave open to air- every night shift for wound healing.
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A physician order dated 08/02/24 showed, Paint left posterior pinky toe area with betadine daily leave open to air- every day shift for wound healing,
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A physician order dated 08/02/24 showed, Cleanse right shoulder with NS, apply Triamcinolone/bacitracin and leave open to air- every day shift for wound healing.
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A physician order dated 08/02/24 showed, Cleanse right elbow with NS, apply Triamcinolone/bacitracin mixture to area, cover with xeroform and wrap with kerlix daily and as needed if soiled or dislodged- every day shift for wound healing.
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A physician order dated 08/02/24 showed, Cleanse left inner thigh with ns, pat dry , apply collagen and leave open to air- every day shift.
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A physician order dated 08/02/24 showed, Cleanse left groin area with ns, pat dry apply collagen to wound and leave open to air- every day shift for wound healing.
-Cleanse right shoulder with NS, apply Triamcinolone/bacitracin and leave open to air- every day shift for wound healing.
-
A physician order dated 08/02/24 showed, Cleanse right arm with ns, pat dry apply mixture of Triamcinolone /bacitracin to all open areas on arm cover with xeroform and wrap with kerlix- every day shift for wound healing.
-
A physician order dated 08/02/24 showed, Cleanse left scrotum area with ns, apply collagen and leave open to air daily- every day shift for wound healing.
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A physician order dated 08/02/24 showed, Cleanse right hand and wrist with ns, apply xeroform and wrap with kerlix daily and prn if soiled or dislodged- every day shift for wound healing.
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A physician order dated 08/02/24 showed, Cleanse right hip with ns, pat dry, mix bacitracin with Triamcinolone a ND apply cover with abd- every day shift for wound healing related to Pemphigus Vulgaris.
Review of the August 2024 Treatment Administration Record (TAR) showed Resident #147 did not receive the following dressing changes on 08/05/24.
-
Cleanse left groin area with ns, pat dry apply collagen to wound and leave open to air- every day shift for wound healing
-
Cleanse left inner thigh with ns, pat dry, apply collagen and leave open to air- every day shift
-
Cleanse left scrotum area with ns, apply collagen and leave open to air daily- every day shift for wound healing
-
Cleanse right arm with ns, pat dry apply mixture of Triamcinolone /bacitracin to all open areas on arm cover with xeroform and wrap with kerlix- every day shift for wound healing.
-
Cleanse right elbow with NS, apply Triamcinolone/bacitracin mixture to area, cover with xeroform and wrap with kerlix daily and as needed if soiled or dislodged- every day shift for wound healing.
-
Cleanse right elbow with NS, apply Triamcinolone/bacitracin mixture to area, cover with xeroform and wrap with kerlix daily and as needed if soiled or dislodged- every day shift for wound healing.
-
Cleanse right hand and wrist with ns, apply xeroform and wrap with kerlix daily and prn if soiled or dislodged- every day shift for wound healing
-
Cleanse right hip with ns, pat dry, mix bacitracin with Triamcinolone a ND apply cover with abd- every day shift for wound healing related to Pemphigus Vulgaris.
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Cleanse right ankle with NS, apply collagen cover with xeroform to the area and cover with border dressing- every day shift for wound healing.
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Cleanse right shoulder with NS, apply Triamcinolone/bacitracin and leave open to air- every day shift for wound healing.
-
Paint left posterior pinky toe area with betadine daily leave open to air- every day shift for wound healing.
2. An observation on 08/06/24 on 10:58 a.m. revealed Resident #47 was sitting in a wheelchair beside his bed. Resident #47 had a soiled dressing on his right lower leg not dated. Resident #47 had blankets under his foot.
During an interview on 08/06/24 on 10:58 a.m., Resident #47 stated he had been dealing with the swelling in his right lower leg for over a month. Resident #47 stated he put the blankets were under his right foot because sometimes his leg would drain a small pool of fluids out of it.
A review of the admission Record showed Resident #47 was originally admitted to the facility on [DATE] with diagnoses that included but not limited to chronic embolism and thrombosis of unspecified deep veins of proximal lower extremity, bilateral, low back pain, unspecified osteoarthritis, type 2 diabetes and hereditary and idiopathy neuropathy.
A review of the quarterly Minimum Data Set (MDS) dated [DATE], Section C-Cognitive Patterns showed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition.
A review of the Order Summary Report showed the following physician orders related to dressing changes:
-
A physician order dated 08/03/24 showed, Cleanse right lower leg with NS pat dry apply medical grade honey, add silver calcium alginate and wrap with kerlix. - every day shift.
A review of the August 2024 Treatment Administration Record (TAR) showed Resident #47 did not receive the following dressing change on 08/05/24:
-Cleanse right lower leg with NS pat dry apply medical grade honey, add silver calcium alginate and wrap with kerlix. - every day shift.
During an interview on 08/07/24 at 4:49 p.m., Staff F, Regional Nurse Consultant (RNC) stated she expected staff to date all dressings and to document the treatment in the TAR.
Review of the facility's policy Dressing Change revised date 12/06/17 stated, Policy: A clean dressing will be applied by a nurse to a wound as ordered to promote healing. Sterile dressing will be used only if specifically ordered. Procedure: .Document in medical record.

Based on record review and interview, the facility failed to ensure one Dietary Manager out of one Dietary Manager met at least one of the minimum qualifications for the position.
Findings included:
During an interview on 08/06/24 at 9:00 a.m., Staff B, Dietary Manager (DM) identified as the facility's Dietary Manager.
Review of the dietary staff credentials, provided by the facility, showed a Servsafe Certification for Staff A, Corporate Area Support Manager (CASM) with an expiration date 11/12/26.
During an interview on 08/06/24 at 1:41 p.m., the Administrator stated Staff A, CASM was not full time and goes between two facilities. The Administrator stated Staff A, CASM was not on the employee list because he was a Traveler and worked for a contracting company.
A review of the Nursing Home Key Staffing Form identified Staff B, Dietary Manager as the Dietary Manager for the facility.
A review of the Active Employee Report provided by the facility, showed Staff A, CASM was not an employee listed for the facility.
During an interview on 08/06/24 at 1:55 p.m., Staff B, Dietary Manager (DM) stated that she was not a Certified Dietary Manager (CDM). Staff B stated she started as the Dietary Manager in the facility around November 2023. Staff B stated that Staff A, CASM goes between his facility and this facility to help. Staff B stated that she was not Servsafe certified but planned to get that certification soon.
During an interview on 08/08/24 at 11:00 a.m., Staff A, CASM stated he came to the facility every now and then and was not present in the facility daily. Staff A, CASM stated that he was more like the Problem Solver for the facility.
During an interview on 08/08/24 at 4:08 p.m., Staff C, Human Service Director (HSD) stated when she first started working at the facility on 06/06/22 Staff B was a Cook. Staff C was unable to verify what date Staff B became the designated Dietary Manager for the facility.

Based on interview and record review, the facility failed to honor a resident's decision to formulate an advance directive and did not ensure a current copy of the Advance Directive was in the resident's medical record for one resident (#55) of five sampled residents.
During an interview on 8/6/2024 at 4:55 p.m., Resident #55 stated, I have spoken to several nurses when I returned from the hospital as I want to be a Full Code and change my Health Care Surrogate (HCS). I know this conversation occurred prior to 7/2/2024. I met with the Director of Social Services (DSS), discussed the [HCS] and request of being a full code. The DSS came back and told me everything was taken care of. Resident #55 continued to state never receiving the requested copies from the DSS and kept checking with the nurses regarding the changes and wanting to be a Full Code. Resident #55 stated, On [7/2/2024] the physician stated I was capable of making my own decisions. Still, I was not changed to a Full Code. I've seen the DSS at the nurses' cart, while the cart was at my door. Although, the DSS would state she didn't have time right now.
Review of a progress note from the Resident's Advanced Practice Registered Nurse (APRN), 6/30/2024 at 21:18 revealed CODE STATUS: Full Code.
Review of the Order Summary dated 8/7/2024 reveals Resident #55 was a DNR.
Review of Resident #55's plan of care revealed resident was a DNR.
An interview was conducted with Staff O, Licensed Practical Nurse (LPN) on 8/7/2024 at 1:40 p.m. Staff O stated caring on a regular basis for Resident #55. Staff O confirmed Resident #55 had been asking to be a Full Code since return from the hospital earlier this summer. I told the DSS on a couple occasions that Resident #55 wanted to be Full Code. I don't know why it has taken so long to complete.
An interview was conducted with the Director Social Service (DSS) on 8/7/2024 at 2:04 p.m. The DSS stated Resident #55 requested to see her regarding wanting to be a DNR, this was completed. The DSS continued to state the resident did request to change her HCS and this was completed. The DSS stated not having any knowledge Resident #55 wanted to change her code status.
An interview was conducted with the Director of Nursing (DON) on 8/7/2024 at 2:15 p.m. The DON said the process for a code change for a resident who was alert and oriented should be followed. The nurse would contact the physician and receive the order change and ensure all documents were in order.
Review of the facility policy and procedure titled Advanced Directives with a revision date of 11/14/2018, revealed: Policy: The center will abide by state and federal laws regarding Advanced Directives. The center will honor all properly executed advanced directives that have been provided by the resident and/or representative. Process: . 2. Social Service Director and/or Business Development Coordinator/designee will assist the resident/resident representative to complete the Advanced Directives Discussion Document. If an advanced directive exists, the Social Services and/or Business Development Coordinator/designee will obtain a copy and place it in the resident's medical record. 5. Advanced directives will be reviewed: *quarterly *Hospice admission .
Request for a Do Not Resuscitated Policy and Procedure was requested and not provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and medical record review, the facility failed to arrange transportation to a medical appointment, which resulted in a delay of care and treatment, for one resident (#43) of 38 sampled residents.
Findings included;
During an interview conducted with Resident #43 on 4/18/22 at 1:12 p.m., he reported he had an appointment for a follow up with his orthopedic surgeon in (City) approximately ten days ago and wanted to see him again because he was having a high amount of pain. Resident #43 stated he had a follow up appointment with his orthopedic surgeon in (City) scheduled for 4/19/22 at 1:30 p.m. The facility was to arrange the transportation.
Review of the admission Record revealed Resident #43 was admitted to the facility on [DATE] with multiple diagnoses to include orthopedic after care, fracture of left femur, fracture of shaft of left tibia, fracture of left fibula and foot drop. Resident #43 was identified as his own responsible party.
A review of the Minimum Data Set (MDS), dated [DATE], showed in Section C - Cognitive Patterns Resident #43's Brief Interview for Mental Status (BIMS) score was a 15, indicating he was cognitively intact.
A review of a progress note dated 4/14/22 at 12:17 p.m. revealed: Received called from orthopedics Dr. office in (City), office stated that the pt (patient) had called them stating that he had twisted his left leg and was in pain, has been seen here and evaled (evaluated) in past days placed on Medrol-dose pack for what he stated was a gout flare-up which is why the increased pain. Orthopedics office wants to see pt in (City) on Tuesday (4/19/22) at 1:45 (p.m.). Spoke to nurse practitioner getting x-rays of left leg from hip and tib/fib (tibula/fibula) 2 view r/t (related to) pain. Transport being arranged for Tuesday appt. Pt did not state to facility or during therapy that he twisted his leg will continue to monitor.
On 4/20/22 at 10:30 a.m. during an additional interview with Resident #43, to follow up with the outcome to his appointment scheduled on 4/19/22 with his surgeon, he confirmed he was not picked up and his appointment had to be rescheduled for 4/21/22.
On 4/20/22 at 11:00 a.m. an interview was conducted with Staff N, Licensed Practical Nurse (LPN)/Unit Manager in regard to the reason the resident did not get taken to his appointment on 4/19/22. She reviewed the electronic medical record (EMR) and was unable to answer the question. Staff N called Staff O, Medical Records, who is responsible to arrange medical transportation. Staff N was informed there was no authorization (insurance) for transportation, but they were able to obtain one for Thursday 4/21/22. At this time, Staff O, Medical Records was asked to provide any documentation showing an effort was made to accommodate the resident's medical transportation needs. Staff O reported she began making efforts on 4/14/22 to obtain an insurance authorization, she was on leave on Friday 4/15/22, and Staff N, LPN/Unit Manager and Staff D, Registered Nurse (RN)/MDS were going to follow up with Resident #43's transportation needs for his appointment with his surgeon.
During an interview with Staff N, LPN/Unit Manager and Staff D, RN/MDS on 4/20/2022 at 2:00 p.m. revealed they worked on trying to make transportation arrangements but had not documented in the medical record.
Staff O, Medical Records reported on 4/20/2022 at 2:16 p.m. the facility needs need to obtain an authorization from the insurance company due to the travel time being more than an hour long. She confirmed Resident #43 had an emergency follow up appointment with his orthopedic surgeon scheduled for 4/19/2022.
The Assistant Director of Nursing confirmed on 04/20/2022 at 3:18 p.m. the facility did not have a policy on transportation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the resident or the responsible party for three residents (#47, #25, and #30) of four residents sampled for hospital transfers were provided with a written notice of transfer.
Findings included:
1. Review of the admission Record revealed Resident #47 was initially admitted to the facility on [DATE] with a readmission date of 03/12/22. Resident #47 had multiple diagnoses to include quadriplegia, chronic osteomyelitis, acquired absence of right leg above the knee and neuromuscular dysfunction of the bladder. Further review revealed Resident #47 was his own responsible party and had one emergency contact noted.
On 04/21/22 at 9:30 a.m. Resident #47 confirmed he was transferred to the hospital on [DATE] and returned on 03/12/22.
Review of the medical record revealed Resident #47 was transferred to the hospital on [DATE] through 03/12/22 to treat a wound on the resident's right lower leg. Further review of the resident's medical record revealed upon transfer he did not receive a written notice of transfer as required.
On 04/21/22 at 9:51 a.m. an interview with Staff O, Medical Records revealed she was unable to locate the transfer form in Resident #47's paper or electronic record. Staff O confirmed the Agency for Healthcare Administration Nursing Home Transfer and Discharge Notice (AHCA Form 3120) was to be completed by the nursing staff upon transferring or discharging a resident.
On 04/21/22 at 11:17 a.m. Staff O indicated Resident #47 was not provided with the required documentation and the medical record was silent in this respect.
2. A review of the admission Record revealed Resident #25 was admitted to the facility initially on 02/01/22 and readmitted on [DATE]. The admission Record included diagnoses not limited to end stage renal disease, dependence on renal dialysis, and unspecified chronic obstructive pulmonary disease (COPD).
The medical record identified the resident's attending physician deemed the resident incapacitated on 02/11/22 and a family member was appointed as the medical proxy on 02/14/22.
A review of Resident #25's medical record included a Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer Form, dated 02/25/22, that identified the resident was sent to an acute facility for the reason of other. The form identified the resident was capable of making decisions and the proxy was notified of the transfer. The Acute Care Transfer Documentation Checklist did not identify any documents were sent with the resident.
The review of Resident #25's medical record included a Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer Form, dated 04/18/22, an identified the resident was sent to an acute care facility for other.
Review of a progress note indicated on 04/18/22 the resident was observed with plus 4 pitting edema, jerking, and slow to respond. The Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer Form indicated the medical proxy was notified of the resident's transfer and clinical situation. The Agency for Healthcare Administration Nursing Home Transfer and Discharge Notice (AHCA Form 3120), given to the resident on 04/18/22, did not include the address or phone number of the resident's proxy, effective date, location to which the resident was transferred or discharged , or a brief explanation for the transfer. The form identified the location in which the resident was transferred or discharged was a required section. The resident's AHCA Form 3120, dated 04/18/22, did not indicate a date the notice was given to the Resident, Legal Guardian or Representative, or the Local Long Term Care Ombudsman Council, and placed in the Resident Clinical Record, or included the attachments of the requests for Ombudsman Review and Fair Hearing.
3. A review of the admission Record for Resident #30 revealed the resident was initially admitted on [DATE], recently discharged on 04/06/22, and readmitted on [DATE]. The admission Record included diagnoses of cause unspecified cardiac arrest, chronic respiratory failure with hypoxia, anoxic brain damage not elsewhere classified, and persistent vegetative state. The admission Record identified three family members as the emergency contacts for Resident #30.
The AHCA Form 3120, identified the notice was given to the resident representative on 04/06/22. The form did not include the location to which the resident was transferred or discharged , or a brief explanation of why the needs were not met by the facility. The notice identified the resident or representative was notified by phone and did not indicate the notice was given to Resident, Legal Guardian, or Representative, Local Long Term Care Ombudsman Council or Resident's Clinical Record.
On 04/20/22 at 4:50 p.m., Staff N, Unit Manager/Licensed Practical Nurse (UM/LPN) stated a copy was to be made of the AHCA Form (3120) and to be kept in the chart.
The Interim Director of Nursing (DON) identified, on 04/21/22 at 11:31 a.m., the facility does not have an AHCA Form 3120 for Resident #30's recent (04/10/22) hospitalization. She stated staff were recently educated on the bed hold notice and the AHCA transfer forms. She stated the facility sends a red folder to the hospital with the resident's information including the bed hold and the AHCA transfer. She stated she did not know if the nurses sent the forms to the hospital and confirmed they had not made copies for the clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and review of the facility policy, the facility failed to ensure three residents (#47, #128, and #25) or their representatives were provided a notice of bed hold policy when the residents were transferred to the hospital of four residents reviewed for hospital transfers.
Findings included;
1. Review of the admission Record revealed Resident #47 was initially admitted to the facility on [DATE] with a readmission date of 03/12/22. Resident #47 had multiple diagnoses to include quadriplegia, chronic osteomyelitis, acquired absence of right leg above the knee and neuromuscular dysfunction of the bladder. Further review revealed Resident #47 was his own responsible party and had one emergency contact noted.
On 04/21/22 at 9:30 a.m. Resident #47 confirmed he was transferred to the hospital on [DATE] and returned on 03/12/22. Resident #47 reported he wasn't able to return to his same room immediately. He reported he had to be in another part of the facility for a certain number of days.
Review of the medical record revealed Resident #47 was transferred to the hospital on [DATE] through 03/12/22 to treat a wound on the resident's right lower leg. Further review of the resident's medical record revealed, upon transfer, he did not receive the notice of bed hold policy indicating the length of time the facility would hold his bed during the hospital stay.
2. A review of the admission Record for Resident #128 showed the resident was admitted to the facility on [DATE] with multiple diagnoses to include paraplegia and neuromuscular dysfunction of bladder. Resident #128 was identified as his own responsible party.
A closed medical record review revealed on 05/07/21 the resident was transferred to a local hospital to be evaluated and treated and returned to the facility on [DATE]. Further review of the resident's medical record revealed, upon transfer, he did not receive the notice of bed hold policy indicating the length of time the facility would hold his bed during the hospital stay.
On 04/21/22 at 9:51 a.m. an interview with Staff O, Medical Records revealed she was unable to locate the bed hold notice forms in Resident #47's and #128's paper or electronic records. Staff O confirmed the bed hold notice was to be completed by the nursing staff upon transferring or discharging a resident.
On 04/21/22 at 11:17 a.m. Staff O indicated Resident #47 was not provided with the required documentation and the medical record was silent in this respect.
3. A review of the admission Record revealed Resident #25 was admitted to the facility initially on 02/01/22 and readmitted on [DATE]. The admission Record included diagnoses not limited to end stage renal disease, dependence on renal dialysis, and unspecified chronic obstructive pulmonary disease (COPD).
The medical record identified the resident's attending physician deemed the resident incapacitated on 02/11/22 and a family member was appointed as the medical proxy on 02/14/22.
A review of Resident #25's medical record included a Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer Form, dated 02/25/22, that identified the resident was sent to an acute facility for the reason of other. The form identified the resident was capable of making decisions and the proxy was notified of the transfer. The Acute Care Transfer Documentation Checklist did not identify any documents were sent with the resident.
A closed medical record review of Resident #25's information from 02/2022 revealed a blank bed hold notice.
The review of Resident #25's medical record included a Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer Form, dated 04/18/22, an identified the resident was sent to an acute care facility for other.
Review of a progress note indicated on 04/18/22 the resident was observed with plus 4 pitting edema, jerking, and slow to respond. The Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer Form indicated the medical proxy was notified of the resident's transfer and clinical situation.
The Bed Hold Notice, dated 04/18/22, for Resident #25 did not identify the reason for the notice and indicated the resident was unable to sign and did not indicate the medical proxy for the resident was notified.
On 04/20/22 at 4:50 p.m., Staff N, Unit Manager/Licensed Practical Nurse (UM/LPN) stated there should be a bed hold (notice) in the front of every chart so that it was easy to find. The Staff N stated if the resident was unable to sign, the facility was to call the family member, make a copy, and send the original with the patient and keep a copy in the chart.
The Interim Director of Nursing (DON) stated, on 04/21/22 at 11:31 a.m., the staff were recently educated on the bed hold notice and the AHCA transfer forms. She stated the facility sends a red folder to the hospital with the resident's information including the bed hold and the AHCA transfer. She stated she did not know if the nurses sent the forms to the hospital and confirmed they had not made copies for the clinical record.
The policy titled, Bed Hold Notice Upon Transfer, implemented 11/2021 and revised 03/10/22, indicated, At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. The policy identified the facility would keep a signed and dated copy of the Bed Hold Notice given to the resident and/or representative in the resident's file.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, facility policy and record reviews, the facility failed to ensure the interventions on the resident centered care plan were revised, related to wearing a left-hand soft orthosis for contracture management for one resident (#15) of thirty-eight residents sampled.
Findings included:
On 04/18/22 at 10:04 a.m. Resident #15 was observed with a left hand contracture, not wearing a soft hand orthosis device.
A second observation on 04/18/22 at 12:59 a.m. of Resident #15 was conducted. Resident #15 was sleeping in a (medical recliner chair) and not wearing a left hand soft hand orthosis device.
On 04/19/22 at 9:19 a.m. Resident #15 was observed to be lying in bed, not wearing a soft hand orthosis device, and a certified nursing assistant (CNA) was in the room.
A second observation on 04/19/22 at 10:02 a.m. of Resident #15 was conducted. Resident #15 was seated in the (medical recliner chair) in the activities room, and not wearing a left hand soft hand orthosis device.
On 04/20/22 at 8:01 a.m. an observation of Resident #15 revealed the resident sleeping in bed, dressed, and not wearing a left hand soft hand orthosis device.
A second observation of Resident #15 conducted on 04/20/22 at 10:11 a.m. revealed that she was lying in bed sleeping, and not wearing a left hand soft hand orthosis device.
A review of the admission Record for Resident #15 indicated she was originally admitted on [DATE] and re-admitted on [DATE], with diagnoses to include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and contracture.
A review of the Order Summary Report, dated 04/20/22, for Resident #15 revealed an active physician order dated and started on 05/05/21 for a Left soft wrist hand orthosis for contracture management, on after AM (morning) meal, off prior to evening meal. May be removed for meals, self-care tasks, activities and per patient request, every day and evening shift.
On 04/20/22 a review of the active care plans for Resident #15 was conducted and revealed the care plan with a focus area as: (Resident #15) has decreased ability to perform ADL (activities of daily living) self-care tasks in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfers, wheelchair locomotion and toileting related to advanced age and dementia, CVA (Cerebrovascular Accident) with left hemiparesis and left hand contracture, impaired cognition, initiated on 12/31/21 and revised on 02/14/22. The care plan also included a focus area as (Resident #15) is at risk for pain/discomfort secondary to immobility, contracture left UE (upper extremity), left knee pain, bruising. (Resident #15) has dementia and may have difficulty verbalizing her discomfort. A review of the active care plan revealed it was silent of an intervention for a left hand soft ortho device for contracture to be worn by Resident #15 as ordered by the physician on 05/05/21.
On 04/20/22 at 1:53 p.m. an interview was conducted with the Director of Occupational Therapy and Rehabilitation (DOR). During the interview, the DOR confirmed Resident #15 needed to wear the left-hand soft orthosis for contracture management, and therapy was applying it at this time. The DOR stated, She tolerates one hour to one and a half hours. We are training her contracture right now; and after three weeks restorative program, the CNAs will do range of motion (ROM) and apply the device. The staff were not putting the device on her contracture, and it got worse.
In an interview conducted with the Assistant Director of Nursing (ADON) on 04/20/22 at 2:02 p.m., she confirmed Resident #15 should be care planned to wear the left hand soft ortho device for contracture and did not know why it was omitted as an intervention on the care plan.
An interview was conducted on 04/20/22 at 2:11 p.m., with the Minimum Data Set (MDS) Coordinator, who is responsible for updating care plans. During the interview she confirmed the intervention was not on the current care plan. She further indicated if there is an active physician order in the medical record, then it must be on the care plan too.
Immediately after the interview, the MDS Coordinator revised Resident #15's care plan focus area related to ADLs by adding the intervention. The intervention, initiated on 4/20/22, read: Place-left soft wrist hand orthosis for contracture management after morning meal and remove prior to evening meal. May be removed for meals, self-tasks, activities, and per patient request.
A review of the facility policy titled, Comprehensive Care Plans, revised on 4/15/22, read as follows:
POLICY:
It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.
Policy explanation and compliance guidelines:
2. The comprehensive care plan will be developed within 7 days after completion of the comprehensive MDS assessment.
3. The comprehensive care plan will describe, at a minimum, the following:
a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
b. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment.
c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR (Preadmission Screening and Resident Review) recommendations.
d. The resident's goals for admission, desired outcomes, and preferences for future discharge.
e. Discharge plans, as appropriate.
5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.
8. Staff personnel responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, it was determined the facility failed to arrange a physician ordered appointment for eye surgery in a timely manner for one resident (#38) out of a sample of thirty eight residents.
Findings included:
An interview with Resident #38 on 04/18/2022 at 11:50 a.m. revealed the resident lying in bed with the lights off. He stated a couple of months ago, he had a concern and asked his nurse if she could schedule an appointment due to his vision becoming cloudy and experiencing blurriness. Resident #38 was still concerned at this time, and explained the blurriness is getting worse.
A review of the admission Record revealed Resident #38 was readmitted to the facility on [DATE] and initially admitted on [DATE] with diagnoses to include type 2 diabetes mellitus with hyperglycemia and unspecified severe protein-calorie malnutrition.
A review of the Order Summary Report, dated 04/20/2022, for the dates of 01/01/2022 - 01/31/2022 revealed a physician order for: Refer to YAG laser (laser used to clear the frosting from the back surface of an intraocular lens) treatment to both eyes (physician name) due to secondary cataracts, order date was 01/10/2022. A review of the electronic medical record under the Orders tab showed this order was entered on 01/10/2022 at 17:20 (5:20 p.m.) by Staff G, Licensed Practical Nurse (LPN).
A review of Resident #38's care plan, initiated on 01/11/2022, revealed:
Focus - (Resident #38) has vision impairment related to Cataracts.
Goals - (Resident #38) will maintain baseline level of visual acuity through the review date as evidenced by no complaints of decreased vision.
Interventions/Tasks included: Arrange for appts (appointments)/follow-ups with eye care provider as ordered.
On 04/19/2022 at 3:30 p.m. an interview was conducted with Staff S, LPN. Staff S said, Once the nurse gets the physician order, they input it into the system, under the tab labeled Orders for that resident medical record. They would then check the resident's insurance to find a provider that would take it for the specific appointment. The nurse would then call that provider and schedule the appointment. Once that is completed, it would then be entered into the resident's electronic medical record. This sends an alert to staff that the resident has an upcoming appointment with date and time and name of provider. They would also inform the resident that an appointment was made. Staff S continued with, If they are unable to find a suitable provider, they would then contact the social services department, who would then look for a provider that takes the resident's insurance. Once completed they would then call the provider and schedule the appointment, which then would be added to the resident's MAR (medication administration record). The information would be shared with the resident and notification to any family if applicable.
On 4/20/2022 at 12:50 p.m. the Assistant Director of Nursing (ADON) provided a policy titled, Process for scheduling and Making Follow-up Appointments. The steps were documented as follows:
1. During morning meeting orders are reviewed for all residents for any appointment needs.
2. All orders for appointments are discussed. The medical records representative will take notes regarding appointment details in order to make appointment.
3. Once appointment has been scheduled, it is added to notification in Electronic Medical Record (EMR) Software.
4. At same time the appointment is made transportation is also arranged.
The ADON stated during the interview on 04/20/2022 at 12:50 p.m. they do not have a current policy or procedure from the new company in regard to the arranging of medical appointments for the residents. The ADON stated they had to create a policy this morning.
On 04/20/2022 at 3:30 p.m. an interview with Staff G, LPN (nurse who entered the physician order on 01/10/2022) accessed the EMR to review the physician order record for Resident #38. After review, she confirmed she did not finish filling in the order. Staff G confirmed the order entered on 1/10/2022 was never sent.
An interview with Staff N, LPN was conducted on 04/20/2022 at 4:30 p.m. Staff N stated, No, the order needs to be completely processed, which then gives enough information to create a complete care plan. If the staff had witnessed an order that was not processed, they should have notified me immediately and we could have processed the resident's order for the medical appointment.
On 04/20/2022 at 4:45 p.m. an interview was conducted with the ADON. The ADON stated it was her expectation that all orders are followed through on, from receiving the PO (physician order), to inputting the order in the EMR. She said it should then be discussed in morning meeting the next day during new orders review. Transportation should be arranged for the appointment, and this allows all disciplines, who need to be involved, are notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure a Stage IV pressure ulcer was treated in a manner to promote healing and prevent infections for one resident (#45) out of 14 facility residents with pressure injuries.
Findings included:
Resident #45 was admitted to the facility on [DATE] with a diagnoses, including Type 2 Diabetes Mellitus with foot ulcer (onset 12/22/21), morbid (severe) obesity due to excess calories, and unspecified complication of skin graft (onset 1/9/22).
An observation was conducted, on 4/20/22 at 2:19 p.m., with Staff M (Agency Licensed Practical Nurse/LPN) of the wound care for Resident #45. The resident was observed lying on the bed as the staff member removed the gray non-slip sock from the resident's left foot. The staff member did not place a barrier under the resident's foot as she removed the elastic bandage from the area and exposed the rolled gauze underneath. Staff M began pulling at the tape holding the rolled gauze and tearing at the rolled gauze as she removed it. Staff M did not use scissors to cut away the rolled gauze. An area of tan and red discoloration was observed on the rolled gauze at the heel area. The staff member used wound cleanser to loosen the gauze sponge and blue Hydrofera pad from the wound. She cleansed the wound by spraying wound cleanser and using a 4x4 gauze sponge which had been sitting on the resident's dresser without a barrier to pat the wound dry. Staff M opened a package of 4x4 Hydrogel, a prism of Collagen and Silver, and a 4x4 drain sponge. She stated the Hydrogel was an off brand of the ordered Hydrofera sponge dressing. Resident #45 informed Staff M she was missing the purple one. Staff M reported to the resident she was not missing anything, she had written everything down. A review of what the staff member had written down identified Hydrofera. The resident informed the nurse the purple dressing was on the left side of the top drawer of the dresser. Staff M removed an opened package of Hydrofera blue, then removed the sponge dressing with bare hands and placed the packaging on top of the bedspread with the sponge. Staff M left the resident room, went to the treatment cart, and removed a pair of scissors, then began to return to the resident's room. The staff member confirmed she had contaminated the Hydrofera sponge by removing it from the packaging with bare hands. She stated, I took my gloves off. The staff member went into the unit's pantry, looked around and then reported to Staff E, Minimum Data Set (MDS) Coordinator, she needed another Hydrofera, because it got contaminated. After several minutes Staff E returned to the unit and had produced an unopened package of Hydrofera. Staff M placed the scissors onto the resident's bedspread, applied a pair of gloves (without performing hand hygiene), sprayed wound cleanser into the wound and used a 4x4 gauze pad to pat dry the wound. She picked up the scissors from the bedspread and cut off a piece of the Hydrofera, then placed the remaining piece on top of the packaging. She placed a drain sponge on top of the blue sponge, applied a large abdominal pad, then began to wrap rolled gauze around the dressings and the resident's foot. Prior to adhering the rolled gauze, she removed the rolled gauze, the abdominal pad, drain sponge, and the blue sponge. The LPN applied the prism to the wound bed, used scissors (that had been lying on the bedspread) to cut another piece of the Hydrofera before applying it, then she placed the previous 4x4 drain sponge, the previously applied abdominal pad, and then used the previously applied rolled gauze to secure the dressing to the left heel before wrapping the area with an elastic bandage. The staff member applied the previously removed gray sock, threw away all the trash, removed gloves, and washed hands for approximately 10 seconds.
Immediately following the observation, an interview was conducted with Staff M. She stated hand hygiene was to be done before and after care. She acknowledged hand hygiene should be done between dirty and clean applications, and the scissors were contaminated from lying on the bedspread. Staff M stated she was assured the scissors removed from the treatment cart were clean.
A review of Resident #45's April 2022 Order Summary Report identified the resident had the following orders:
-Continue dressing change 3 times (x) per week, use Prisma Promogram followed by Hydrofera Blue, 4x4, Abdominal (AND), wrap with rolled gauze ([NAME]) every day shift every Monday, Wednesday, and Friday for treatment. Start date: 3/9/22 with no discontinuation date.
- Continue dressing changes 3 x/week to left heel using Hydrofera Blue, 4x4, AND, [NAME], Ace wrap any questions every day shift every Monday, Wednesday, Friday for open area. Start date: 4/18/22 with no discontinuation date.
A review of the April 2022 Treatment Administration Record (TAR) for Resident #45 identified Staff M had documented she completed both of the wound care treatments listed above for the resident on 4/20/22.
A review of the Weekly Pressure Wound Evaluation dated 2/22/22 identified Resident #45 had acquired a left heel stage II pressure ulcer on 11/29/21.
A review of the Encounter note from the physician dated 4/3/22 indicated Resident #45 had a left heel ulcer with continuing wound care.
A review of the Skin/Wound note dated 4/11/22 at 9:59 a.m., indicated Resident #45 had a Stage IV pressure ulcer to (the) left heel.
The Care Plan for Resident #45 identified the following:
- (Resident) had actual skin breakdown: 11/15/21 trauma/scratching to Right buttock, 11/29/21 chronic slow-healing left heel surgical wound - history of infected diabetic foot ulcer (surgically closed with graft at readmission since debrided) 1/9/22 rash. Revised 3/25/22. The goal was to remain free from signs and symptoms of infection related to actual skin issues. The interventions included treatments as ordered.
A review of the policy entitled Clean Dressing Change, undated as to implementation and revision dates, indicated the following:
Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination.
Policy Explanation and Compliance Guidelines:
- 5. Set up clean field on the overbed table with needed supplies for wound cleansing and dressing application:
-- a. if the table is soiled, wipe clean.
-- B. Place a disposable cloth or linen over on the overbed table.
-- c. Place only the supplies to be used per wound on the clean field at one time (include wound cleanser, gauze for cleansing, disposable measuring guide, and pen/pencil, skin protestant products as indicated, dressings, tape).
- 6. Establish area for soiled products to be placed (chux or plastic bag).
- 7. Wash hands and put on clean gloves.
- 8. Place a barrier cloth or pad next to the resident, under the wound to protect the bed linen and other body sites.
- 9. Lose the tape and remove the existing dressing. If needed to minimize skin stripping or pain, moisten with prescribed cleansing solution, or use adhesive remover to remove tape.
- 10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle.
- 11. Wash hands and put on clean gloves.
- 12. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound (i.e., clean outward from the center of the wound). Pat dry with gauze.
- 13. Measure wound using disposable measuring guide.
- 14. Wash hands and put on clean gloves.
- 15. Apply topical ointments or crams and dress the wound as ordered.
- 16. Secure dressing. [NAME] with initials and date.

Based on observations, record review, and interviews, the facility failed to ensure one (#31) of two sampled residents reviewed for enteral feedings received nutritional support as ordered.
Findings included:
Resident #31 was admitted on to the facility in 2018 with diagnoses to include unspecified protein-calorie malnutrition, subsequent encounter for diffuse traumatic brain injury without loss of consciousness, persistent vegetative state, and gastrostomy status.
An observation on 4/18/22 at 10:39 a.m., identified an opened (spiked) bottle of Jevity 1.5 calorie connected to a nutrition pump. The manufacturer label identified the enteral nutrition bottle held approximately 1000 milliliters (ml)/ 33.8 fluid ounces/1 liter of liquid. The label indicated the bottle was hung at 12:00 PM on 04/17/22 with a run rate of 55 ml per hour (hr). The observation revealed the bottle contained approximately 700 ml, indicating the resident had received approximately 300 ml since the bottle was hung, approximately 22 hours and 39 minutes prior to the observation. The observation on 4/18/22 at 2:01 p.m. indicated the resident was receiving nutrition at 55 ml/hr and the bottle of nutrition continued to appear to contain approximately 700 ml. On 4/18/22 at 2:58 p.m. and 3:16 p.m., an observation identified the nutrition pump was not running, the same bottle dated 4/17/22 at 12 p.m. was hanging and contained slightly less than 700 ml. Photographic evidence was obtained.
A review of Resident #31's April 2022 Order Summary Report indicated the following orders related to the resident's nutrition:
- Nothing by mouth (NPO) diet, NPO texture for Enteral Feeding, start 4/8/22.
- Enteral Feed Order every shift. Flush feeding tube with 30 ml of water before and after medication administration and 5-15 ml between each individual medication.
- Enteral Feed Order four times a day. Flush tube with 150 cubic centimeters (cc) of water.
- Enteral Feed Order one time a day for nutrition. Restart Jevity 1.5 at (@) 55 ml/hr., ordered 4/10/22.
- Shut down Jevity 1.5 for 4 hours daily, down @ 6 a.m., up @ 10 a.m.
A review of Resident #31's April 2022 Medication Administration Record (MAR) indicated the following:
- Enteral Feed Order one time a day for nutrition. Restart Jevity 1.5 at (@) 55 ml/hr., ordered 4/10/22. Scheduled at 10:00 a.m.
- Enteral Feed Order four times a day. Flush tube with 150 cubic centimeters (cc) of water. Scheduled at 9 a.m., 1 p.m., 5 p.m., and 9 p.m.
A review of the medical record identified Resident #31 should have received enteral nutrition and water flushes for 18 hours from 4/17 at 12 p.m. to 4/18/22 at 6 a.m. (scheduled time for nutrition to come down). The resident should have received water flushing four times during the time period, including a flushing scheduled at 9 a.m. The orders reflected the resident was to receive 14 hours of enteral nutrition and 4 hours of water supplement during the time period. The amount of enteral nutrition would equal 770 ml (14 hours x 55 ml/hr.). The bottle was observed hanging from the pole, on 4/18/22 at 10:39 a.m., next to the resident with only 300 ml's of enteral nutrition delivered between 4/17 at 12 p.m. and 10:39 a.m. on 4/18/22, totaling a deficit of enteral nutrition of approximately 470 ml in the time period.
On 4/18/22 at 3:10 p.m., Staff Member T (Licensed Practical Nurse, LPN) stated Resident #31 had been re-admitted to the unit yesterday after being on the south hall. The LPN observed the residents' nutrition was not running and confirmed it should be running at 55 ml/hr. She stated the nutrition was good for 24 hours and should have been changed at 12 p.m. on 4/18/22. The staff member stated she had not restarted the nutrition until 12 p.m. because she was behind. The nurse stated when she hooked the nutrition up to the resident (at 12 p.m.) she had not looked at the bottle. Staff T was unable to calculate the amount of nutrition the resident had received in the approximate 25-hour period between the time the bottle was hung and interview, stating I'm tired, I can't calculate, I can't figure it out. The staff member confirmed the resident should have received more nutrition and it was obvious the resident had not gotten enough. She stated, I don't know what happened.
The Director of Nursing (DON) observed Resident #31's enteral nutrition feeding, on 4/18/22 at 3:20 p.m., and stated she knew it was not running and it should be. The DON confirmed the resident had not gotten enough nutrition and 300 ml of nutrition from 12 p.m. on 4/17/22 was not acceptable. She stated her expectation was to follow the physician orders for enteral feeding.
A review of the policy titled Assisted Nutrition and Hydration, undated, indicated the Residents within the facility will maintain adequate parameters of nutritional and hydration status, to the extent possible, to ensure each resident is able to maintain the highest practicable level of well-being. The Explanation and Compliance guidelines indicated the facility would provide nutritional and hydration care and services to each resident, consistent with the resident's comprehensive assessment and to provide a therapeutic diet taking into account the resident's clinical condition and preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure medications were monitored for behaviors related to the administration of psychotropic medication(s) and failed to clarify a dosage for Acetaminophen for one (Resident #178) of five residents sampled for unnecessary medications.
Findings included:
Resident #178 was admitted to the facility on [DATE] with diagnoses which included metabolic Encephalopathy, alcoholic cirrhosis of liver without ascites, delirium due to known physiological condition, unspecified hallucinations, unspecified anxiety disorder, and unspecified recurrent major depressive disorder.
An observation on 4/18/22 at 11:41 a.m., was conducted with Resident #178. The resident was observed sitting on the side of the bed. On 4/20/22 at 11:05 a.m., the resident was observed lying in bed covered with a blanket.
A review of Resident #178's April 2022 Order Summary Report as of 4/20/22 at 1:56 p.m. included the following:
- Acetaminophen Tablet - Give 2 tablet by mouth every 4 hours as needed for mild pain, started 4/15/22.
- Acetaminophen Tablet - Give 2 tablet by mouth every 4 hours as needed for Temperature above 101.3 Fahrenheit, started 4/15/22.
- Fluoxetine Hydrochloride 10 milligram (mg) capsule - Give 1 capsule by mouth one time a day for depression, start 4/15/22.
- Restoril Capsule 30 mg - Give 1 capsule by mouth at bedtime for insomnia, start 4/17/22.
- Risperidone Tablet 0.5 mg - Give 1 tablet by mouth every 12 hours for psychosis, start 4/15/22.
The Order Summary Report did not include orders for monitoring the behaviors or the side effects of the psychotropic medications and the Acetaminophen orders for the resident did not include a dosage.
On 4/20/22 at 1:56 p.m., Staff N, Unit Manager/Licensed Practical Nurse (UM/LPN), confirmed Resident #178 should be monitored for behaviors and side effects. She stated staff had to go into the order set and select types of monitoring based on resident needs and this should be done at admission.
Staff N stated, at 4:40 p.m. on 4/20/22, the facility had 325 and 500 mg tablets of Acetaminophen available. She reviewed the orders for Resident #178 and stated, that's a problem.
A review of Resident #178's April 2022 Medication Administration Record (MAR) identified the monitoring for the behaviors and side effects related to the administration of the antidepressant, antipsychotic, and sedative/hypnotic medications began on the evening shift of 4/20/22. A dosage of 325 mg was added to the resident's Acetaminophen orders at 4:40 p.m. on 4/20/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-seven medication administration opportunities were observed and two errors were identified for two (Residents #74 and #47) of five residents observed. These errors constituted a 7.41% medication error rate.
Findings included:
1. On 4/19/22 at 11:45 a.m., an observation of medication administration with Staff T, Registered Nurse (RN), was conducted with Resident #74. The staff member dispensed the following medications:
- Novolog FlexPen - 2 units.
Staff T held the pre-filled Insulin FlexPen upright without a needle and stated there was no air bubble so it was all clear. Staff T wiped the end of the syringe and dialed it to 2 units. Staff T injected the 2 units into the upper left extremity of Resident #74. Staff T stated she would have primed the Novolog pen if there was room for an air bubble.
2. On 4/20/22 at 8:36 a.m., an observation of medication administration with Staff M, Licensed Practical Nurse (LPN), was conducted with Resident #47. Staff M dispensed the following medications:
- Amiodarone 200 milligram (mg) oral tablet
- Buspirone 5 mg oral -2 oral tablets
- Carvedilol 3.125 mg oral tablet
- Eliquis 5 mg oral tablet
- Omeprazole 20 mg oral tablet
- Iron 325 mg oral tablet
- Loratadine 10 mg oral tablet
- Multi Vitamin oral tablet
- Vitamin C 500 mg oral tablet
- Zinc 220 mg oral tablet
- Fluticasone nasal spray
A review of Resident #47's April Medication Administration Record (MAR) identified the resident was scheduled at 9:00 a.m. to receive a Multi Vitamin with minerals one time a day for a supplement. The dose given to the resident did not contain minerals.
According to the manufacturers' pharmaceutical insert, located at https://www.novo-pi.com/novolinr.pdf, instructed users to give an air shot before each injection:
-- Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to make sure you take the right dose of insulin:
-- Turn the dose selector to select 2 units.
-- Hold your Novolin® R FlexPen® with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge.
-- Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0.
-- A drop of insulin should appear at the needle tip. If not, change the needle, and repeat the procedure no more than 6 times.
-- If you do not see a drop of insulin after 6 times, do not use the Novolin® R FlexPen® and contact Novo Nordisk at [PHONE NUMBER].
-- A small air bubble may remain at the needle tip, but it will not be injected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure medications were stored and labeled properly in two (300-hall 1 and 300-hall 2) of four medication carts and one (south) of two medication rooms.
Findings included:
On 4/19/22 at 5:15 p.m., an attempt was conducted to observe medication administration with Staff U, Licensed Practical Nurse (LPN). Staff U opened the top drawer of the 300-hall 1 medication cart and removed a medication cup with medications in it and then entered Resident #40's room. When the Staff U returned to the medication cart, she stated she had administered the resident a chewable Vitamin C and the scheduled Oxycodone. Staff U then removed a blister card of Doxycycline tablets from the medication cart, dispensed a tablet into a medication cup, left the card of tablets on the top of the medication cart, and re-entered Resident #40's room. She came back out and stated she had signed out the Oxycodone and confirmed she had pre-dispensed medications due to the computer not staying charged if not plugged in. The cart was parked between rooms [ROOM NUMBERS]; an electrical outlet was observed on the other side of the door to room [ROOM NUMBER], on the wall between rooms [ROOM NUMBERS], and between the room [ROOM NUMBER] and the mechanical room. Staff U reported she had four other residents that she had pre-dispensed medications for. She removed a medication cup from the top drawer of the cart and identified the medications were for Resident #14. Staff U verified, at 5:26 p.m. on 4/19/22, she had pre-dispensed medications for the residents in room [ROOM NUMBER] who were in the Dining Room, room [ROOM NUMBER], and room [ROOM NUMBER]. Staff Member U walked away from the medication cart and stated, you planning on giving me a long vacation, I hope so.
On 4/19/22 at 5:30 p.m., the 300-hall 2 medication cart was reviewed with Staff U. The observation included the following:
- an insulin FlexPen prefilled syringe labeled with an illegible resident name and date. The staff member stated it could be 4/17, 4/18, or 4/19.
- A container of Microdot Bleach wipes stored in the same drawer compartment with boxes of inhalation solution, HFA inhalers, and a pre-filled Admelog syringe stored in a bag labeled for Novolog.
On 4/21/21 at 2:46 p.m., a review of the South medication room was conducted with Staff V, agency Registered Nurse (RN). The review of the medication room identified a drawer with 13 prefilled syringes of Heparin in it and was labeled Safe Needles. Staff V stated Heparin is patient-specific and did not know why it was stored like that.
The policy - Medication Storage, implemented 11/2020 and reviewed 3/15/22, indicated it was the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. The guidelines identified During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. and External Products: Disinfectants and drugs for external use are stored separately from internal and injectable medications.
On 4/19/22 at 5:49 p.m., the Interim Director of Nursing (DON) stated nurses are not allowed to pre-pour medications and the one stipulation was if medications are poured and the resident was indisposed at the time. She stated there was no reason for pre-dispensing 4-5 residents. On 4/20/22 at 8:45 a.m., the Interim DON stated she had spoken with Staff U and the staff member confirmed the findings.
The Consultant Pharmacist stated, on 4/22/22 at 11:07 a.m., Heparin syringes are patient specific, stored in a bag with the resident name and was also an Emergency Drug Kit item and said she had notified the DON the syringes needed to be returned and the pharmacy should make sure there was enough.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility's quality assurance (QA) and assessment committee failed to implement an effective plan of action to correct deficient practice identified during the recertification survey and complaint survey originally conducted 4/18/22 through 4/22/22 as evidenced by: 1) failure to ensure an allegation of neglect was reported to state agencies for one (#5) of three residents sampled for abuse and neglect (F609), 2) failure to ensure allegations of abuse and neglect were thoroughly investigated for two (#5 and #7) of three residents sampled for abuse and neglect (F610), 3) failure to monitor for behaviors and side effects for psychotropic medications and failure to limit as needed psychotropic medications to 14 days for two (#1, #5) of three residents reviewed for psychotropic medications (F758), and 4) failure to ensure the medication error rate was less than 5.00%. Twenty-eight medication administration opportunities were observed, and twelve errors were identified for two (#1 and #13) of 8 residents observed. These errors constituted a 42.8% medication error rate (F759).
Findings included:
1. On 6/30/22 at 3:05 p.m., an interview was conducted with the Regional Director of Clinical Services (RDCS), Nursing Home Administrator (NHA), and the DON to discuss the facility's quality assurance program. The facility's administrative team reviewed everything that they had done according to the plan of correction for each deficiency cited during the survey ending on 4/22/22. They reported that the QA committee met on 5/5/22 to discuss all tags cited during the survey ending 4/22/22. They met again on 5/27/22 and 6/23/22 to address all citations and found that the corrective action plan was effective with no concerns. The facility's administrative team reported that if they had identified a problem, they would have done a Root Cause Analysis (RCA) or updated/changed their audits, but they believed the plan was effective, so no changes were made.
2. Review of the facility's Quality Assurance/Risk Management (QA/RM) and Quality Assurance/Performance Improvement (QAPI) Policy/Plan, reviewed/revised November 2021, revealed:
Policy: It is the policy of this facility to develop and effective, comprehensive facility and discipline specific Quality Assurance and Risk Management Program that focuses on the indicators or outcomes of resident care and quality of life. The facility will coordinate and evaluate activities under the QAPI program, including the development of Performance Improvement Projects (PIPs) if necessary.
Policy Explanation and Compliance Guidelines:
d. Develop and implement appropriate PIPs to correct identified quality deficiencies.
3. The QAPI plan will address the following elements:
b. Process addressing how the committee will conduct activities necessary to identify and correct quality deficiencies. Key components of this process include, but are not limited to, the following:
v. Developing and implementing performance improvement plans and or activities.
5. Program Systematic Analysis and Systemic Action-
a. The facility takes actions aimed at performance improvement as documented in QAA/RM Committee meeting minutes and improvement plans. Results of the PIP will be monitored and documented in subsequent QAA/RM/RM Committee.
b. To ensure improvements are sustained, the effectiveness of performance improvement activities will be monitored in QAA/RM/RM Committee meetings.
3. Review of the facility's plan of correction for the survey ending 4/22/22 with a completion date of 5/19/22 revealed the following measures would be taken to correct the deficient practice which was identified at F609 and F610:
3. The administrator and director of nursing were educated on reporting requirements and investigation of allegations of abuse, neglect, and misappropriation by the Regional Nurse consultant on 5/10/2022.
Staff educated on reporting abuse, neglect, and misappropriation was completed on 4/22/2022.
Newly hired staff will be educated upon hire regarding abuse, neglect, and exploitation during orientation.
4. Director of nursing/designee will review skin assessments for 10 random residents weekly X 4 weeks, then monthly X 2 months to ensure any injuries of unknown origin have been reported and investigated per state and federal guidelines if indicated. Administrator/designee will conduct interviews with 5 random residents weekly x 4 weeks, then monthly to ensure if voiced, any allegations of abuse or neglect are reported and investigated per state and federal guidelines. Results will be presented to QAPI Committee monthly. Ongoing quality review schedule may be modified based on findings to ensure compliant practice remains in place.
On 6/29/22 and 6/30/22 a revisit survey was conducted to ensure compliance with F609 and F610. The revisit survey identified the following on-going concerns with F609 and F610:
Interview on 6/29/22 at 3:35 PM with Resident #5 revealed that on 6/24/22 he used his call light to call for help and the assigned (agency) Certified Nursing Assistant (CNA) came in. He told her he needed help and some wipes. He reported that the CNA did bring the wipes, and then left the room. He reported that he wiped as much as he could without help and needed more wipes. The resident stated he used the call light, waited for 2 hours, and no one came. Resident #5 reported that he eventually used his phone to call the front desk and ask for more wipes. After that, an unknown person brought the wipes and left the room. He reported that the assigned CNA never came back to assist him with personal hygiene after having a bowel movement.
Review of a behavior note written by Staff A, Licensed Practical Nurse (LPN)/Unit Manager (UM) dated 6/24/22 at 14:00 (2:00 PM) revealed this writer was sitting at nurse's station as resident was self-propelling wheelchair around corner. Resident stated, That's it I am going to the Hospital I am checking out of this place. This writer asked why he needed to to to the hospital. Resident stated, My foot is [expletive] killing me, and I have been covered in [expletive] for 2 hours. Assigned nurse stated that she administered as needed pain medication to Resident. This writer asked resident if he received pain meds. Resident stated yeah, about 20 minutes ago. Resident stated, Come here I want to show you something. This writer followed, resident into his room. Resident stated, I am leaving this place; I should not have to be covered in [expletive] for 2 hours. This writer assessed resident with no visible signs of fecal matter or fecal smell emitting from resident at this time. Resident pointed to bedside commode. This writer observed bag with feces and cleaning cloths inside. Resident stated, The aide would not help him and I asked her to change the bed and she said why? At that time, the assigned aide walked into room and asked the resident if he needed anything. I asked resident, with aide present, if he asked the aide for help and she would not assist him? Resident stated, I am sitting on the toilet I shouldn't have to ask for help. This writer reiterated to resident, did he ask assigned aide to assist him and she refused? Resident stated, No, she helped me. Resident then stated, My bed is covered in [expletive], and I asked you to make it. This writer observed an approximately 4 inches by 4 inches brown colored area on bed. Assigned aide at that time stated, You asked me to make the bed. Resident then stated, Well I need you to make it again. Assigned aide left room to gather linen. This writer removed bag of soiled items from commode as well as bag from trash can next to commode . Resident is alert, oriented, able to make all needs known and possesses a BIMS score of 15.
Interview on 6/29/22 at 3:25 PM with the Regional Nurse Consultant and the Nursing Home Administrator (NHA) revealed that if a resident alleged sitting in filth for 2 hours, this should be considered an allegation of neglect and should be investigated as such.
Interview on 6/29/22 at 4:15 PM with Staff A, LPN/UM and the Director of Nursing (DON), who also was the facility's Risk Manager, revealed that this was not an allegation of neglect because when they entered the resident's room, the bedside commode had stool in it, the garbage can next to the commode had stool stained tissue in it, and the bed did have a brown substance on it which the resident could have caused after the bed was made by the staff. The DON reported that she did not need to do anything else about the documented incident because they interviewed the CNA at that time. The DON stated that the CNA reported that the resident had asked for wipes which she provided, and the resident requested his bed to be made, which she also did.
Follow-up interview on 6/30/22 at 9:34 AM with the DON/Risk Manager reported that there was no other information regarding the incident involving Resident #5's allegation that he did not receive care. The DON/Risk Manager confirmed that only the CNA involved was interviewed, but there was no statement written and no statements or interviews were obtained from the resident or other residents and staff who may have had knowledge of the incident or experienced a similar occurrence. The DON stated that the allegation was not reported.
Review of the facility's incident log for the month of June 2022 revealed an incident dated 6/10/22 indicating Other for Resident #7. Review of the incident revealed that on 6/10/22, Resident #7's roommate called the front office and reported that a CNA hit Resident #7 in the face. Review of the facility's investigation packet revealed an immediate and five-day federal report was completed. An investigation was started on 6/10/22 and the accused staff person was taken off of the schedule on 6/10/22. The facility's investigation packet included two written statements from two CNA's (one being the alleged perpetrator, Staff F). Continued review of the investigation packet revealed that there was no statement from Resident #7, no statement from the roommate, no statements from the assigned nurse, and no statement from any other resident who the accused staff member was assigned to.
On 6/30/22 at 9:31 AM, Resident #7 was observed seated in the common area. Interview with the resident revealed he was waiting to take a shower. The resident reported that a staff member had hit him a few weeks ago (resident could not recall the date), and the nurse took care of it. The resident reported that he was not hurt but fell when trying to hit the staff member back.
Review of a progress note dated 6/10/22 at 17:58 (5:58 PM) revealed the DON/Risk Manager documented that the resident's roommate called up to nurses' station and made a report that the CNA in room hit patient in the face. Nurse management went to patient's room to assess situation. CNA was leaving room and patient was standing in the doorway. Patient was asked if he was hit by staff member and he stated no. He was also asked if he was harmed, touched rough or injured by staff. He again stated no. Patient started motioning and swinging his arm stating, me me. When asked, did you try to hit the staff? He stated yes. Skin assessment was completed. Small red abrasion was noted on patient's back from when he fell. Face had no redness or edema noted. Resident's roommate's curtain was pulled all the way around his bed like the resident prefers it, and roommate had his sound proof headphones on and was lying on his side toward the wall. Patient continues to deny pain and denies being hit or touched.
Interview on 6/30/22 at 10:40 AM with the DON/Risk Manager revealed that if she received allegations, she would remove the staff person, question the resident involved, question the roommate who reported the allegation, obtain statements from the staff member involved or anyone else involved, perform a skin assessment, complete all reporting and notifications to include the physician and family. She reported that for this allegation, she did not interview any other residents assigned to the accused staff person, no statements from the resident involved in the allegation or the resident's roommate who made the allegation were taken, no statements from the nurse or any other staff assigned to the unit were obtained and no statements or interviews were conducted with other residents cared for by this CNA. She reported that she was still in training for the position of Risk Management.
Interview on 6/30/22 at 11:08 AM with the Regional Nurse Consultant revealed that she was told that staff and residents were interviewed so she knows that this task was done; however, the documentation was not provided.
A review of the facility's Active Employee Report with a run date of 6/29/22 revealed Staff F was still listed as an active agency employee with this facility. Staff F's hire date was listed as 6/10/22.
4. Review of the facility's plan of correction for the survey ending 4/22/22 with a completion date of 5/19/22 revealed the following measures would be taken to correct the deficient practice which was identified at F758:
2. On 5/10/2022 an quality audit was conducted by the Director of nursing on anti psychotropic medication for behavior monitoring and side effect monitoring present for each medication.
3. On 5/17/2022 the Director of nursing/designee completed education with the licensed nurses on medication monitoring and side effect monitoring for all psychotropic medication and education on medication orders including dosage and strength.
New hired staff to be educated during orientation
4. Director of Nursing/Designee will complete 5 random resident audits to check for behavior monitoring and side effect monitoring for residents receiving psychotropic medication. Both audits will be done weekly X 8 weeks and monthly X 1 month.
The results of these audits will be presented at the monthly QA/Risk Management meeting for a minimum of 3 months or until the committee has determined substantial compliance has been achieved.
On 6/29/22 and 6/30/22 a revisit survey was conducted to ensure compliance with F758. The revisit survey identified the following on-going concerns with F758:
Record review of the active physician orders revealed Resident #1 had the following orders for psychotropic medications:
Citalopram Hydrobromide 20 mg (milligrams) daily for depression with an order/start date of 6/9/22
Mirtazapine 7.5 mg at bedtime for depression with an order/start date of 6/9/22
Xanax 0.25 mg every 12 hours as needed (PRN) for anxiety with an order/start date of 6/9/22 (with no 14-day end date)
Record review of the care plan initiated on 6/9/22 and last reviewed on 6/27/22 revealed the resident was at risk for complications related to the use of psychotropic drugs including antidepressants, antianxiety for depression, and anxiety. The care plan goal was to have the smallest most effective dose without side effects. Interventions included: monitor for continued need of medication as related to behavior and mood; monitor for changes in mental status and functional level and report to physician as indicated; monitor for side effects and consult physician and or pharmacist as needed.
Review of the June 2022 Medication Administration Record (MAR), Treatment Administration Record (TAR), and progress notes revealed no monitoring for behaviors and side effects associated with the psychotropic medications could be located.
During an interview on 06/30/22 at 2:01 p.m., the DON verified the Xanax order did not have an end date and was ordered as needed. She also verified there was no behavior or side effect monitoring in place for these medications. The DON reported possible negative outcomes of not monitoring behaviors and side effects of psychotropic medications would be failure to provide a timely gradual dose reduction, not adjusting medications, and not knowing if an adverse reaction to a medication was occurring.
On 07/01/22 at 3:36 p.m., the Pharmacy Manager stated that PRN psychotropics such as Xanax should have a 14-day end date. He stated that the pharmacy will not send out more than 14 days of medication. He stated that psychotropics such as antidepressants and antianxiety medications should have behavior and side effect monitoring in place.
Record review of the facility's policy, Use of Psychotropic Medication, dated 01/22/22 revealed Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Policy Explanation and Compliance Guidelines: .9. PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e., 14 days). 10. The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as: .D. in accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care. 11. The resident's response to the medication(s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record.
Review of Resident #5's active physician orders revealed an order dated 6/2/22 for Xanax Tablet 1 MG (ALPRAZolam) Give 1 tablet by mouth every 8 hours as needed for anxiety. Continued review of physician orders revealed that there was no end date for the use and no discontinue order for the Xanax.
Interview on 06/30/22 at 2:05 PM with the DON confirmed that Resident #5's Xanax order did not have an end date and was ordered on an as needed basis.
5. Review of the facility's plan of correction for the survey ending 4/22/22 with a completion date of 5/19/22 revealed the following measures would be taken to correct the deficient practice which was identified at F759:
3. On 5/17/2022 the Director of nursing/designee completed education with the licensed nurses on about proper insulin administration including priming insulin pens prior to administration.
On 5/17/2022 the Director of nursing/designee completed education with the licensed nurses on following physician orders including all over the counter medication.
4. Director of Nursing/Designee will complete an audit on 5 random nurses during medication administration to ensure medication error rate is < 5% this medication administration will be done weekly X 8 weeks and monthly X 1 month.
The results of these audits will be presented at the monthly QA/Risk Management meeting for a minimum of 3 months or until the committee has determined substantial compliance has been achieved.
On 6/29/22 and 6/30/22 a revisit survey was conducted to ensure compliance with F759. The revisit survey identified the following on-going concerns with F759:
Observation and interview on 06/29/2022 at 11:00 a.m. with Resident #1 revealed he was lying in bed with the head elevated and an air mattress in place. He stated he had not had any of his morning medications yet to include his insulin and pain medications.
Staff A, Licensed Practical Nurse (LPN)/Unit Manager (UM) on 06/29/22 at 11:20 a.m. stated he had an order for blood glucose monitoring due to his Humalog insulin 8 units not being given on time (due at 7:30 a.m.). According to Staff C, LPN, none of the resident's medications had been given as of 11:35 a.m. On 06/29/22 at 11:42 a.m., Staff A told Staff C the physician ordered 8 units of Novolog via a quick pen.
On 06/29/22 at 11:52 a.m., Staff C, LPN entered Resident #1's room with a cup and Novolog-R and Novolog quick pens of insulin. Resident #1 asked why he was getting his insulin so late. Staff C stated she was going to give him Novolog 8 units and Novolog-R 5 units. Resident #1 asked, How could she know the sliding scale dose without doing his [blood sugar]? The LPN stated she was running late. He told Staff C he needed a pain pill before he went to therapy. Staff C performed the blood glucose measurement, and his blood sugar was 297. The LPN did not administer any insulin at this time. Interview with Staff C, LPN at the time of the observation revealed she was not giving any insulin due to the resident questioning the amount of insulin.
Staff C, LPN went back to the nursing station to speak to Staff A, LPN/UM again regarding dosage. Staff A stated the physician wanted him to have the Novolog 8 units he was supposed to get this morning. Staff A stated that the sliding scale was just added this morning. Staff A stated that the order read to give Novolog 8 units and Novolog-R 5 units. Staff A stated, if he had gotten his 8 units this morning, he may have not been close to 300 now and needed sliding scale insulin.
On 06/29/22 at 12:45 p.m. Staff A, LPN/UM entered Resident #1's room and apologized for his medications being so late. Resident #1 stated, they have promised things would get better and they have not. This has been going on for 3 weeks. Staff A asked if he wanted his insulin now or after lunch because he was eating. Resident #1 said now. Staff A administered both insulin doses into the right upper arm per resident request. The Novolog 8 units was in a quick pen and the Novolog-R 5 units was from a vial.
On 06/29/22 at 12:50 p.m. with Staff C, LPN observed medication administration of the 9:00 a.m. medications for Resident #1.
Ferrous Sulfate 325 mg (milligrams) / 65 mg daily for anemia
[NAME] / plus 8.6 mg daily for constipation
Montelukast Sodium 10 mg daily for allergies
Ropinirole HCL 0.5 mg every 12 hours for restless legs
Pantoprazole 40 mg daily for gastroesophageal reflux disease (GERD)
Amiodarone HCL 200 mg daily for arrhythmia
Carvedilol 25 mg every 12 hours for Hypertension
Citalopram Hydrobromide 20 mg daily for depression
Lisinopril 10 mg daily Hypertension
On 06/29/22 at 12:50 p.m., Staff A/UM, Staff C, and the DON verified there was no Percocet 5-325 mg give one by mouth every 4 hours as needed for severe pain in the narcotic drawer in the medication cart. The resident had his last dose on 06/29/22 at 6:12 a.m. per the June Medication Administration Record (MAR). The DON called the pharmacy to check on the arrival time of the Percocet and for authorization to remove one from the EDK (emergency drug kit) kit. She told the pharmacy it had been ordered. The pharmacy staff stated that they would get the Percocet to the facility tomorrow evening (06/30/22). The three staff members went to the EDK and there was no Percocet listed. The pharmacy stated if they do not use the medication within a certain time frame it will be discontinued from the EDK.
On 06/29/22 at 2:15 p.m., Staff A, UM called the physician to change the Percocet order to another pain medication.
On 06/29/22 at 3:30 p.m., Staff A, UM and the DON stated the Percocet order was lost at the pharmacy. The physician called the pharmacy and was unable to connect with anyone, and the pharmacy was unable to connect with the physician. The physician called the facility and told them to have the pharmacy call him. Staff A, UM and the DON got an order for a one-day dose of Hydrocodone 10 mg for Resident #1 from the physician. They placed a stat order on the Percocet, which means it will be at the facility within 2 hours. The DON stated Resident #1 had not asked for pain medication until 1:30 p.m. (Observed the resident tell Staff C, LPN he had pain and wanted pain medication at 11:52 a.m.) The DON stated he was offered Tylenol but declined wanting to wait on the Hydrocodone.
Review of the June 2022 MAR showed he received Hydrocodone-Acetaminophen 10-325 mg for pain at 1721 (5:21 p.m.). Per his orders he could have had a dose of Percocet at 10:15 a.m. if it had been available.
Review of the progress notes written for Resident #1 revealed on 06/29/22 an entry made at 18:00 (6:00 p.m.) written by Staff A, LPN/UM. The health status note stated at approximately 11:30 a.m. this writer was alerted that resident did not receive scheduled 0900 medications. At this time writer notified Healthcare Provider that 0900 scheduled medications were not administered including 0730 insulin. This writer obtained new orders at this time, may administer 0900 medications unscheduled, may administer [blood glucose monitoring] at 11:30, may discontinue Humalog Kwik Pen Solution Pen-injector 100 units/ml (insulin Lispro (1 Unit Dial) may start Novolog Flex Pen Solution Pen-injector 100 unit / ml (Insulin Aspart) 8 units with meals. At approximately 12:30 p.m. resident complained of pain. Assigned licensed staff went to pull narcotic from draw and was unavailable at this time. Pharmacy was called and acquired authorization from pharmacy. This writer attempted to obtain Percocet with second licensed staff member. Percocet unavailable from the medication dispensing system. This writer called Healthcare Provider, Physician, new order obtained may give Norco 10-325 one-time dose only for pain management. Norco administered at this time.
During observation and interview on 06/29/22 at 8:33 a.m. Staff C, LPN entered Resident #13's room. He was sitting in his room with his breakfast tray in front of him. He had eaten part of his breakfast. He stated that he had not received his insulin yet, and he was supposed to get it before he ate. Staff C performed a blood glucose measurement (with an order time of 7:30 a.m.) on Resident #13 with a blood glucose result of 429. Staff C stated the blood glucose results were outside of the sliding scale parameters, and she needed to call the physician. Staff C received an order to administer 10 units of Novolog. At 8:50 a.m., Staff C administered 10 units of Novolog insulin to Resident #13 in his left arm in the hallway. At this time, the observation involving Resident #13 was discussed with Staff A and Staff C. Staff A stated her expectation was for the nurse to call the physician if the medication was going to be administered late. Staff A, LPN/UM verified that Staff C was administering medications late and the physician needed notifying.
Review of Resident #13's active physician orders revealed an order dated 6/26/22 for Novolog sliding scale subcutaneously before meals for diabetes, call physician if blood sugar over 400 (scheduled at 7:30 a.m.). Medication Admin Audit Report showed Novolog (Aspart) given on 06/29/22 at 9:31 a.m. by Staff C, LPN.
During an interview on 06/30/22 at 2:01 p.m., the DON verified the expectation was for the nurse to give the medications timely. If they are not timely the nurse was to call the physician, make him aware, and obtain an order to administer the medication outside of the parameters. The possible negative outcomes that could occur related to late medications could include: if twice a day medication, they would be administering doses too close together; if an insulin was missed and blood glucose results were elevated, they may have to administer more insulin than desired; if blood pressure medications were not timely, the resident's blood pressure may be elevated.
On 07/01/22 at 3:36 p.m., the Pharmacy Manager stated that medications should be given per the schedule.
Record review of the facility's policy, Preparation and General Guidelines, dated 2006 showed handwashing and hand sanitation: the person administering medications adheres to good hand hygiene, which includes washing hands thoroughly: before beginning a medication pass, prior to handling any medication, after coming into direct contact with a resident. 4) FIVE RIGHTS-right resident, drug, dose, route and time. 11) if a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted, or medication removed from the night box/emergency kit. B Administration 11) a schedule of routine dose administration times is established by the facility and utilized on the administration records. 12) medications are administered within (60 minutes) of scheduled time, except before, with or after meal orders, which are administered (based on mealtimes). Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility.
Record review of the facility's Medication Administration Times, showed
one daily was at 9:00 a.m.
twice daily was at 9 a.m. and 5 p.m.
three times daily was at 9 a.m., 1 p.m. 5 p.m.
before meals was at 6:30 a.m. and 11 a.m.
every 12 hours was 9 a.m. and 9 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure medications were consumed during medication administration for one resident (Resident #54) out of the sampled forty-four residents.
Findings included:
On 02/15/21 at 1:15 p.m., a cup with nine medications was observed on the bedside table next to the bed in Resident #54's room (photographic evidence obtained). Resident #54 reported that the nurse gave her the pills without pudding and that she could not take them without pudding because she had difficulty swallowing pills.
On 02/15/21 at 1:55 p.m., Staff A, Licensed Practical Nurse (LPN), reported that she always watches Resident #54 take her pills and that she takes them with pudding and water. Staff A stated that she did not know where the cup of pills came from.
A review of the admission Record revealed that Resident #54 was initially admitted into the facility on [DATE] with a primary diagnosis of osteonecrosis left femur. Section C of the admission Minimum Data Set (MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating cognitively intact.
A review of the Order Summary Report with active orders as of 02/17/2021 revealed that Resident #54 did not have an order to self-administer medications.
No assessment for self-administering medications was found in the resident's record.
On 02/18/21 at 12:02 p.m., the Director of Nursing (DON) stated that the nurses should stay and watch residents take medications. You don't leave them until they take the pills stated the DON. The DON reported that she spoke to two of Resident #54's nurses and they both stated that they watched her take the pills. She stated that she was not sure where the pills came from.
On 02/18/21 at 01:31 p.m., the DON confirmed that she could not find an assessment for self-administering medications.
The policy provided by the facility Medication Administration revised 11/21/2021 revealed the following:
15. Observe resident consumption of medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, medical record review and policy review, the facility failed to follow their policy and procedure related to providing education, and obtaining consent for the influenza vaccination, for one resident (#39), of five sampled residents that were reviewed for of immunization documentation.
Findings included:
Record review of the quarterly Minimum Data Set (MDS) dated [DATE], identified in Section C, that resident # 39's Brief Interview For mental Status (BIMS) score was 15, (indicating cognitively intact); and Section O, listed under Influenza Vaccine as not receiving one, with no choice selected for the area of reason not given.
A record review of Resident #39's Immunization report revealed that the resident consented to receive the Influenza Vaccination, in the right Deltoid on 10/10/2020. A further record review of the Electronic Medical Record (EMAR) was conducted and read Fluzone Quadrivalent Suspension filled Syringe 0.5 ml (influenza Vac Quad. Inject 0.5 ml intramuscularly) on 11/20/2020, with the nurse's initials who administered the vaccination
Further record review of the EMAR and Resident #39's paper chart revealed that there was no current (Year 2020) consent, and education documented in the resident's record. The last consent signed by Resident #39 for an Influenza vaccination was on 10/17/2018.
During an interview conducted with the Director of Nurses on 02/18/2021 at 2:42 p.m. she confirmed that appropriate documentation of education and recent consent were not found in Resident #39's record. She indicated that Resident #39 should have written proof of consent and education in his medical record.
A facility provided policy titled, Influenza Vaccination, dated 11/15/2021 was reviewed Page 01 of 02, revealed:
7. Individuals receiving the influenza vaccine, or their legal representative, will be required to sign a consent form prior to the administration of the vaccine. The completed signed and dated record will be filed in the individual's medical record.
9. The resident's medical record will include documentation that the resident and/or resident's representative was provided education regarding the benefits and potential side effects of immunization, and that the resident received or did not receive the immunization due to medical contradiction or refusal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to schedule outside appointments in a timely manner for one resident (Resident #13) out of the one sampled resident.
Findings included:
On 02/15/21 at 12:30 p.m., Resident #13 reported that he had been trying to get an appointment scheduled for months with a urologist. The resident reported that he spoke to the Social Services Director (SSD) about scheduling the appointment and he reported that there were issues with his Medicaid.
The admission Record revealed that Resident #13 was admitted into the facility on [DATE] with a primary diagnosis of multiple sclerosis (MS).
Section C of the Quarterly Minimum Data Set (MDS) revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating cognitively intact.
On 11/18/20, a physician's note revealed that Resident #13 wanted to see a urologist. The resident's levels of testosterone needed to be checked before a referral to the urologist.
There were no notes that indicated that the resident had a scheduled urologist appointment.
On 02/17/21 at 1:42 p.m., the Social Services Director reported that Resident #13 had reported to him that he wanted to see a urologist last week. The SSD stated that he reported this information to the Nurse Practitioner, and she stated that she would reach out to a urologist. Nurses usually work with the residents to get appointments scheduled. He stated that he had not had any luck with getting the appointments scheduled and he had no documentation that indicated that he had attempted to get the appointments scheduled.
On 02/18/21 at 2:37 p.m., the Director of Nursing (DON) reported that nurses are responsible for scheduling outside appointments and setting up transportation.
On 02/18/21 at 4:29 p.m., the DON reported that they did not have a policy on scheduling outside appointments.

Based on observations, record reviews, and interviews, the facility failed to ensure food was dated and labeled in two of two nourishment refrigerators.
Findings included:
On 02/15/21 at 10:15 a.m., the nourishment room on the 100 hall was observed. Temperatures were missing from the Refrigerator Temperature Log for 02/11, 02/12, 02/13, and 02/14. Inside the refrigerator were the following foods with no label or date: an opened bottle of Gatorade, an opened orange juice, a brown bag that held a plastic bag of unknown food, a container of opened ice cream, a frozen to go fast food cup, an opened bag of pizza rolls, 3 sandwiches in plastic bags, and an open carton of French vanilla with an expiration date of 02/04/21. On the counter was an uneaten breakfast tray with eggs and toast. The Certified Dietary Manager (CDM) reported that breakfast was at 7:30 a.m.
The nourishment room on the 300 hall was observed. Inside the refrigerator were the following foods with no label or date: two frozen to go fast food cups, an opened package of sausage, and a plastic container of carrots.
At 10:25 a.m., the CDM reported that he thinks the nurses are responsible for taking the temperatures. The CDM stated that his expectation is that everything in the refrigerator should be dated and labeled.
The policy provided by the facility Date Marking for Food Safety revised on 11/21/2021 revealed the following:
Policy
The facility adheres to a date marking system to ensure the safety of ready to eat, time/temperature control for safety food.
Policy Explanation and Compliance Guidelines for Staffing:
3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared.
4. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded.

Based on observation, interview and record review the facility failed to ensure a resident's fall on 2/6/21 was investigated to ensure effective interventions were in place after a previous fall on 2/3/21 for one (Resident #65) of two sampled residents.
Findings included:
Review of Resident #65's medical record showed their diagnoses included Repeated falls.
Review of the nursing progress notes dated 2/6/21 at 10:46 p.m. revealed the resident fell. The nursing observations, evaluation, and recommendations were: Resident confused and tries to walk unassisted.
Review of the resident's care plan reflected the a focus area of at risk for fall related injury created on 2/8/21 to include interventions: anticipate needs, provide prompt assistance, follow facility fall protocol, and report falls to physician and responsible party.
Review of the fall risk evaluation dated 2/6/21 at 10:32 p.m. reflected a score of 14 for at risk for falls.
During an interview with the Director of Nursing (DON) on 2/18/21 at 02:54 PM the DON confirmed the resident had a change in condition on 2/6/21 but did not see a fall on 2/6/21. After review of the record the DON stated she would have to call the nurse that completed the documentation as she was not aware of the fall.
During an interview with the DON on 2/18/21 at 3:31 p.m. she stated the resident should have a change of condition and progress note related to the falls. The DON confirmed an investigation for the fall on 2/6/21 was never started or completed.
During an interview with the Advanced Practice Nurse Practitioner (ARNP) on 2/19/21 at 9:28 a.m. she stated she reduced Resident #65's blood pressure medicine on 2/4/21 after a fall the day before due to a vasovagal response. The ARNP confirmed she was notified on the 2/7/21, the day after the fall but did not document in her notes.
Review of the facility policy for fall prevention program dated 11/21/20, 2 pages, from the compliance store revealed: 9. When any resident experiences a fall, the facility will: a. assess the resident, b. complete a post fall assessment, c. complete an incident report, d. notify the physician and family, e. review the resident's care plan and update as indicated, f. document all assessments and actions, g. obtain witness statements in the case of injury.
Review of the facility policy for documentation in the medical record dated 11/19/20, one page from the compliance store, revealed: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.
Review of the facility policy for notification of changes dated 11/21/21, two pages, revealed: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to perform full body skin assessment weekly for one resident (Resident #72) out of the sampled forty-four residents.
Findings included:
A review of the admission Record revealed that Resident #72 was originally admitted into the facility on [DATE] with diagnoses that included but were not limited to quadriplegia, pressure ulcer of sacral region, and pressure ulcer of right ankle.
A review of Section C of the Nursing Home Comprehensive Minimum Data Set (MDS) dated [DATE] revealed that Resident #72 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating cognitively intact. Section M of the MDS revealed that Resident #72 was at risk for pressure ulcers/injuries.
A review of the Order Summary Report with active orders as of 02/18/2021 revealed that there was not an order for skin assessments.
A review of the Medication Administration Record and Treatment Administration Record dated February 2021 revealed that there was no documentation related to skin assessments.
A review of the Progress Notes for February 2021 revealed that no skin assessments were documented.
A review of the assessments tab for weekly skin checks revealed that no skin assessments had been completed (photographic evidence obtained).
The care plan related to skin with an initiation date of 02/09/2021 revealed that Resident #72 was at risk for skin breakdown due to impaired mobility related to diagnosis of quadriplegia and malnutrition, incontinence of bowel, indwelling catheter, and current area to left lateral thigh. Interventions included but were not limited to complete weekly skin assessments, monitor skin during bathing and daily, and monitor skin for signs and symptoms of skin breakdown.
On 02/18/21 at 2:31 p.m., Staff A, Licensed Practical Nurse (LPN), reported that skin checks are done on second shift. Skin checks are done as needed with a shower. Skin checks are completed under assessments.
On 02/18/21 at 3:40 p.m., the Director of Nursing (DON) stated that skin checks are done weekly and that it was a standard. They are documented in the assessment section of the medical record. The DON confirmed that no skin assessments had been completed for Resident #72.
The policy provided by the facility Skin Assessments revised on 11/21/2021 revealed the following:
Policy: It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management.
Policy Explanation and Compliance Guidelines:
1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, medical record review and facility policy review, the facility failed to ensure that a resident centered care plan was developed and implemented related to wearing a Wander Guard Device/Bracelet for one (Resident #24) of forty-four residents in the sample group.
Findings included:
On 02/18/2021 at 3:00 p.m., Resident #24 was observed to be walking with an unidentified Certified Nursing Assistant, (CNA) into his resident room, and as he lifted his leg up to step forward his pants moved slightly, showing a white Wander Guard Device/Bracelet on his ankle.
A medical record review for Resident #24 indicated he was admitted on [DATE] with multiple diagnoses that included Cerebral Infarction, Aphasia, Atrial Fibrillation and Cognitive Communication Deficit. A record review of active Physician Orders revealed that Resident #24 did not have an order to wear a Wander Guard Device/Bracelet. Record review of the quarterly Minimum Data Set (MDS) dated [DATE], identified in Section C, that resident #24's Brief Interview for Mental Status (BIMS) score was 09, (indicating moderate cognitive impairment).
Further record review of Resident #24's care-plan dated 02/15/2021, with several revisions since admission did not include a Focus area for a Wander Guard Device/Bracelet care and monitoring with goals and intervention/tasks to be followed by facility staff.
On 02/19/2021 at 09:00 a.m. an interview was conducted with the Director of Nursing (DON). The DON was informed of the observation made of Resident #24 wearing an ankle Wander Guard Device/Bracelet and that there were no active orders, or a Care Plan area developed or implemented to wear one if the facility considered Resident #24 to be an Elopement Risk. The DON indicated she would investigate the matter and get back to the surveyor. At 9:09 a.m. a physician order was observed to be placed in Resident #24's medical record and written by the Regional Clinical Nurse.
On 02/19/2021 at 10:00 a.m., the DON approached the survey team with three Elopement Binders containing Resident #24's picture and information regarding the Wander Guard Device/Bracelet. She revealed that she has performed a visual inspection of the resident's information in all the books, and also checked Resident #24's Wander Guard Device/Bracelet with a Secure Care Tester Box, which showed that it was functioning. She said her staff will be checking placement for Resident #24's Wander Guard Device/Bracelet on the 11-7 shift. The DON further indicated information from Resident #24's medical record dropped off when new ownership took over operational control of the facility. The DON was asked what her expectation was for her staff related to development and implementation of care plans, and she stated I would expect the resident to be care-planned if he has an order for a wander-guard bracelet.
On 02/19/2021 at 10:19 a.m., an interview was conducted with the Regional Clinical Reimbursement Nurse, filling in as MDS(Minimum Data Set)/Care Plan Coordinator, who confirmed that Resident #24 was not care-planned to wear a Wander Guard. Device/Bracelet. She stated I saw the order put in today for the Wander Guard, and I confirm the resident did not have a Wander Guard area in his care plan. I did the update to the care plan today from the quarterly care plan that was originally completed on 02/15/2021.
A review of the facility policy titled Comprehensive Care Plans, with incorrect implementation date and reviewed/revised date of 11/21/2021, Pages 02 of 02 revealed:
Policy Explanation and Compliance Guidelines:
6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that their policy related to identifying and arranging an appropriate representative to make health care decisions was implemented for one Resident (#231) of forty-four residents sampled.
Findings included:
A review of the facility policy titled Resident Rights Regarding Treatment and Advance Directives, with implementation date of 11/21/2021 revealed:
Policy Explanation and Compliance Guidelines:
5. The facility will identify or arrange for an appropriate representative for the resident to serve primary decision maker if the resident is assessed as unable to make relevant health care decisions.
A record review for Resident #231 indicated she was originally admitted on [DATE] and re-admitted on [DATE] with multiple diagnoses that included Cerebral Infarction, Traumatic Subarachnoid Hemorrhage with loss of consciousness of unspecified duration, Gastrostomy, and Tracheostomy.
A continued record review revealed no advance care planning with no advance directive. Active physician orders dated 02/16/2021 listed the resident as a Full Code. A review of care plan dated 01/28/2021 denotes under Focus area dependent on staff for all her daily care needs secondary to vegetative state.
The review of the quarterly Minimum Data Set (MDS) dated [DATE], identified in Section C, that resident # 231 did not have a Brief Interview For Mental Status (BIMS) score and was listed as comatose, could not be aroused. The most recent updated MDS made on 02/09/2021 was requested, but not provided by the facility.
On 02/16/2021 at 11:04 a.m. a telephone interview was conducted with the Responsible Party/Emergency contact listed on Resident #231's facility profile sheet. During the family interview the party revealed that he was the resident's ex-husband, and he is listed because he is trying to help her out since her children were living in another country and has not been able to find or contact them in the past five (5) years. During the interview he indicated he did not know where Resident #231 was at the present time, and had not spoken to anyone regarding where she was. He further indicated that when the resident was recently hospitalized , he was called by the hospital to provide her Medicaid number and social security number. He said he did not have that information, and did not know where to get it, since he was not officially made the resident's guardian or official health care decision maker.
During an interview conducted on 02/17/2021 at 09:30 a.m., with the Social Services Director (SSD), he was asked if the facility is trying to obtain a guardian for Resident #231. The SSD could not provide any documentation or progress notes in the clinical medical record to show that he attempted to contact the resident's ex-husband. He stated I tried to call him to do a Health Care Proxy last week, he does not answer the phone, I left a voice mail. I promise that I spoke to him when she first arrived for first 72 hours, I will print it out for you to see. We only do the 72 hour the first time, and she has been out to the hospital more than once, and her last re-admit was 2/9/2021
An observation was conducted on 02/17/21 at 08:20 a.m. of Resident #231 sleeping with the Head of the bed up at 45 Degrees. The G-Tube (GT) was observed to be running, and the enteral feed pump transfusing at 60 ml/hr.
On 02/19/21 at 08:50 a.m. an interview was conducted with the Resident #231's Advance Practice Nurse (ARNP) who was aware of the resident not having a health care decision maker/guardian. She stated, She will call and have the advance care-plan discussion with the ex-husband who will be the designated surrogate once he signs and returns the paperwork.