NORTHGATE HEALTH AND REHABILITATION CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure residents had the right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of another resident.The facility failed to ensure door access to residents after 8:00PM daily for 1 of 10 residents (Resident #3) reviewed for visitation rights.This failure could lead to reduced communication and contact between residents, families and others, resident isolation and a decreased quality of life. Findings included: Record review of Resident #3's admission record dated 11/19/2025 revealed Resident #3 was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses of Alzheimer's Disease with late onset, Dysphagia, Oropharyngeal Phase (swallowing difficulties due to neurological or muscular impairments), Other Abnormalities of Gait and Mobility, Vascular Dementia (cognitive impairment due to loss of blood flow to the brain), moderate with other behavioral disturbance, Major Depressive Disorder, single episode, moderate; Other Specified Anxiety Disorders; Muscle Weakness, generalized; Cognitive Communication Deficit and Other Lack of Coordination.Resident #3's annual MDS dated [DATE] reflected Resident #3 had a BIMS score of 00 indicating severe cognitive impairment.An interview with Resident #3's POA on 11/19/2025 at 9:05AM revealed the POA had to come to the facility prior to 8:00PM to see Resident #3 due to the front door being locked and no one answering the doorbell after 8:00PM. She stated Resident #3 had an electronic surveillance device in her room and the POA had asked staff entering the room to come to the front door because she had been standing there and no one had answered the doorbell. The POA stated she had spoken with the DON, the Administrator and the Corporate RVP regarding the door not being answered after 8:00PM, but nothing had been done to rectify the situation.An interview with the DON and Administrator on 11/21/2025 at 10:15AM revealed the DON thought the door alarm for the front door was attached to the fire system, so the facility could not have a push button that could be used by families to enter through the front door at their leisure. She stated discussion had taken place regarding an on-call phone number being posted outside the front door for families to call to request entrance to the facility but had not been put into place by the leadership team. The Admn. stated the leadership team had discussed a schedule for the team to cover phone/door duty but the schedule had not been put into practice. She was unable to answer what families were to do when leadership team members were not in the building, particularly after regular business hours, but thought a solution might be to give one of the charge nurses a cordless phone so they could answer the phone or door if needed. Review of facility policy entitled Resident Rights dated February 2021 revealed the following: Policy Statement: Employees shall treat all residents with kindness, respect, and dignity.Policy Interpretation and Implementation1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to:f. communication with and access to people and services both inside and outside the facility;aa. visit and be visited by others from outside the facility;bb. be informed of safety or clinical restrictions or limitations of visitation;cc. access to a telephone, mail and email;dd. communicate in person and by mail, email and telephone with privacy.Review of facility policy entitled Visitation dated September 2022 revealed the following:Policy Statement:Our facility permits residents to receive visitors subject to the residents' wishes and the protection of the rights of other residents in the facility.Policy Interpretation and Implementation:1. Residents are permitted to have visitors of their choosing at the time of their choosing.2. The facility provides 24-hour access to individuals visiting with the consent of the resident. 3. Family members are designated by the resident or resident representative. Immediate family is not limited to individuals related by blood, adoption, marriage or common law.4. Visitors may include, but are not limited to:a. spouses (including same-sex and transgender spouses).b. domestic partners (including same-sex and transgender domestic partners). c. other family members; andd. friends.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure residents had the right to reasonable access to the use of a telephone and a place in the facility where calls can be made without being overheard.The facility failed to protect and facilitate residents' right to communicate with individuals and entities within and external to the facility, including reasonable access to a telephone, for 2 of 10 residents (Resident #4 and Resident #10) reviewed for Resident Rights.Resident #4 had a personal cell phone but was unable to use it due to decline in visual impairment.Resident #10 did not have a personal cell phone and the only means of outside communication was through a facility-provided telephone.These failures could lead to reduced communication and contact between residents, families and others, resident isolation, and decreased quality of life. Findings Included: Record review of Resident #4's admission record dated 11/19/2025 revealed Resident #4 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4 had a diagnoses of Other Acute Osteomyelitis (infection of a bone), Right Femur; Presence of Right Artificial Hip Joint; Subacute Osteomyelitis (bone infection of more than 2 weeks), Right Femur; Generalized Anxiety Disorder; other Speech and Language Deficits following Cerebral Infarction (stroke); Difficulty in Walking, not elsewhere classified; Depression, unspecified; Major Depressive Disorder, recurrent, moderate; Anxiety Disorder, unspecified; other Chronic Pain; Hemiplegia and Hemiparesis (weakness on half the body) following Cerebral Infarction affecting left non-dominant side; Hemiplegia, unspecified affecting left non-dominant side; other Abnormalities of Gait and Mobility; other Lack of Coordination, and Muscle Weakness, generalized. Resident #4 had a BIMS score of 13, indicating she was cognitively intact. An interview with Resident #4's Emergency Contact on 11/20/2025 at 11:42AM revealed Resident #4 had a personal cell phone but was unable to understand how the phone was used at times, due to rapid decline in visual function. He stated he called the facility almost daily to inquire how Resident #4's day had been and to see how she was feeling. The Emergency Contact stated the telephone rang multiple times every time he called but was rarely answered. The Emergency Contact stated he inquired about Resident #4's use of a landline phone when he spoke with the Activities Director and was told there was a cordless phone that was used by residents on the hallway where Resident #4 lived.Record review of Resident #10 admission record dated 11/20/2025 reflected Resident #10 was an [AGE] year-old female who was admitted to the facility on [DATE].Resident #10 had a diagnosis of Difficulty in Walking not Elsewhere Classified, Muscle Weakness (Generalized), Dysphagia, Oral Phase (swallowing disorder), Other Chronic Pain, Other Specified Anxiety Disorders, Other sequelae of Cerebral Infarction (loss of consciousness during a stroke), Vascular Dementia (cognitive impairment due to loss of blood to the brain), Moderate, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Other Atrioventricular Block (problem of heartbeat signal from top to bottom of heart), Chronic Diastolic (Congestive) Heart Failure and Other Speech and Language Deficits following Cerebral Infarction. Record review of Resident #10's Resident #10 had a BIMS score of 15 indicating she was cognitively intact.An interview with Resident #10 on 11/20/2025 at 1:18PM revealed she did not have a cell phone for her personal use and the cordless phone that could be used by residents who lived on the hallway was not in operating order. She stated she had asked the nursing staff many times about the cordless phone and had been told the phone needed charging or was not in working order.Observation of the cordless phone on the 300/400 hallway reflected it was not plugged into a power source, and the wiring had been pushed into a hole in the wall behind the phone.An interview with the DON on 11/20/2025 at 1:24PM while inspecting the phone revealed the phone worked fine and there were no issues with residents using the phone. She was shown the phone with the wiring not plugged into a power source and the cords pushed into a hole behind the phone and stated the maintenance man would have to look at it. The maintenance man approached during the conversation and stated the phone had not worked for an undetermined period of time and he would inquire about getting a new phone for the hallway. He stated the residents could have walked to the 100/200 hall and used their cordless phone but was unable to say how the bed bound residents were to access a phone if they did not possess a personal cell phone.An interview with the DON and Administrator on 11/21/2025 at 10:15AM revealed the DON thought the door alarm for the front door was attached to the fire system, so the facility could not have a push button that could be used by families to enter through the front door at their leisure. She stated discussion had taken place regarding an on-call phone number being posted outside the front door for families to call to request entrance to the facility but had not been put into place by the leadership team. The Admn. stated the leadership team had discussed a schedule for the team to cover phone/door duty but the schedule had not been put into practice. She was unable to answer what families were to do when leadership team members were not in the building, particularly after regular business hours, but thought a solution might be to give one of the charge nurses a cordless phone so they could answer the phone or door if needed. Review of facility policy entitled Resident Rights dated February 2021 revealed the following: Policy Statement:Employees shall treat all residents with kindness, respect, and dignity.Policy Interpretation and Implementation1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to:f. communication with and access to people and services both inside and outside the facility;aa. visit and be visited by others from outside the facility;bb. be informed of safety or clinical restrictions or limitations of visitation;cc. access to a telephone, mail and email;dd. communicate in person and by mail, email and telephone with privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 4 residents (Resident #1) reviewed for adequate supervision in that: <BR/>The facility failed to ensure Resident #1 received supervision during mealtimes to prevent choking or aspiration. <BR/>An IJ was identified on 4/12/24. The IJ template was provided to the facility on [DATE] at 6:19 PM. While the IJ was removed on 04/14/24 the facility remained out of compliance at a scope of isolated with a severity of potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>This failure could place residents at risk of choking, weight loss, decline in health, and death. <BR/>The findings included: <BR/>Record review of Resident #1's face sheet dated 4/10/24 revealed a [AGE] year-old male, admitted on [DATE] and readmitted on [DATE] with diagnoses of seizures, cerebrovascular disease, aphasia following cerebral infarction (a person may be unable to comprehend or unable to formulate language because of damage to specific brain regions), contracture right elbow (shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement), contracture right wrist, hemiplegia (weakness of one entire side of the body) and hemiparesis (complete paralysis of half of the body). The facesheet stated Resident #1 was allergic to morphine, mushrooms, and penicillins. <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was severely impaired for daily decision making, dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with ADLs in the areas of eating and drinking, and was on a mechanically altered diet. <BR/>Record review of Resident #1's comprehensive person-centered care plan, dated 02/20/24, revealed the resident's interventions for ADLs included REQUIRED***EATING: Resident requires set up assist. Resident #1 had unplanned/unexpected weight loss with interventions for ice cream as ordered, monitor and record food intake at each meal, notify the dietician of the weight loss upon their next visit, notify the physician, resident and family of the weight loss, provide verbal assistance and cues during meals, weigh the resident weekly for at least 4 weeks or until weight has stabilized. <BR/>Record review of Resident#1's Physician Order, dated 01/18/24 revealed an order for diet-regular, mechanical soft, and thin fluids. Special instructions FMP to all meals. Divided plate for every meal. The order was signed on 02/01/24 by the physician.<BR/>Record review of a nursing progress note, dated 02/12/2024, stated Patient eating breakfast and begins coughing episode directly after eating. Patient airway patent upon assessment. Patient sitting upright in bed, call light with reach. NP notified RP, MD and staff nurse. <BR/>Record review of document titled Speech Therapy Plan of Care - 03/13/2024, dated 03/13/2024, revealed profound language impairments and mild pharyngeal swallow function impairments (71-85% ability). Section titled Underlying Impairments listed Verbal Expression- Automatic speech severe impairment, Auditory Comprehension- 1 step commands severe impairment, Auditory Comprehension- wh questions- Severe Impairment, and Pharyngeal Swallow Deficits- after swallow. The reasons for referral were without therapeutic intervention patient at risk for: choking, aspiration, weight loss, inability to meet nutritional needs via PO intake of least restrictive diet .Bedside Swallowing Assessment .Pharyngeal phase: Patient demonstrated no signs or symptoms of aspiration during meal or when drinking . Patient demonstrated strong reflexive coughing episode &gt; 10 minutes after last PO intake with face reddening/eye tearing, suspected aspiration/penetration of secretions vs reflux material. Patient seized coughing and resumed normal breathing pattern within 20 seconds. Conclusion patient demonstrated grossly within functional limits oropharyngeal swallow at his current/baseline diet level however it is strongly recommended that the patient take meals in the dining room with staff supervision going forward, if he were to experience choking/aspiration during a meal in his room, staff would not be able to recognize the signs or help him in a timely manner, increasing his risk of an emergency event. Additionally patient shows signs that he may be aspirating/choking on reflux material after eating, and should be kept in an upright position, such as in his wheelchair and within close proximity to staff for supervision and assistance if necessary. SLP to provide skilled dysphasia intervention to provide staff education on choking/ reflux precautions and order/ complete MBSS to objectively assess for risk of aspiration, reflux, esophageal dysmotility, etc. <BR/>Record review of Speech Therapy daily notes 03/13/2024 through 04/12/2024 stated: <BR/>03/18/2024 patient taken for on site MBSS (Modified Barium Swallow Study (MBSS) is a specialized x-ray procedure that helps both the Radiologist (who specializes in using x-rays) and the Speech Language Pathologist (SLP) identify why someone is having trouble with swallowing). Patient presented with very high anxiety when SLP and transport aide attempted to bring him out- shaking, yelling, waving people away. Patient was briefly calmed while being taken to the van and set up. patient resumed elevated behavior when evaluating SLP presented trials. Patient accepted one teaspoon of thin liquid by cup and began to shout and rock back and forth violently before swallowing. Agitation continued across other trials/ consistencies attempted, and with multiple feeders. results inconclusive due to lack of patient participation, however no penetration/ aspiration observed with 1 swallow. Anatomy noted with cervical osteocytes (Osteophytes are exostoses (bony projections) that form along joint margins) and decreased lordodic curvature nearing pharyngeal space and creating pharyngeal pressure system deficit (the decrease of the normal curvature, near the throat, can cause increased pressure in the airway causing partial or complete block). Recommendations are to continue current diet (mechanical soft and thin liquid, crushed meds) while taking all meals upright and supervised with assistance as needed. <BR/>03/21/2024 SLP discussed with CNA recommendations for patient to be up in wheelchair in dining room for lunch period CNA reported patient becoming severely agitated (screaming, shaking, vehemently refusing) during attempts to get him out of bed. CNA attempted again today and reported similar behavior. SLP acknowledged and documented CNA's report.<BR/>03/29/2024 SLP assisted patient with lunch at bedside. Patient mostly self-fed with fingers, occasionally accepting prefilled spoons with help from SLP. Patient ate rapidly/ impulsively and was not responsive to verbal/ gestural cues to pace himself or alternate bites/sips. Patient refused liquid wash each time it was offered. No signs or symptoms aspiration T/ O meal, adequate oral clearance at the end of the meal.<BR/>04/09/2024 patient had 1/2 PBJ sandwich, unmodified, self-fed. Patient was able to take bites out of the sandwich. Ataxia (neurological sign consisting of lack of voluntary coordination of muscle movements that can include trouble eating and swallowing) evident during mastication but patient still able to manipulate and propel bolus effectively. Patient used liquid wash on his own. SLP checked oral cavity to ensure no pocketing/stasis after he finished. <BR/>During an observation on 04/10/24 at 11:13 a.m. Resident #1 was in his room alone in bed. Resident #1 was sitting up in bed. Resident #1 had a regular plate (not a divided plate as indicated in the resident's order) with spaghetti, cooked squash, a hard brown piece of toast, a dessert dish with watery gelatin snack, a coffee cup with no top, and a clear cup with a purple liquid drink with no top. The tray of food had liquid spilled all over it. A napkin was soaked with brown liquid and the diet sheet was also stained with brown liquid. Resident #1 grabbed the hard toast, took a bite, and a crunch noise was heard. The resident put the bread down. This survey asked Resident #1 if the bread was too hard and Resident #1 nodded his head yes. Resident #1 lifted his fork with his left hand. Resident #1's hand was shaking, and food fell off the fork. The Resident #1 put the fork down on the tray. Resident #1 grabbed a handful of spaghetti and began to shove it in his mouth. Resident #1 ate quickly. No straws, condiments, or cheesecake were noted on the tray of food. There was a diet sheet from the kitchen which showed Resident #1's name, stated he was on a regular mechanical soft diet with thin liquids, no allergies were listed, adaptive equipment: divided plate, entr&eacute;e: meat sauce, starch: spaghetti noodles, vegetable: zucchini, bread garlic toast, dessert: cheesecake, condiment salt/pepper/margarine, and beverage: choice of beverage and water. <BR/>During an observation on 04/11/24 at 11:30 Resident #1 was delivered a meal tray by an unidentified male staff. The staff exited the room right after delivering the tray. Resident #1 was eating in his room alone. At 11:38 a.m. an unidentified female staff went into his room. The resident's plate had no food left. The staff lifted a utensil with the last bite of food for the resident to eat. The staff stated Resident #1 can eat on his own, but she will go in to help him because he made a mess. Resident #1 again had a regular plate. The staff stated the resident chose to eat with his hands. <BR/>During an interview on 04/11/24 at 2:40 p.m. the Dietary Manager (DM) stated she had a binder of forms with dietary preferences and allergies for some residents but not all. The DM stated if a resident had an allergy, nursing would notify them with a paper . The DM stated she did not have a form in her binder for Resident #1. The DM stated they were not aware of Resident #1's food allergy to mushrooms and the spaghetti did not have mushrooms in it. The DM stated the kitchen did not have any mushrooms in it and it had been a while since the kitchen had any mushrooms. The DM stated the facility had divided plates available. The DM stated Resident #1 was supposed to receive a divided plate and staff needed to pay attention to what the diet sheet showed the resident needed for adaptive equipment. The DM stated the divided plate was needed to help the resident get his food better. The DM stated the cooks had over cooked the bread and needed to pay attention because residents would not be able to eat hard bread especially if they are on a mechanical soft diet. The DM stated the gelatin snack was not made right and was too watery. The DM stated the cooks had substituted the cheesecake with the gelatin snack but the resident should not have been served the watery gelatin snack. <BR/>During an interview on 04/12/24 at 9:12 a.m. the Speech Therapist stated Resident #1 was evaluated in March. The SP stated she was working with the Resident due to history of stroke and he had dysphagia. The SP stated if Resident #1 was presented food he would not take it and preferred to eat with his hands. The SP stated in March she recommended Resident #1 eat in the dining room per her notes because he could not communicate to staff and in case of an emergency he needed to be with in sight. The SP stated she they attempted to take Resident #1 to the dining room for meals in March after her recommendation but the Resident had a panic attack. The SP stated her recommendations were given to the rehab director and to the DON. The SP stated the Resident should have a divided plate with meals and his cups should have plastic lids and a straw. The SP stated she did go in the room to assist the resident with meals because she also helped with other residents and could not always be in the room with him. <BR/>During an interview on 04/12/24 at 12:35 a.m. the DON stated the Rehab director would usually let them know what findings they had from an evaluation. The DON stated Resident #1 was supervised only for meals, he was able to feed himself, he could use utensils, staff would set the tray up uncover everything for him, give him the spoon, he would pick it up and feed himself, and she did not see him shake or have tremors. The DON stated they were notified Resident #1 needed to eat in the dining room for queuing (prompting to eat) and or if he dropped his silverware. The DON stated the resident was very contracted and he refused to go to the dining room because it was painful for him to move. The DON stated staff would set the resident up at 90 degrees in bed, would set up his tray, and would go in and out of his room to supervise him during meals in his room. The DON stated they did not document or care plan the resident's refusals to go to the dining room. The DON stated staff would attempt 3 times to get the resident up and then would notify the nurse if he refused. The DON stated the SP would go in the room to sit with the resident and help him eat. The DON stated she had not read the SP evaluation and plan of care for Resident #1. The DON read the POC and stated she did not agree that staff would not be able to assist the resident in an emergency because the staff was CPR certified and could also perform the Heimlich maneuver. The DON stated she had never been notified that the resident would cough or choke while eating and the SP should have reported this to nursing. <BR/>During a joint interview on 04/12/24 at 4:37 p.m. with Rehab director and SP stated it was the RD's responsibility to communicate any evaluations and recommendations at clinical meetings to the nursing staff. They stated they were unable to get the resident to the recommended barium swallow study because the residents refused cooperate. The SP stated the resident did not want to get into the wheelchair and he had no signs or symptoms of choking such as a pneumonia. The RD stated the evaluation was done in March of 2024 and since then the resident had progressed. The RD stated the resident did not need supervision with meals. The RD stated he would not get supervision from staff they would just check in on him when he ate. The RD stated the doctor signed the SP evaluation on 03/19/24 with no further recommendations. The RD stated she was never notified or told the resident was coughing while eating or choking.<BR/>Record review of the facility's policy titled 'Nutritional Recommendations, dated 12/2017, stated policy: it is the policy of this home that the deal in/ DON will address recommendations by the console dietitian within three working days, if possible, of the exit of the dietician consult. Procedure: 1. the consultation will complete the nutritional recommendation form and/ or enteral feeding recommendations, sign, and date. 2. The consult dietitian will discuss the recommendations and exit conference with the administrator, director of nursing, and dietary service manager for clarification. After completion of the discussion, each will sign the form. 3. The dietitian will keep one copy of the form and give the other copy to the director of nursing. 4. The director of nursing or designee will contact the physician for orders or denial of the recommendation. The director of nursing or designee will write the physician's response and date and the follow up section. A note should be made regarding the reason for refusal if the physician denies the recommendation. 5. when recommendations have been completed and follow up column filled in, the director of nursing gave a copy to the administrator and dietary service manager. 6. The director of nursing/ designee will write orders in the medical records to initiate the approval recommendations. 7. The [nursing/ dietary communication form] will be completed regarding any diet or supplement changes. The original copy will be placed in dietary section of the medical record and the copy will be given to the dietary. 8. On the console dietitian next visit, the completed recommendations will be reviewed, and if indicated, follow up will be made in the clinical software. 9. It is the administrator's responsibility to see that recommendations are addressed within three business days, if possible, of the consulting dietitians exit conference.<BR/>The Administrator was given the IJ template and was notified of the IJ on 4/12/24 at 6:19 PM and a POR was requested.<BR/>On 04/14/24 at 1:35 PM, the POR was accepted. It was documented as follows:<BR/>4/12/2024<BR/>Plan of Removal - F 689 <BR/>Immediate Action Taken <BR/>Resident Specific <BR/>Resident #1 will be supervised by staff during all 3 meals daily beginning on 4/12/2024 at 7:00 pm.<BR/>Resident #1 had the appropriate care plan updates completed on 4/13/2024 at 11:20 am.<BR/>System Changes<BR/>On 4/12/2024 at 7:00 pm a facility audit took place to ensure that all residents requiring supervision for meals will receive appropriate supervision.<BR/>On 4/12/2024 at 7:00 pm DON and therapy reviewed all residents who require supervision for meals have had their care plans audited to ensure that the care plans accurately reflect the residents need for supervision with meals. <BR/>Starting on 4/12/2024 and ongoing therapy will be present in morning meetings to ensure that all orders are communicated directly between nursing and therapy to ensure that residents requiring supervision with meals will have recommendations reviewed and carried out appropriately. <BR/>Starting on 4/12/2024 and ongoing the DON will monitor two meals daily x 5 days a week to ensure staff compliance with meal supervision for those residents requiring supervision. <BR/>Starting on 4/12/2024 and ongoing residents dietary and supervision statuses will be audited upon change of condition, appropriate MDS cycles or anytime necessary. <BR/>Starting 4/13/2024 at 11:00 am the facility's mechanism for ensuring correct diet texture for the residents is that all trays will be compared to the actual plated meal for the resident by a licensed staff member prior to being served to the resident. The meal ticket/diet order will be compared for accuracy.<BR/>Education <BR/>On 4/12/2024 at 7:00 pm the Assistant Director of Nursing provided education to all staff regarding residents needing to have supervision at meals to ensure those residents will be supervised at mealtimes. Staff on future shifts will be educated prior to taking the floor. This will be accomplished by having a designated staff member in the building for that purpose and with that specific assignment. Licensed staff will be assigned by the DON to ensure that all trays/plates are correct prior to being served to the residents. Diet orders will match correctly to what is being served to the residents. This assigned licensed staff member will ensure specifically that texture, larger utensils, cup covers etc are being utilized for the residents.<BR/>On 4/12/2024 at 7:00 pm the Regional Clinical Consultant provided education to Administrator and Director of Nursing regarding residents needing supervision for meals. <BR/>On 4/12/2024 at 7:15 pm the Regional Clinical Consultant will educate DOR and clinical team as to communication and follow up during morning meetings. <BR/>Starting on 4/12/2024 at 7:00 pm the regional clinical consultant will be responsible for ensuring that staff receive the in-service/training regarding residents needing supervision during meals.<BR/>Starting on 4/12/2024 the residents dietary and supervision status will be communicated to facility staff directly by the DON and ADON. This process will be accomplished through photocopy and written communication.<BR/>Starting on 4/12/2024 the DON will be responsible for ensuring that the residents who require supervision during meals receive supervision.<BR/>Starting on 4/12/2024 at 7:00 pm during the daily stand up process all recommendations and orders will be audited by the clinical team in consultation with the therapy team to ensure compliance and follow up for all residents with orders and recommendations. The clinical consultant will review orders and recommendations daily x 4 weeks as a tool for oversight to ensure compliance.<BR/>100% Staff education compliance of the above mentioned by noon 4/14/24.<BR/>Verification of Plan of Removal:<BR/>Confirmed via Observation of lunch and dinner meals on 04/13/2024.<BR/>Confirmed via Record Review of Resident #1's care plan . <BR/>Confirmed via Interview with Regional Clinical Consultant and DON. They each had a list of all staff with check marks. Interviewed about their process for identifying residents who needed supervision and how they ensured no one was falling through the cracks. Interviewed each independently and they both said they went through each clinical record looking at: therapy notes and recommendations, physician notes, POC notes from CNAs, progress notes from LVNs and RNs, MDS assessments, and care plans. <BR/>On 4/12/2024 at 7:00 pm DON and therapy reviewed all residents who require supervision for meals have had their care plans audited.<BR/>Confirmed via Interview with Dir of Rehab and DON.<BR/>Record review of the care plans for all eight of the residents (Resident #1 and additional seven who require assistance). Five care plans had been updated - edits were observed - and the updates clarified and added more specific language. For example, instead of saying supervision as needed the language was updated to read supervision at all times by nursing staff. The two that were not updated were already very precise and specific in their wording. <BR/>Confirmed via Interview with Dir of Rehab DON, and Administrator <BR/>Confirmed via Interview with DON.<BR/>Record review of chart of items to check for each resident identified and had filled in the chart for each meal served since IJ was called. <BR/>Confirmed via Interview with Regional Clinical Consultant, DON, MDS/Care Plan Coordinator, and Administrator. <BR/>There were 52 total staff members 41 of the 52 staff have received in-service. Interview in person or by phone with 32 of the 52 staff members and confirmed they received the trainings and could verbalize understanding of the training. Of the 11 staff who did not receive the training: 1 FMLA, 1 vacation, and 9 PRN. Observation of a sign on the time clock stated for staff not to clock in for shift until they received in-service trainings dated 04/12/2024. <BR/>Observation of both lunch and dinner service on 04/13/2024 revealed each meal had an assigned licensed nurse to check meal tickets against trays. Observation of weekend RN meal tickets and trays revealed checking tickets for 15 residents versus what they had been served were completed and all were correct. The DON stated she would personally check two meals per day M-F, and weekend RN would check all three weekend meals (The DON and weekend RN work 6 am to 6 pm ). <BR/>Observation of the residents who required assistance in dining hall revealed staff were treating them with dignity, their tickets and meals were correct, and assistive devices(e.g. divided plate, built up utensils) were in place. <BR/>Observation of Resident #1 dining in his room revealed his ticket and meal were correct, a divided plate was in place, covered cups in place, and a member of nursing staff was providing 1 on 1 supervision. <BR/>Interviews conducted on 4/13/24 from 3:42 p.m. to 7:45 p.m. and on 4/14/24 from 9:03 a.m. to 1:30 p.m. revealed there were 14 nurses on staff, and interviewed 12 of them and all have received the in-service trainings (more detail on trainings below). <BR/>Interviews conducted on 4/13/24 from 3:42 p.m. to 7:45 p.m. and on 4/14/24 from 9:03 a.m. to 1:30 p.m. revealed there are 17 CNAs on staff, 13 of them were interviewed and all received the in-service trainings.<BR/>Confirmed via Interview with Regional Clinical Consultant and Record Review of in-service training.<BR/>Confirmed via Interview with DON and with ADON.<BR/>Record review of the in-services. One of the in-services which was given to all nursing staff identified all eight residents who require supervision and/or assistance for dining. <BR/>Confirmed via Interview with DON.<BR/>Observation of lunch and dinner comparison of their care plans and meal tickets against the meal, assistive devices, and level of supervision for the eight residents who required assistance received during both lunch and dinner, revealed each was correct. <BR/>Confirmed via Interview with Regional Clinical Consultant and DON, MDS/Care Plan Coordinator, and Administrator. <BR/>During interviews staff confirmed abuse and neglect training was done in general and every staff member confirmed ANE trainings are provided at least monthly. <BR/>Regional Clinical Consultant confirmed via interview that she was personally ensuring that all staff received in-service trainings. She was onsite today and planned to stay to catch the oncoming night shift. She provided her documentation via a staff list with check offs. <BR/>An IJ was identified on 4/12/24. While the IJ was removed on 04/14/24, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 of 10 resident (Resident #6) reviewed for Diet Meets the Needs of Each Resident.The facility failed to ensure Resident #6 received the prescribed therapeutic diet.This failure could place residents at risk of their nutritional needs not being met. Findings included:Record review of Resident #6's admission record dated 11/19/2025 reflected a [AGE] year-old male who was admitted to the facility on [DATE].Resident #6 had a diagnoses of Acute Respiratory Failure with Hypoxia (low levels of oxygen in muscle tissues); Muscle Weakness (Generalized); Difficulty in Walking, Not Elsewhere Classified; Unspecified Lack of Coordination, Mild Intermittent Asthma, Uncomplicated; Pain in Right Shoulder; Age-related Osteoporosis without Current Pathological Fracture (progressive bone density loss in aging adults); Body Mass Index (BMI) 70 or greater; Morbid (Severe) Obesity due to excess calories; Post-traumatic Stress Disorder, Chronic; Bipolar Disorder, Current Episode Mixed, Moderate, and Major Depressive Disorder, Recurrent, Moderate.Resident #6's annual MDS dated [DATE] reflected Resident #6 had a BIMS score of 15 indicating he was cognitively intact.Record review of Resident #6's dietary orders dated 10/16/2024 reflected he was to receive a Regular diet; Regular texture, thin liquids; Double portions of protein at all meals and double portions of vegetables at lunch and dinner.An interview with the Ombudsman on 11/18/2025 at 4:36PM revealed Resident #6 had communicated with the Ombudsman concerning not receiving his prescribed meal portions. She stated Resident #6 had sent her several photos of his meal tray tickets and the accompanying meal. The Ombudsman stated in most of the photos, the tray tickets indicated Resident #6 was to receive double portions of protein at all meals and double portions of vegetables at lunch and dinner, but the accompanying photo of the meal tray did not depict portions prescribed by the physician.An interview with Resident #6 on 11/19/2025 at 1:50PM revealed Resident #6 was a Bariatric patient who weight approximately 559 pounds. Resident #6 was a good historian and produced several photos from an undetermined amount of time, that showed he had not received his prescribed diet. Resident #6 produced photos of the tray ticket from his lunch tray today and the accompanying entree. Photo #1 showed the tray ticket that was on the tray of food he received at lunch today. The tray ticket indicated he was allergic to fish and a tuna salad sandwich was on the menu. The substitution was a ham and cheese sandwich with French fries.The accompanying photo (photo #2) depicted the plate Resident #6 received, which consisted of 2 ham and cheese sandwiches and a serving of French fries. The prescribed double portion of protein was satisfied by the ham and cheese sandwiches, but the serving of French fries did not satisfy the double portion of vegetables which were prescribed.Photo #3 depicted the breakfast tray ticket from yesterday, 11/18/2025. The tray ticket showed Resident #6 should have received a 4-ounce glass of juice, 8 ounces of cereal of choice, 1 slice of bacon 8 ounces of scrambled eggs, 1 slice of bread of choice, 1 pat of margarine, 1 tablespoon of jelly, 8 ounces of milk and 8 ounces of another beverage of choice. The ticket showed Double Protein circled and the Resident's request for fried eggs.The accompanying photo (photo #4) depicted 1 serving of scrambled eggs, one slice of toast and one sausage patty. There was also a container of margarine on the tray. There was no cereal, juice, bacon, jelly, milk or another beverage.The text message that accompanied the photo of the breakfast place that was sent to this investigator by Resident #6 describe the following: Because of budget that are always running out of food, and you don't get your full meal. If you don't have family that can send you food, you're in bad shape. The facility gets paid to house, feed us and take care of our needs, but out of greed, the facility is trying to cut corners.Photo #5 showed the dinner tray ticket from 11/04/2025 which indicated Resident #6 should have received 3 ounces of glazed meatloaf, 4 ounces of roasted red potatoes, 4 ounces of green beans, a roll, margarine, a 4-ounce gelatin parfait and an 8-ounce beverage of choice. Again, Double Protein and Vegetables is circled on the ticket.The accompanying photo of the dinner plate Resident #6 received (photo #6) depicted 2 slices of meatloaf, 2 scoops of mashed potatoes with gravy and a serving of what appeared to be cooked red cabbage. Resident #6 also received vanilla pudding and iced tea. There were no red potatoes, green beans, roll or parfait on Resident #6's tray.An interview with the Dietary [NAME] on 11/20/2025 at 9:45AM revealed he did not think that French fries or mashed potatoes qualified as a vegetable. He stated both are starches. He also stated residents could receive fried eggs, if requested.An interview with the Administrator and DON on 11/20/2025 at 9:52AM revealed the Administrator and DON did not think French fries or mashed potatoes were considered vegetables. The Administrator stated residents could have eggs prepared however they pleased, but there were no fresh eggs in the kitchen, due to the new management company did not allow fresh eggs to be served. The Administrator stated she would have to contact the corporate office to get a list of vegetables that could be served.Record review of the facility's Dining Master list of foods did not indicate what foods were considered to be vegetables, rather it showed serving sizes for various vegetables.Observation of the kitchen and the refrigerators on 11/21/2025 at 9:30AM reflected the following:7 heads of Romaine lettuce1 partial 10-pound box of fresh onions, and1 partial 10-pound box of fresh tomatoesObservation of the freezer reflected the following:(2) 2-pound bags of frozen green beans1 partial 20-pound box of frozen cut carrots, and1 partial 20-pound box of frozen Capri blend vegetables.There were no fresh fruit or eggs.An interview with the Dietary Manager on 11/21/2025 at 9:42AM revealed the new management company had cut her food budget and she did not have enough money to purchase fresh items for the residents. She stated 6 heads of lettuce from their distributer cost $30 and she used to get an entire case of lettuce for that price. She stated she had spoken with the management team regarding the issue, but they were not concerned about the residents receiving fresh food. She stated, If my residents want something I should be able to give it to them. It breaks my heart to not be able to give them what they want. She stated she used to be able to offer a hamburger/cheeseburger plate and/or a chef salad as an alternative choice but had been told both were too expensive and would not be provided. She also stated there often was not enough food to provide what would be considered to be a double portion of food, as she was only allowed to cook for the number of residents in the building. She stated this number did not consider second helpings or double portions. If the recipe stated it was 50 servings, that was all she was allowed to prepare.Review of facility policy Therapeutic Diets dated 04/2021 reflected the following:Policy Statement:Therapeutic diets are an integral part of resident well-being and nutrition and shall be served accordingly.Policy Interpretation and Implementation: The Physician shall give an order for all therapeutic diets served to residents. Physician orders shall be followed without exception.a. Substitutions can be made for resident allergies and preference according to the physician's order and review from the registered dietician. The facility will provide all necessary food to fulfill the physician's order, including protein shakes and fortified foodsThe registered dietician could not be reached for comment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the discharge of Resident #1 was documented in the EMR for one resident (#1) of four residents reviewed for discharge.<BR/>The facility failed to provide Resident #1 with a 30-day discharge notice when he was sent to the hospital for a change in condition and the facility refused to take him back. Documentation of discharge was not present in Resident #1's EMR to include physician's orders or a discharge summary.<BR/>This failure could affect residents who go to the hospital for a change in condition and result in an unsafe discharge.<BR/>The findings included:<BR/>Record review of Resident #1's electronic face sheet dated 06/25/2025 reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: Pressure ulcer (a localized injury to the skin and underlying tissue) of other cite, unstageable (depth of wound could not be determined), neurogenic bladder (condition where nerve damage disrupts the normal function of the bladder), neurogenic bowel (condition where nerve damage disrupts the normal function of the bowel), constipation, a (infrequent bowel movements or difficulty passing stools) and quadriplegia (paralysis and/or weakness affecting all four limbs). <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected he scored a fifteen out of fifteen on his BIMS which indicated he was cognitively intact. He could understand and be understood. He had a suprapubic urinary catheter (tube inserted through a small incision in the abdomen, just above the pubic bone to drain urine from the bladder) and was always incontinent of bowel. He had a Stage 4 pressure ulcer to his sacrum (wound is deep and severe, extending beyond skin and fat layers to expose muscle, tendon, or bone). <BR/>Review of Resident #1's care planning notes dated 04/29/2025 reflected he had a care plan conference which addressed he refused and was non-compliant with following MD orders/recommendations i.e.: repositioning, and lying down to relieve pressure from wounds, resident likes to sit up in his wheelchair for long periods of time. <BR/>Record review of Resident #1's comprehensive care plan reflected start date, 11/06/24, revised 3/24/25, category Behaviors. Non-compliant with smoking policy and procedures. <BR/>Record review of Resident #1's comprehensive care plan revised date of 03/24/25 reflected discharge planning: Return to Community Referral desires to transition to community or another nursing facility. Long Term Goal Target Date: 06/11/2025, Approach, assist with discharge planning needs to include coordination of HH, PCP follow up and DME needs. <BR/>Record review of Resident #1's change in condition Observation Detail List Report dated 06/06/2025 reflected Resident #1 was discharged , Resident requesting to go to ER due to him not feeling well, per family wanting him to go and get checked out, family at bedside, vitals with normal range.<BR/>Record review of Resident #1's EMR on 06/25/2025 reflected there were no discharge orders or discharge summary for 06/06/2025. The facility provided the surveyor with a discharge order and summary dated 06/26/2025.<BR/>Record review of Resident #1's hospital review of his encounter in the ER dated 06/06/2025 reflected Social History: Reports that he has never smoked. He has never used smokeless tobacco. He reports that he does not currently use alcohol. He reports current drug use. Frequency: twenty times per week. Drug: Marijuana.<BR/>During an interview on 06/23/2025 at 4:00 pm with Resident #1 via telephone, he stated he was in the hospital and made a statement about using marijuana, but it was not true, and the facility refused to take him back which impacted his ability to go across the street and pick up his son from school, and there was not many facilities that would do rectal stimulation, which is a part of care he needed.<BR/>During an interview on 06/25/2025 at 08:28 am with Regional Consultant RN A, she stated Resident #1 was non-compliant with his wound care and does not off load to get pressure off from his bottom and he missed appointments with the wound care doctor. She stated there was suspicion of drug use, and he would leave the facility and return at 3 am. She stated there was concern Resident #1 was selling drugs outside the facility but there was no evidence. She stated there was drug paraphernalia found in his room. She stated, the Administrator, DON and SW decided it was a big liability for the facility, and when his paperwork from the hospital showed he smoked marijuana daily the decision was made to take a citation instead of having him come back. Resident #1 was considered a risk and an endangerment to others. She stated Resident #1 was on psychoactive medications. <BR/>During an interview on 06/25/2025 at 2:26 pm with Dr. B, who was Resident #1's physician and the Medical Director for the facility stated Resident #1's drug use was highly suspicious, and he would have conversations with the resident about his narcotics. He supported the facility's decision not to readmit Resident #1. He stated he was not aware at the time Resident #1 was discharged , but knew he was sent out for a change in condition.<BR/>During an interview on 06/26/2025 at 10:44 am with the SW, he stated he had worked at the facility for almost one month and did not know Resident #1 well but supported the decision of not taking the resident back based on his behaviors and suspected drug use.<BR/>During an interview on 06/26/2025 at 1:16 pm with the DON, she stated the facility received information from the hospital that Resident #1 smoked marijuana about twenty times a week. She stated he was young, and it would be difficult to ensure his safety since he was on narcotics for pain and used an electric wheelchair. She stated she was a new DON and did not realize a discharge order nor summary was done for Resident #1. She stated after the decision not to readmit Resident #1; it was not well communicated. She stated a smooth discharge process for a resident was essential to provide safety and necessary care.<BR/>During an interview on 06/26/2025 at 2:00 pm with the Administrator, she stated when the hospital reported Resident #1 was smoking marijuana, she and the DON decided it was a safety risk to other residents. She stated she was aware he refused much of his care and was not in the building. <BR/>Record review of the facility Nursing Policy and Procedure, titled Discharge-Transfer of the Resident dated 10-2020 reflected It is the policy of this home that residents and/or responsible parties will be notified prior to transfer or discharge. discharged residents will have documentation related to discharge or transfer in clinical software., the attending physician is required to write a discharge order, discharge summary completed by DON/designee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 1 of 3 Residents (Resident #1) reviewed for injuries of unknown origin, in that:<BR/>The facility discovered an injury of unknown origin for Resident #1 and did not report the injury of unknown origin to the abuse, neglect, exploitation coordinator, the Administrator, and/or the state agency.<BR/>This failure could place residents at risk for further abuse, neglect, exploitation, and/or injuries of unknown origin. <BR/>The findings included :<BR/>A record review of Resident #1's face sheet, dated 03/07/2023, revealed an admission date of 12/29/2023 with diagnoses which included dependence on renal dialysis [a blood purifying treatment given when kidney function is not optimum], end stage renal disease [a term for any condition that damages the kidneys, the organs that filter waste and excess fluid from the blood], morbid severe obesity, and chronic pain. <BR/>A record review of Resident #1's re-entry MDS , dated 01/16/2023, revealed Resident #1 was a [AGE] year-old female who was diagnosed as medically complex. Resident #1 was assessed as a severely morbidly obese person who was non-ambulatory, bedfast, chairfast, and needed assistance with transfers and required dialysis services. Resident #1 was assessed with a Brief Interview for Mental Status with a score of 15 out of 15 indicating no mental cognition impairment. <BR/>A record review of Resident #1's care plan, dated 03/07/2023, revealed, Resident #1 needs dialysis .encourage Resident to go to dialysis appointments .transport to [dialysis facility] every Monday, Wednesday, Friday with [name of transport contractor], pick up time 1315 [01:15 PM] in wheelchair with Hoyer sling under [a Hoyer lift is a hydraulic lift device which uses a sling for caregivers that transition those with limited mobility to or from a chair, bed, toilet, or a standing position].<BR/>A record review of Resident #1's nursing progress notes revealed a note, dated 01/08/2023, authored by LVN A, resident gets anxious at times, making moaning noises when sleeping. this nurse went to check on her and ask if she is OK. resident verbalized she is OK and wanted pain medicine for her legs. pain medicine given; we'll continue to monitor for any changes.<BR/>A record review of Resident #1's nursing progress notes revealed a note, dated 01/09/2023, authored by LVN B, CNA noted to this nurse large open area with some bleeding. Upon assessment, noted type 2 skin tear 11.5 centimeters by 11.0 centimeters partial flap intact, with scant sanguineous drainage. Patient has no complaint of pain and is not sure what happened. Due to inclusion of open areas in intergluteal cleft, treatment to be close monitoring and use of barrier cream. At the time dialysis transport arrives they tell staff the resident had slid down in wheelchair on return from dialysis. [on Friday 01/06/2023].<BR/>A record review of Resident #1's skin integrity event document, dated 01/09/2023, authored by LVN B, revealed new physician's orders for barrier cream and skin tear monitoring for signs and symptoms of infection every shift until healed. <BR/>A record review of Resident #1's nursing progress notes revealed a note, dated 01/10/2023, authored by ex-DON, Spoke with [name of transport contractors office personnel] at [name of transport contractor] requested the dialysis transport be changed from wheelchair to stretcher van starting tomorrow. She was able to make that change.<BR/>During an interview on 03/07/2023 at 02:06 PM, Resident #1's Family Member stated Resident #1 was dropped on the floor, neglected, and declined in health. Resident #1's Family Member could not recall any specific dates and or times for the allegations made. <BR/>During an interview on 03/07/2023 at 04:00 PM, the ADON stated she was not sure of exact details but believed Resident #1 has slid out of her wheelchair during a return transport from dialysis. The ADON stated LVN A, on 01/08/2023, discovered Resident #1 had an injury to her lower back, did not report the incident to the physician, did not document the skin tear injury, but did call the wound care nurse, LVN B, and gave a report. The ADON stated LVN B assessed Resident #1 on 01/09/2023 and gave a report to the physician and received new orders for Resident #1's wound care. The ADON stated LVN B did not document the details of the report given to the doctor in Resident #1's nursing progress notes. The ADON stated the facility currently has a new adjunct DON and at the time of Resident #1's discovered skin-tear the DON was the ex-DON. <BR/>During an interview on 03/08/2023 at 1:00 PM, LVN A stated she assessed Resident #1 on 01/08/2023 for pain and discovered Resident #1 had a large skin tear and could not assess how the injury occurred. Resident #1 could not state how she received the injury. LVN A medicated Resident #1 for pain, but had not documented the skin injury discovery and supporting details in Resident #1's medical record. LVN A stated she had not called the physician to give a report. LVN A stated she did not give a report to the DON or the Administrator. LVN A stated she did not recognize the injury of unknown origin, where there were no witnesses, and the Resident could not explain the injury was an allegation of abuse and/or neglect and should be reported to the Administrator. LVN A stated she had received training for abuse, neglect, and exploitation prevention but still failed to recognize Resident #1's unwitnessed, unexplainable, skin injury was a reportable discovery. LVN A stated she understands she should have recognized the injury of unknown origin with Resident #1 inability to give an account for the injury, and reported the injury of unknown origin to the Administrator. <BR/>During an interview on 03/08/2023 the adjunct DON stated she had researched the incident where, on Friday, 01/06/2023, Resident #1 received a skin tear during a return trip from dialysis, via the facility's transportation contractor, where the van driver suddenly came to an abrupt stop, causing Resident #1 to slide down out of her wheelchair. The adjunct DON stated the transportation contractor's driver did not report the incident to anyone until Monday 01/09/2023, when he was questioned by the ex-DON. The driver stated Resident #1 slid out of the wheelchair upon arrival to the facility. The adjunct DON stated the ex-DON did not report the allegation of abuse/neglect to the Administrator and/or the state agency. The adjunct DON stated the expectation is for all staff that have a suspicion of abuse, neglect, exploitation, mistreatment, and injuries of unknown origin are to immediately report the suspicion to the Administrator and to the state agency. The adjunct DON stated the ex-DON was responsible for the failure of not reporting the suspicion of abuse and/or neglect, and as the DON the ex-DON was responsible to review all incidents and at a minimum should have recognized the injury of unknown origin, without Resident #1's ability to give an account for the injury, as a reportable incident and should have at a minimum given the Administrator a report. The adjunct DON stated the failure could have placed residents at risk for further abuse and/or neglect to include injuries. <BR/>During an interview on 03/08/2023 at 5:00 PM, the Administrator stated he was not aware of the incident on 01/06/2023 where Resident #1 slid out of her wheelchair while being transported by the transportation contractor from Resident #1's dialysis appointment. The Administrator stated the ex-DON did not provide a report or document the details of the incident. The Administrator stated the expectation was for the ex-DON to immediately report the injury and to provide sufficient documentation to support Resident #1's needs for care and safety. the Administrator stated LVN A, LVN B, and the ex-DON all had abuse, neglect, and exploitation, prevention training; all had knowledge of Resident #1's injury of unknown origin, and still no one reported the injury to me [the Administrator]. <BR/>Record review of the facility's Abuse / Reportable Events policy, dated 01/10/2017, revealed, All residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation .the facility will provide and ensure the promotion and protection of resident rights . it is everyone's responsibility to recognize, report, and promptly investigate actual or alleged abuse neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility . injury of unknown source, any injury to a resident where; the source of the injury was not observed by any person or the source of the injury could not be explained by the Resident; and the injury is suspicious because of the extent of the injury or the location of the injury for example the injury is located in an area not generally vulnerable to trauma or the number of injuries observed at one particular point in time or the incidence of injuries overtime .facility employees must report all allegations of; abuse, neglect, exploitation, mistreatment of residents, misappropriation of residence property or injury of unknown source to the facility Administrator. The facility administrator or designee will report the allegation to HHSC.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide evidence that all alleged violations of neglect, abuse, misappropriation of property were thoroughly investigated in order to prevent further potential neglect, abuse, misappropriation while the investigation was in progress for 1 of 6 resident (Resident #1) reviewed for neglect, in that:<BR/>The facility did not thoroughly investigate an incident that Resident #1 choked and died after receiving routine medications. <BR/>This deficient practice could place residents at risk for harm to include death.<BR/>The findings were: <BR/>Record review of facility's Abuse/Reportable Events policy dated [DATE] read: .Neglect: is the failure of the facility .to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .Investigation: Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated . <BR/>Record review of Resident #1's Nurse note dated [DATE] revealed: resident was re-admitted to the facility for long term care directly from a local hospital. Hospital diagnoses included: advanced dementia, depression, altered mental state, and a subdural hematoma (bleeding in the brain).<BR/>Record review of Resident#1's face sheet, dated [DATE], and EMR (electronic medical record) revealed, the resident was admitted on [DATE] with diagnoses that included: traumatic subdural hemorrhage (brain bleed-primary), pneumonia (acquired at the facility on [DATE]) and dementia. Resident was a female; age [AGE]. Advanced Directive was DNR (do not resuscitate). RP (responsible party) was listed as: a family member.<BR/>Record review of Resident# 1's Care Plan, dated [DATE], revealed goals and interventions that included: Pneumonia. Interventions included: monitor for signs of symptoms of pneumonia. Another goal was administration of psychotropic drugs. Interventions included: behavior management.<BR/>Record review of Resident#1's admission MDS (minimum data set), dated [DATE], revealed: <BR/> BIMS (brief interview of mental status) Score was 2 (meaning the resident had severe impairments in cognition). The Resident's ADLs (activities of daily living) revealed: resident was incontinent of bowel and bladder. The resident required assistance with transfer by one staff; and bed mobility required two staff assistance. The resident had no range of motion impairment. <BR/>Record review of Resident #1's Dietary Flow Sheet revealed a diet order with a start date of [DATE] and an end date of [DATE] for a diet order being regular and thin liquids. <BR/>Record review of Resident#1's MAR (medication administration record), dated [DATE], revealed, the resident received the following medications prior to the choking incident:<BR/>*Vitamin C 500 mg daily<BR/>*Divalproex 500 mg daily (for seizures)<BR/>*Folic acid 1 mg (vitamin)<BR/>*Multi-vitamin 0.4 mg daily<BR/>*Wellbutrin (for depression) 150 mg daily <BR/>Record review of Resident#1's Nurse Note, dated [DATE], authored by Nurse B, read: <BR/>at 0705 [7:05 AM] this nurse raises HOB {Head of bed board} and gives pt [patient] water using straw, when pt ready admin meds [medications] po [by mouth] individually, pt sipping between meds. Pt takes meds then nods when asked if would like more water, pt finishes water quickly and at 0712 [7:12 AM] pt sputters water from mouth, pt noted with tongue thrusting, this nurse laid HOB flat rolled pt to L [left] side and cleared water, pt cont [continued]with tongue thrusting, called to LVN [Nurse C] for assistance came to room assist with positioning abd [abdominal] thrust and back thrusting. 0715 [7:15 AM] LVN activate 911, sx [crash cart/suctioning] machine retrieved by this nurse. Additional airway clearing by resident at 0720 [7:20 AM], pulse is weakly noted by LVN, sent RN supervisor to door to allow access for EMS. SX cleared some med residual that had been coughed out, pt lips noted blue tinged with no reading from pulse . 0725 [7:25 AM] EMS arrives sets up leads, 0729 [7:29 AM] SAFD Doc [physician] called with TOD [time of death] 0729 [7:29 AM] . <BR/>Record review of resident #1's SBAR dated [DATE], authored by Nurse B, read: sputters water, tongue thrusting at 7:12 AM.<BR/>Record review of Resident #1's DNR was dated [DATE], signed by MD and witnessed; and signed by RP. <BR/>During an interview on [DATE] at 3:33 PM, Nurse A stated: they read in the progress notes and Nurse D said that Resident #1 was deceased due to choking on pills after the resident was given medications by Nurse B. Nurse A stated that Heimlich maneuver was attempted by Nurse B and Nurse C but with no success. [Nurse A had no knowledge as to whether the facility investigated the choking death of Resident #1.] <BR/>During an interview on [DATE] at 3:49 PM, the Administrator stated: he did not know what caused Resident #1 to die on [DATE]. The Administrator trusted the information given to him by nurse management (DON) that the death was no suspicious. Therefore, the Administrator stated he did not investigate the incident; and did not report the death to HHS. The Administrator added that the facility did contact law enforcement on [DATE]; and law enforcement released the resident's body back to the facility. <BR/>During an interview on [DATE] at 5:02 PM, Nurse B stated: . I went in at 7:05 AM on [DATE] ; placed the head of the bed at 50 degrees; gave her (Resident #1) the pills in a med cup ; and gave her water with the straw in a cup; she took the medicine; I asked whether she wanted more water; she started sputtering and then water came out of her mouth; tongue started thrusting out of the mouth .I put the bed flat and she started coughing .I called for help .[Nurse C] came in and we attempted abdominal thrust [which was a modified Heimlich maneuver] . I got the crash cart and [Nurse C] was calling 911 (7:15 AM) .we always maintained observation of the resident .I was setting up the suction machine in the room and EMS arrived at 7:25 AM .they hooked resident to the EKG .I gave them the out-hospital DNR form .resident was no incubated .MD called and resident pronounced deceased by MD (Fire Department) .RP and facility MD called .cause of death was unknown .medication did not require crushing or to be put in a liquid form .I gave her one pill at a time .she got all the pills down .7:12 AM was when the resident started sputtering .DON notified .incident was spontaneous .Fire Department called Law Enforcement . Homicide Unit investigated (Case #2309920)- .Homicide Unit did not suspect that a crime was committed and the resident was released to the funeral home. Nurse B stated the Administrator and DON did not submit a self-report to HHS. Nurse B stated that Resident #1 did not have a history of aspiration. CPR was not done by nursing staff because the resident was DNR. Nurse B stated that she gave a verbal accounting of the incident to Nurse D and the DON; and documented the timeline in a nurse note dated [DATE]. [Nurse B had no knowledge as to whether the facility investigated the choking death of Resident #1.] <BR/>During an interview on [DATE] at 5:28 PM, Nurse C stated: I arrived around 7:10 AM and at 7:15 AM called 911 .because the resident was turning blue .resident was DNR .I started a modified Heimlich (pushing down on the stomach) .putting pressure on the abdomen in upward .she [Resident #1] would spit up water .once the suctioning machine arrived we hooked her up and started suctioning her month and was able to clear one pill. Nurse C did not know how many pills were given to the resident. Nurse B got a copy of the out-of- hospital DNR for EMS. Nurse B she took over the suctioning while Nurse C listened for a heartbeat and heard none and then EMS arrived around at 7:25 AM. The resident was pronounced at 7:27 by the Fire Department physician. Nurse C commented that Law Enforcement and the Homicide Unit arrived and conducted a brief investigation and released the body to the facility. Nurse C expressed the opinion that there might have been a delay in starting the Heimlich maneuver when the resident was choking [ 7:12 AM to 7:13 AM]. Nurse C added that the Resident (#1) had no history of aspiration or choking. [Nurse C had no knowledge as to whether the facility investigated the choking death of Resident #1.]<BR/>During an interview on [DATE] at 8:26 AM, Nurse B stated: the timeline of the incident on [DATE] involving the choking death of Resident #1 was as follows:<BR/>*7:05 AM-entered residence's room to dispense medications<BR/>*7:12 AM-Resident #1 started spurting. Nurse B laid resident flat in bed, turned resident to the side, and started back trusts (striking resident on the back). Called for help.<BR/>*7:13 AM- Nurse C arrived in the room and started abdominal trusts (modified Heimlich maneuver)<BR/>*7:15 AM- Nurse C called 911<BR/>*7:15 AM- Nurse B left to get the crash cart<BR/>*7:17 AM-crash cart present and suctioning started<BR/>*7:20 AM-low pulse and resident turning blue<BR/>*7:25 AM- EMS arrived<BR/>*7:27 AM-Resident #1 pronounced deceased by Fire Department MD<BR/> Regarding the 7-minute gap between 7:05 AM to 7:12 AM, Nurse B stated, they dispensed the medication slowly to the Resident (#1) so as to allow the resident to drink between each pill given. Nurse B stated that the choking incident started at 7:12 AM and not sooner.<BR/>During an interview on [DATE] at 8:40 AM, Nurse C stated (regarding the timeline).<BR/>*At 7:13 AM- [Resident #1 started spurting water and was choking. Nurse B laid the resident flat in bed, turned the resident to the side, and started back trusts (striking resident on the back. Nurse B Called for help.) Nurse C saw the resident flat in bed to the side when they arrived at 7:13 AM. Nurse C restated, . she (resident #1) was choking when I entered the room .<BR/>During an interview on [DATE] at 9:15 AM facility MD stated: putting Resident #1 on the side was appropriate and a safe position. It was a stressful situation and Nurse (B) did her best .in hindsight starting the Heimlich sooner might have been another intervention .but Nurse (B) did call for help . The facility MD added that doing a modified Heimlich early in a crisis does not necessarily result in the resident not choking and not dying. Likewise, in a crisis, the intervention by another professional staff helps in the assessment of the resident and what further interventions are needed. Facility MD said the nurses [Nurse B and Nurse C] did the right procedures and CPR was never given because the Resident was DNR. In the crisis, the facility MD stated, the nurses attempted different interventions; and the resident had symptoms of choking and was alive for a period of time. EMS was also guiding the nurses (Nurse B and C) before their arrival. The facility MD saw no neglect in the tragic death of Resident #1. [The facility MD had no knowledge as to whether the facility investigated of the incident.] <BR/>During an interview on [DATE] at 9:43 AM, The DON stated: an investigation was not done because the facts were known and the death was not suspicious. HHS was not contacted because the death was not suspicious. Nursing staff performed as they were trained and in-serviced, according to the DON. <BR/>During an interview on [DATE] at 9:52 AM, the Administrator stated: there was no suspicion regarding the death of the resident and therefore no need to investigate or to report to the state (HHS). The Administrator relied on the nursing staff for guidance on whether to investigate and to report to HHS. As stated by the Administrator, I did not suspect neglect existed in the death of Resident (#1). The Administrator stated that law enforcement was called and the Homicide Unit released the body of Resident #1 back to the facility. The Administrator did not report the unexpected death of Resident #1 from choking on routine medications because there was no neglect. However, the Administrator was not certain of the timeline involving the choking and nursing interventions given. He and the DON did not conduct a formal investigation and document their findings.<BR/>Record review of facility's Incident Log from March-[DATE] revealed, the medication choking incident on [DATE] involving Resident #1 was not recorded or investigated. <BR/>Record review of facility's Heimlich Maneuver policy dated 12/2017 read: Resident becomes unconscious .Position resident on back, face up, and delegate a person to call 911 .Give 4 abdominal thrusts as described for resident lying down .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident had a right to a safe, clean, comfortable, and homelike environment for 1 (Resident #1 room) of 4 resident reviewed for resident rights, in that: <BR/>A pile of yellow liquid was seen on the restroom floor of Resident #1's room.<BR/>This failure could result in physical and psychosocial harm due to diminished quality of life and increased risk for falls. <BR/>The findings were:<BR/>Record review of Resident #1's face sheet, dated 04/06/23, noted the resident was admitted to the facility on [DATE] with diagnoses including: Depression, Anxiety, Tremor, Lack of Coordination, Type 2 Diabetes Mellitus, Hyperlipidemia, Chronic Obstructive Pulmonary Disease (a lung disease that blocks airflow and makes it difficult to breath), Cognitive Communication Deficit (difficult with communication caused by an impairment in cognitive processes), Unsteadiness on Feet, Paranoid Schizophrenia, Seizures, and Abnormalities of Gait and Mobility. <BR/>Record review of Resident #1's Quarterly MDS assessment, dated 12/23/24, noted a BIMS score of 08 which indicated moderate cognitive impairment. <BR/>Record review of Resident #1's care plan, dated 01/13/25, noted Resident #1 exhibits functional bowel/bladder incontinence, with a goal, Resident #1 will be free from complications related to bowel incontinence through the review date. Approaches included Check resident frequently and assist with toileting, incontinent, and pericare needs as needed and to Provide loose fitting, easy to remove clothing and to Provide pericare after each incontinent episode. The care plan further noted Resident #1 is at risk for falling R/T unsteady gait. Approaches included Assure the floor is free of glare, liquids, foreign objects. and staff tor perform frequent housekeeping rounds.<BR/>Observation on 01/22/25 at 11:10 AM revealed the presence of a pile of yellow liquid on the floor of the bathroom. A foul odor was noted in the room, and the floor of the room was sticky underfoot.<BR/>During an interview with LVN A on 01/22/25 at 11:10 AM, when asked what was on the floor of Resident 1's bathroom, LVN A stated it looked like urine. When asked what could happen if urine was on the floor, LVN A stated a resident could slip and fall and get a fracture. <BR/>During an interview the DON, on 1/23/25 at 2:15 PM, the DON stated the facility uses the TAC Chapter 554, Subchapter R, Rule 554.1701 as their policy for homelike environment.<BR/>During an interview with the Regional Consultant Nurse on 1/23/25 at 3:24 PM, the Regional Consultant Nurse stated the facility used the TAC Chapter 554, Subchapter R, Rule 554.1701 as their policy for homelike environment.<BR/>Record review of the TAC Chapter 554, Subchapter R, Rule 554.1701 on 1/23/25 at 2:15 PM noted The facility must be designed, constructed, equipped, and maintained to protect the health and ensure the safety of residents, personnel, and the public. The TAC further states Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents had the right to be informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options for 1 of 6 residents (Resident #39) reviewed for informed consent.The facility failed to ensure a psychotropic medication consent was included in the medical record for Resident #39's Olanzepine (an atypical antipsychotic medication).This failure could place residents at risk of receiving care/treatment without consent and knowledge of adverse side effects.The findings included:<BR/> Review of Resident #39&rsquo;s face sheet with an original date of 12/23/24 and a readmission date of 4/2/25, documented a [AGE] year-old female with diagnoses including Type 2 Diabetes Mellitus, Paranoid Schizophrenia (a mental health disorder that affects how a person thinks, feels, and behaves with symptoms that include delusions and auditory hallucinations), and Celiac Disease (a disorder that causes a reaction in your body to the protein, gluten which damages your small intestine and stops it from working properly).<BR/> Review of Resident #39&rsquo;s most recent quarterly MDS assessment dated [DATE] documented a BIMS of 6 indicating severe cognitive impairment; a diagnosis of schizophrenia; and the use of an antipsychotic medication.<BR/>Review of Resident #39&rsquo;s care plan dated 6/24/25 documented antipsychotic medication usage with interventions including &ldquo;AIMS every as ordered; Monitor resident&rsquo;s behavior and response to medication; Pharmacy consultant review.&rdquo;<BR/>Review of Resident #39&rsquo;s electronic medical record documented an order for the antipsychotic medication Olanzepine 10mg daily with a start date of 1/20/25.<BR/>Review of Resident #39&rsquo;s progress note initiated on 7/22/25 at 3:00 PM documented &ldquo;Call placed to [local/contracted psychiatry agency] in regard to 3713 consents for Olanzepine 10mg.&rdquo; and &ldquo;Currently awaiting consent form to be sent. Plan of care to continue.&rdquo;<BR/>Review of Resident #39's electronic medical record revealed there was no informed consent found for the use of the antipsychotic Olanzepine 10mg QD.<BR/>During an interview with the MDS Coordinator on 7/22/25 at 2:42 PM, the MDS Coordinator stated if a resident has a consent form for a psychotropic medication it would be found under the psychotropic consents tab in a resident&rsquo;s documents section of the EMR.<BR/>During an interview with the DON on 7/24/25 at 9:23 AM, the DON stated there is no specific staff member in charge of obtaining consents for psychotropic medications. The DON stated when a consent is needed for psychotropic medications, the facility will speak to the responsible party and provide them information on the medication including side effects and any other information. The DON stated if consent is granted, they get a verbal consent or written signature on the consent form. The DON stated it was important to get psychotropic medication consents signed quickly, so residents can be aware of what they are taking and how it can affect them.<BR/> During an interview with the Administrator on 7/24/25 at 9:54 AM, the Administrator stated the nursing staff is primarily responsible for obtaining psychotropic medication consents, and the social worker will sometimes help with those consents. When asked what her expectation is of the timeline for getting psychotropic medication consents, the Administrator stated as soon as possible, within the first few days of admissions. The Administrator stated for any changes to medications, her expectation is for staff to get the consents quickly, within a few days of the change. When discussing the importance of getting psychotropic medication consents signed as soon as possible, the Administrator stated without a signed consent, the facility is unable to give a medication and a breakdown in care could occur for the resident. The Administrator further stated the consent aides the resident in understanding what a medication is for, why they are taking it, and how it can affect them. <BR/>Review of the facility&rsquo;s policy titled Statement of Resident Rights, undated, noted &ldquo;You have a right to: (23) receive information about prescribed psychoactive medication from the person who prescribes the medication or that person's designee, to have any psychoactive medications prescribed and administered in a responsible manner, as mandated by the Texas Health and Safety Code, &sect;242.505, and to refuse to consent to the prescription of psychoactive medications.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 4 residents (Resident #1) reviewed for adequate supervision in that: <BR/>The facility failed to ensure Resident #1 received supervision during mealtimes to prevent choking or aspiration. <BR/>An IJ was identified on 4/12/24. The IJ template was provided to the facility on [DATE] at 6:19 PM. While the IJ was removed on 04/14/24 the facility remained out of compliance at a scope of isolated with a severity of potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>This failure could place residents at risk of choking, weight loss, decline in health, and death. <BR/>The findings included: <BR/>Record review of Resident #1's face sheet dated 4/10/24 revealed a [AGE] year-old male, admitted on [DATE] and readmitted on [DATE] with diagnoses of seizures, cerebrovascular disease, aphasia following cerebral infarction (a person may be unable to comprehend or unable to formulate language because of damage to specific brain regions), contracture right elbow (shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement), contracture right wrist, hemiplegia (weakness of one entire side of the body) and hemiparesis (complete paralysis of half of the body). The facesheet stated Resident #1 was allergic to morphine, mushrooms, and penicillins. <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was severely impaired for daily decision making, dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with ADLs in the areas of eating and drinking, and was on a mechanically altered diet. <BR/>Record review of Resident #1's comprehensive person-centered care plan, dated 02/20/24, revealed the resident's interventions for ADLs included REQUIRED***EATING: Resident requires set up assist. Resident #1 had unplanned/unexpected weight loss with interventions for ice cream as ordered, monitor and record food intake at each meal, notify the dietician of the weight loss upon their next visit, notify the physician, resident and family of the weight loss, provide verbal assistance and cues during meals, weigh the resident weekly for at least 4 weeks or until weight has stabilized. <BR/>Record review of Resident#1's Physician Order, dated 01/18/24 revealed an order for diet-regular, mechanical soft, and thin fluids. Special instructions FMP to all meals. Divided plate for every meal. The order was signed on 02/01/24 by the physician.<BR/>Record review of a nursing progress note, dated 02/12/2024, stated Patient eating breakfast and begins coughing episode directly after eating. Patient airway patent upon assessment. Patient sitting upright in bed, call light with reach. NP notified RP, MD and staff nurse. <BR/>Record review of document titled Speech Therapy Plan of Care - 03/13/2024, dated 03/13/2024, revealed profound language impairments and mild pharyngeal swallow function impairments (71-85% ability). Section titled Underlying Impairments listed Verbal Expression- Automatic speech severe impairment, Auditory Comprehension- 1 step commands severe impairment, Auditory Comprehension- wh questions- Severe Impairment, and Pharyngeal Swallow Deficits- after swallow. The reasons for referral were without therapeutic intervention patient at risk for: choking, aspiration, weight loss, inability to meet nutritional needs via PO intake of least restrictive diet .Bedside Swallowing Assessment .Pharyngeal phase: Patient demonstrated no signs or symptoms of aspiration during meal or when drinking . Patient demonstrated strong reflexive coughing episode &gt; 10 minutes after last PO intake with face reddening/eye tearing, suspected aspiration/penetration of secretions vs reflux material. Patient seized coughing and resumed normal breathing pattern within 20 seconds. Conclusion patient demonstrated grossly within functional limits oropharyngeal swallow at his current/baseline diet level however it is strongly recommended that the patient take meals in the dining room with staff supervision going forward, if he were to experience choking/aspiration during a meal in his room, staff would not be able to recognize the signs or help him in a timely manner, increasing his risk of an emergency event. Additionally patient shows signs that he may be aspirating/choking on reflux material after eating, and should be kept in an upright position, such as in his wheelchair and within close proximity to staff for supervision and assistance if necessary. SLP to provide skilled dysphasia intervention to provide staff education on choking/ reflux precautions and order/ complete MBSS to objectively assess for risk of aspiration, reflux, esophageal dysmotility, etc. <BR/>Record review of Speech Therapy daily notes 03/13/2024 through 04/12/2024 stated: <BR/>03/18/2024 patient taken for on site MBSS (Modified Barium Swallow Study (MBSS) is a specialized x-ray procedure that helps both the Radiologist (who specializes in using x-rays) and the Speech Language Pathologist (SLP) identify why someone is having trouble with swallowing). Patient presented with very high anxiety when SLP and transport aide attempted to bring him out- shaking, yelling, waving people away. Patient was briefly calmed while being taken to the van and set up. patient resumed elevated behavior when evaluating SLP presented trials. Patient accepted one teaspoon of thin liquid by cup and began to shout and rock back and forth violently before swallowing. Agitation continued across other trials/ consistencies attempted, and with multiple feeders. results inconclusive due to lack of patient participation, however no penetration/ aspiration observed with 1 swallow. Anatomy noted with cervical osteocytes (Osteophytes are exostoses (bony projections) that form along joint margins) and decreased lordodic curvature nearing pharyngeal space and creating pharyngeal pressure system deficit (the decrease of the normal curvature, near the throat, can cause increased pressure in the airway causing partial or complete block). Recommendations are to continue current diet (mechanical soft and thin liquid, crushed meds) while taking all meals upright and supervised with assistance as needed. <BR/>03/21/2024 SLP discussed with CNA recommendations for patient to be up in wheelchair in dining room for lunch period CNA reported patient becoming severely agitated (screaming, shaking, vehemently refusing) during attempts to get him out of bed. CNA attempted again today and reported similar behavior. SLP acknowledged and documented CNA's report.<BR/>03/29/2024 SLP assisted patient with lunch at bedside. Patient mostly self-fed with fingers, occasionally accepting prefilled spoons with help from SLP. Patient ate rapidly/ impulsively and was not responsive to verbal/ gestural cues to pace himself or alternate bites/sips. Patient refused liquid wash each time it was offered. No signs or symptoms aspiration T/ O meal, adequate oral clearance at the end of the meal.<BR/>04/09/2024 patient had 1/2 PBJ sandwich, unmodified, self-fed. Patient was able to take bites out of the sandwich. Ataxia (neurological sign consisting of lack of voluntary coordination of muscle movements that can include trouble eating and swallowing) evident during mastication but patient still able to manipulate and propel bolus effectively. Patient used liquid wash on his own. SLP checked oral cavity to ensure no pocketing/stasis after he finished. <BR/>During an observation on 04/10/24 at 11:13 a.m. Resident #1 was in his room alone in bed. Resident #1 was sitting up in bed. Resident #1 had a regular plate (not a divided plate as indicated in the resident's order) with spaghetti, cooked squash, a hard brown piece of toast, a dessert dish with watery gelatin snack, a coffee cup with no top, and a clear cup with a purple liquid drink with no top. The tray of food had liquid spilled all over it. A napkin was soaked with brown liquid and the diet sheet was also stained with brown liquid. Resident #1 grabbed the hard toast, took a bite, and a crunch noise was heard. The resident put the bread down. This survey asked Resident #1 if the bread was too hard and Resident #1 nodded his head yes. Resident #1 lifted his fork with his left hand. Resident #1's hand was shaking, and food fell off the fork. The Resident #1 put the fork down on the tray. Resident #1 grabbed a handful of spaghetti and began to shove it in his mouth. Resident #1 ate quickly. No straws, condiments, or cheesecake were noted on the tray of food. There was a diet sheet from the kitchen which showed Resident #1's name, stated he was on a regular mechanical soft diet with thin liquids, no allergies were listed, adaptive equipment: divided plate, entr&eacute;e: meat sauce, starch: spaghetti noodles, vegetable: zucchini, bread garlic toast, dessert: cheesecake, condiment salt/pepper/margarine, and beverage: choice of beverage and water. <BR/>During an observation on 04/11/24 at 11:30 Resident #1 was delivered a meal tray by an unidentified male staff. The staff exited the room right after delivering the tray. Resident #1 was eating in his room alone. At 11:38 a.m. an unidentified female staff went into his room. The resident's plate had no food left. The staff lifted a utensil with the last bite of food for the resident to eat. The staff stated Resident #1 can eat on his own, but she will go in to help him because he made a mess. Resident #1 again had a regular plate. The staff stated the resident chose to eat with his hands. <BR/>During an interview on 04/11/24 at 2:40 p.m. the Dietary Manager (DM) stated she had a binder of forms with dietary preferences and allergies for some residents but not all. The DM stated if a resident had an allergy, nursing would notify them with a paper . The DM stated she did not have a form in her binder for Resident #1. The DM stated they were not aware of Resident #1's food allergy to mushrooms and the spaghetti did not have mushrooms in it. The DM stated the kitchen did not have any mushrooms in it and it had been a while since the kitchen had any mushrooms. The DM stated the facility had divided plates available. The DM stated Resident #1 was supposed to receive a divided plate and staff needed to pay attention to what the diet sheet showed the resident needed for adaptive equipment. The DM stated the divided plate was needed to help the resident get his food better. The DM stated the cooks had over cooked the bread and needed to pay attention because residents would not be able to eat hard bread especially if they are on a mechanical soft diet. The DM stated the gelatin snack was not made right and was too watery. The DM stated the cooks had substituted the cheesecake with the gelatin snack but the resident should not have been served the watery gelatin snack. <BR/>During an interview on 04/12/24 at 9:12 a.m. the Speech Therapist stated Resident #1 was evaluated in March. The SP stated she was working with the Resident due to history of stroke and he had dysphagia. The SP stated if Resident #1 was presented food he would not take it and preferred to eat with his hands. The SP stated in March she recommended Resident #1 eat in the dining room per her notes because he could not communicate to staff and in case of an emergency he needed to be with in sight. The SP stated she they attempted to take Resident #1 to the dining room for meals in March after her recommendation but the Resident had a panic attack. The SP stated her recommendations were given to the rehab director and to the DON. The SP stated the Resident should have a divided plate with meals and his cups should have plastic lids and a straw. The SP stated she did go in the room to assist the resident with meals because she also helped with other residents and could not always be in the room with him. <BR/>During an interview on 04/12/24 at 12:35 a.m. the DON stated the Rehab director would usually let them know what findings they had from an evaluation. The DON stated Resident #1 was supervised only for meals, he was able to feed himself, he could use utensils, staff would set the tray up uncover everything for him, give him the spoon, he would pick it up and feed himself, and she did not see him shake or have tremors. The DON stated they were notified Resident #1 needed to eat in the dining room for queuing (prompting to eat) and or if he dropped his silverware. The DON stated the resident was very contracted and he refused to go to the dining room because it was painful for him to move. The DON stated staff would set the resident up at 90 degrees in bed, would set up his tray, and would go in and out of his room to supervise him during meals in his room. The DON stated they did not document or care plan the resident's refusals to go to the dining room. The DON stated staff would attempt 3 times to get the resident up and then would notify the nurse if he refused. The DON stated the SP would go in the room to sit with the resident and help him eat. The DON stated she had not read the SP evaluation and plan of care for Resident #1. The DON read the POC and stated she did not agree that staff would not be able to assist the resident in an emergency because the staff was CPR certified and could also perform the Heimlich maneuver. The DON stated she had never been notified that the resident would cough or choke while eating and the SP should have reported this to nursing. <BR/>During a joint interview on 04/12/24 at 4:37 p.m. with Rehab director and SP stated it was the RD's responsibility to communicate any evaluations and recommendations at clinical meetings to the nursing staff. They stated they were unable to get the resident to the recommended barium swallow study because the residents refused cooperate. The SP stated the resident did not want to get into the wheelchair and he had no signs or symptoms of choking such as a pneumonia. The RD stated the evaluation was done in March of 2024 and since then the resident had progressed. The RD stated the resident did not need supervision with meals. The RD stated he would not get supervision from staff they would just check in on him when he ate. The RD stated the doctor signed the SP evaluation on 03/19/24 with no further recommendations. The RD stated she was never notified or told the resident was coughing while eating or choking.<BR/>Record review of the facility's policy titled 'Nutritional Recommendations, dated 12/2017, stated policy: it is the policy of this home that the deal in/ DON will address recommendations by the console dietitian within three working days, if possible, of the exit of the dietician consult. Procedure: 1. the consultation will complete the nutritional recommendation form and/ or enteral feeding recommendations, sign, and date. 2. The consult dietitian will discuss the recommendations and exit conference with the administrator, director of nursing, and dietary service manager for clarification. After completion of the discussion, each will sign the form. 3. The dietitian will keep one copy of the form and give the other copy to the director of nursing. 4. The director of nursing or designee will contact the physician for orders or denial of the recommendation. The director of nursing or designee will write the physician's response and date and the follow up section. A note should be made regarding the reason for refusal if the physician denies the recommendation. 5. when recommendations have been completed and follow up column filled in, the director of nursing gave a copy to the administrator and dietary service manager. 6. The director of nursing/ designee will write orders in the medical records to initiate the approval recommendations. 7. The [nursing/ dietary communication form] will be completed regarding any diet or supplement changes. The original copy will be placed in dietary section of the medical record and the copy will be given to the dietary. 8. On the console dietitian next visit, the completed recommendations will be reviewed, and if indicated, follow up will be made in the clinical software. 9. It is the administrator's responsibility to see that recommendations are addressed within three business days, if possible, of the consulting dietitians exit conference.<BR/>The Administrator was given the IJ template and was notified of the IJ on 4/12/24 at 6:19 PM and a POR was requested.<BR/>On 04/14/24 at 1:35 PM, the POR was accepted. It was documented as follows:<BR/>4/12/2024<BR/>Plan of Removal - F 689 <BR/>Immediate Action Taken <BR/>Resident Specific <BR/>Resident #1 will be supervised by staff during all 3 meals daily beginning on 4/12/2024 at 7:00 pm.<BR/>Resident #1 had the appropriate care plan updates completed on 4/13/2024 at 11:20 am.<BR/>System Changes<BR/>On 4/12/2024 at 7:00 pm a facility audit took place to ensure that all residents requiring supervision for meals will receive appropriate supervision.<BR/>On 4/12/2024 at 7:00 pm DON and therapy reviewed all residents who require supervision for meals have had their care plans audited to ensure that the care plans accurately reflect the residents need for supervision with meals. <BR/>Starting on 4/12/2024 and ongoing therapy will be present in morning meetings to ensure that all orders are communicated directly between nursing and therapy to ensure that residents requiring supervision with meals will have recommendations reviewed and carried out appropriately. <BR/>Starting on 4/12/2024 and ongoing the DON will monitor two meals daily x 5 days a week to ensure staff compliance with meal supervision for those residents requiring supervision. <BR/>Starting on 4/12/2024 and ongoing residents dietary and supervision statuses will be audited upon change of condition, appropriate MDS cycles or anytime necessary. <BR/>Starting 4/13/2024 at 11:00 am the facility's mechanism for ensuring correct diet texture for the residents is that all trays will be compared to the actual plated meal for the resident by a licensed staff member prior to being served to the resident. The meal ticket/diet order will be compared for accuracy.<BR/>Education <BR/>On 4/12/2024 at 7:00 pm the Assistant Director of Nursing provided education to all staff regarding residents needing to have supervision at meals to ensure those residents will be supervised at mealtimes. Staff on future shifts will be educated prior to taking the floor. This will be accomplished by having a designated staff member in the building for that purpose and with that specific assignment. Licensed staff will be assigned by the DON to ensure that all trays/plates are correct prior to being served to the residents. Diet orders will match correctly to what is being served to the residents. This assigned licensed staff member will ensure specifically that texture, larger utensils, cup covers etc are being utilized for the residents.<BR/>On 4/12/2024 at 7:00 pm the Regional Clinical Consultant provided education to Administrator and Director of Nursing regarding residents needing supervision for meals. <BR/>On 4/12/2024 at 7:15 pm the Regional Clinical Consultant will educate DOR and clinical team as to communication and follow up during morning meetings. <BR/>Starting on 4/12/2024 at 7:00 pm the regional clinical consultant will be responsible for ensuring that staff receive the in-service/training regarding residents needing supervision during meals.<BR/>Starting on 4/12/2024 the residents dietary and supervision status will be communicated to facility staff directly by the DON and ADON. This process will be accomplished through photocopy and written communication.<BR/>Starting on 4/12/2024 the DON will be responsible for ensuring that the residents who require supervision during meals receive supervision.<BR/>Starting on 4/12/2024 at 7:00 pm during the daily stand up process all recommendations and orders will be audited by the clinical team in consultation with the therapy team to ensure compliance and follow up for all residents with orders and recommendations. The clinical consultant will review orders and recommendations daily x 4 weeks as a tool for oversight to ensure compliance.<BR/>100% Staff education compliance of the above mentioned by noon 4/14/24.<BR/>Verification of Plan of Removal:<BR/>Confirmed via Observation of lunch and dinner meals on 04/13/2024.<BR/>Confirmed via Record Review of Resident #1's care plan . <BR/>Confirmed via Interview with Regional Clinical Consultant and DON. They each had a list of all staff with check marks. Interviewed about their process for identifying residents who needed supervision and how they ensured no one was falling through the cracks. Interviewed each independently and they both said they went through each clinical record looking at: therapy notes and recommendations, physician notes, POC notes from CNAs, progress notes from LVNs and RNs, MDS assessments, and care plans. <BR/>On 4/12/2024 at 7:00 pm DON and therapy reviewed all residents who require supervision for meals have had their care plans audited.<BR/>Confirmed via Interview with Dir of Rehab and DON.<BR/>Record review of the care plans for all eight of the residents (Resident #1 and additional seven who require assistance). Five care plans had been updated - edits were observed - and the updates clarified and added more specific language. For example, instead of saying supervision as needed the language was updated to read supervision at all times by nursing staff. The two that were not updated were already very precise and specific in their wording. <BR/>Confirmed via Interview with Dir of Rehab DON, and Administrator <BR/>Confirmed via Interview with DON.<BR/>Record review of chart of items to check for each resident identified and had filled in the chart for each meal served since IJ was called. <BR/>Confirmed via Interview with Regional Clinical Consultant, DON, MDS/Care Plan Coordinator, and Administrator. <BR/>There were 52 total staff members 41 of the 52 staff have received in-service. Interview in person or by phone with 32 of the 52 staff members and confirmed they received the trainings and could verbalize understanding of the training. Of the 11 staff who did not receive the training: 1 FMLA, 1 vacation, and 9 PRN. Observation of a sign on the time clock stated for staff not to clock in for shift until they received in-service trainings dated 04/12/2024. <BR/>Observation of both lunch and dinner service on 04/13/2024 revealed each meal had an assigned licensed nurse to check meal tickets against trays. Observation of weekend RN meal tickets and trays revealed checking tickets for 15 residents versus what they had been served were completed and all were correct. The DON stated she would personally check two meals per day M-F, and weekend RN would check all three weekend meals (The DON and weekend RN work 6 am to 6 pm ). <BR/>Observation of the residents who required assistance in dining hall revealed staff were treating them with dignity, their tickets and meals were correct, and assistive devices(e.g. divided plate, built up utensils) were in place. <BR/>Observation of Resident #1 dining in his room revealed his ticket and meal were correct, a divided plate was in place, covered cups in place, and a member of nursing staff was providing 1 on 1 supervision. <BR/>Interviews conducted on 4/13/24 from 3:42 p.m. to 7:45 p.m. and on 4/14/24 from 9:03 a.m. to 1:30 p.m. revealed there were 14 nurses on staff, and interviewed 12 of them and all have received the in-service trainings (more detail on trainings below). <BR/>Interviews conducted on 4/13/24 from 3:42 p.m. to 7:45 p.m. and on 4/14/24 from 9:03 a.m. to 1:30 p.m. revealed there are 17 CNAs on staff, 13 of them were interviewed and all received the in-service trainings.<BR/>Confirmed via Interview with Regional Clinical Consultant and Record Review of in-service training.<BR/>Confirmed via Interview with DON and with ADON.<BR/>Record review of the in-services. One of the in-services which was given to all nursing staff identified all eight residents who require supervision and/or assistance for dining. <BR/>Confirmed via Interview with DON.<BR/>Observation of lunch and dinner comparison of their care plans and meal tickets against the meal, assistive devices, and level of supervision for the eight residents who required assistance received during both lunch and dinner, revealed each was correct. <BR/>Confirmed via Interview with Regional Clinical Consultant and DON, MDS/Care Plan Coordinator, and Administrator. <BR/>During interviews staff confirmed abuse and neglect training was done in general and every staff member confirmed ANE trainings are provided at least monthly. <BR/>Regional Clinical Consultant confirmed via interview that she was personally ensuring that all staff received in-service trainings. She was onsite today and planned to stay to catch the oncoming night shift. She provided her documentation via a staff list with check offs. <BR/>An IJ was identified on 4/12/24. While the IJ was removed on 04/14/24, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 1 of 3 resident (Resident #9) reviewed for enteral feeding:The facility failed to ensure Resident #9's feeding formula and water containers were labeled with the appropriate identifiers and did not discard the feeding containers after the feeding was completed.This deficient practice could place residents who received enteral nutrition at risk of infection, and bloating discomfort.The findings included:Record review of Resident #9's face sheet dated 7/21/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included nausea, aphasia (medical condition that affects a persons' ability to communicate) following cerebral infarct (a type of stroke that prevents blood flow to a part of the brain), dysphagia(condition that involves difficulty with language), gastro-esophageal reflux (chronic condition where stomach acid or bile flows back into the esophagus causing irritation), and gastrostomy status (a medical procedure in which a surgical opening is made into the stomach through the abdominal wall which allows for the placement of a feeding tube).Record review of Resident #9's most recent quarterly MDS assessment dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills and utilized a feeding tube.Record review of Resident #9's comprehensive care plan with edited date 6/29/25 revealed the resident had a feeding tube and approaches that included to provide feedings and water flushes as ordered. Record review of Resident #9's Physician Order Report for July 2025 revealed the following:- Enteral: Free water flushes at 60 ml/hr x 12 hours, special instructions: RUN water at 60 ml per hour from 6:00 p.m. to 6:00 a.m. every night with order date 7/21/25 and no end date.- Nocturnal feedings of Novasource Renal at 45 ml with 60 ml free water flushes x 12 hours feeding tube via dual flow pump (down 6:00 a.m., on 6:00 p.m.) with order date 6/3/25 and end date 7/7/25.Observation on 7/22/25 at 9:29 a.m. revealed Resident #9 in bed and the Novasource formula and water containers were hanging from the feeding pole with the feeding tube connected to the feeding pump and the connecting end of the tube was under the resident's blanket. Resident #9's Novasource formula and water containers were unlabeled, and the feeding pump was turned off.Observation on 7/22/25 at 1:36 p.m. revealed Resident #9's Novasource formula and water containers were hanging from the feeding pole and the feeding pump turned off. During an observation and interview on 7/22/25 at 1:47 p.m., LVN A stated, Resident #9 received nocturnal feedings but was not sure of the time frame. LVN A observed the Novasource formula and water containers hanging from the feeding pole and stated, both the formula and water containers were unlabeled. LVN A stated both the formula and water containers were supposed to be labeled because it was used to identify right person, right rate, right time and right dosage. LVN A stated, without those identifiers, it would not be known how long the formula had been left there. LVN A stated she believed the formula and water had been used/infused even though there was still formula and water seen in the containers. LVN A stated, even though the formula was not finished, they could still use it again, but that would depend on how much of the formula had been infused.During an interview on 7/22/25 at 4:43 p.m. the DON stated Resident #9's feeding formula and water containers should have been labeled with the resident's name, the time, and date the formula was infused. The DON stated, the formula was only good for 24 hours and once it was used, it should be thrown away. The DON stated the resident could be affected if the formula did not have a label that indicated when the formula was given and how much and if the formula was old, it could upset the resident's stomach and make them sick.Record review of the facility document titled Enteral Formula Via: Feeding Tube, Bolus, Gravity, Pump (Closed/Open) Administration, with effective date 12/2017 revealed in part, .It is the policy of this home that the resident, who utilizes enteral nutrition, will be free, to the extent possible, from complications related to enteral nutrition.Pump - administration of formula utilizing a bottle/bag with the tubing placed through the pump device and the rate set on the pump to administer the formula. This method provides a more accurate administration as well as the pump provides the volume administered in a specified time period.The syringe and bag (if used) should be changed every 24 hours. The ready-to-hang bottles should be changed according to the manufacturer recommendations or when total amount has infused if less than the manufacturer recommendation.The syringe, bag, and/or bottle should be labeled with the resident name, room number, date changed, and the nurses' signature/initials. The bag or bottle should also specify the physician order the formula, rate, route, and means of administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident had a right to a safe, clean, comfortable, and homelike environment for 1 (Resident #1 room) of 4 resident reviewed for resident rights, in that: <BR/>A pile of yellow liquid was seen on the restroom floor of Resident #1's room.<BR/>This failure could result in physical and psychosocial harm due to diminished quality of life and increased risk for falls. <BR/>The findings were:<BR/>Record review of Resident #1's face sheet, dated 04/06/23, noted the resident was admitted to the facility on [DATE] with diagnoses including: Depression, Anxiety, Tremor, Lack of Coordination, Type 2 Diabetes Mellitus, Hyperlipidemia, Chronic Obstructive Pulmonary Disease (a lung disease that blocks airflow and makes it difficult to breath), Cognitive Communication Deficit (difficult with communication caused by an impairment in cognitive processes), Unsteadiness on Feet, Paranoid Schizophrenia, Seizures, and Abnormalities of Gait and Mobility. <BR/>Record review of Resident #1's Quarterly MDS assessment, dated 12/23/24, noted a BIMS score of 08 which indicated moderate cognitive impairment. <BR/>Record review of Resident #1's care plan, dated 01/13/25, noted Resident #1 exhibits functional bowel/bladder incontinence, with a goal, Resident #1 will be free from complications related to bowel incontinence through the review date. Approaches included Check resident frequently and assist with toileting, incontinent, and pericare needs as needed and to Provide loose fitting, easy to remove clothing and to Provide pericare after each incontinent episode. The care plan further noted Resident #1 is at risk for falling R/T unsteady gait. Approaches included Assure the floor is free of glare, liquids, foreign objects. and staff tor perform frequent housekeeping rounds.<BR/>Observation on 01/22/25 at 11:10 AM revealed the presence of a pile of yellow liquid on the floor of the bathroom. A foul odor was noted in the room, and the floor of the room was sticky underfoot.<BR/>During an interview with LVN A on 01/22/25 at 11:10 AM, when asked what was on the floor of Resident 1's bathroom, LVN A stated it looked like urine. When asked what could happen if urine was on the floor, LVN A stated a resident could slip and fall and get a fracture. <BR/>During an interview the DON, on 1/23/25 at 2:15 PM, the DON stated the facility uses the TAC Chapter 554, Subchapter R, Rule 554.1701 as their policy for homelike environment.<BR/>During an interview with the Regional Consultant Nurse on 1/23/25 at 3:24 PM, the Regional Consultant Nurse stated the facility used the TAC Chapter 554, Subchapter R, Rule 554.1701 as their policy for homelike environment.<BR/>Record review of the TAC Chapter 554, Subchapter R, Rule 554.1701 on 1/23/25 at 2:15 PM noted The facility must be designed, constructed, equipped, and maintained to protect the health and ensure the safety of residents, personnel, and the public. The TAC further states Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 4 residents (Resident #1 and Resident #5) reviewed for care plans.<BR/>1. The facility failed to care plan Resident #1's refusal eating in the dining room for supervision with meals.<BR/>2. The facility failed to care plan Resident #5's use or refusal to use fall mats. <BR/>This failure could place residents at risk of not having their needs met. <BR/>Finding Included:<BR/>1. Record review of Resident #1's face sheet dated 4/10/24 revealed a [AGE] year-old male, admitted on [DATE] and readmitted on [DATE] with diagnoses of seizures, cerebrovascular disease, aphasia following cerebral infarction (a person may be unable to comprehend or unable to formulate language because of damage to specific brain regions), contracture right elbow (shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement), contracture right wrist, hemiplegia (weakness of one entire side of the body) and hemiparesis (complete paralysis of half of the body). <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was severely impaired for daily decision making, dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with ADLs in the areas of eating and drinking, and was on a mechanically altered diet. <BR/>Record review of Resident #1's comprehensive person-centered care plan, dated 02/20/24, revealed the resident's interventions for ADLs included REQUIRED***EATING: Resident requires set up assist. Resident #1 had unplanned/unexpected weight loss with interventions for ice cream as ordered, monitor and record food intake at each meal, notify the dietician of the weight loss upon their next visit, notify the physician, resident and family of the weight loss, provide verbal assistance and cues during meals, weigh the resident weekly for at least 4 weeks or until weight has stabilized. <BR/>Record review of Resident#1's Physician Order, dated 01/18/24 revealed an order for diet-regular, mechanical soft, and thin fluids. Special instructions FMP to all meals. Divided plate for every meal. The order was signed on 02/01/24 by the physician.<BR/>During an observation on 04/10/24 at 11:13 a.m. Resident #1 was in his room alone in bed. Resident #1 was sitting up in bed. Resident #1 had a regular plate (not a divided plate as indicated in the resident's order) with spaghetti, cooked squash, a hard brown piece of toast, a dessert dish with watery gelatin snack, a coffee cup with no top, and a clear cup with a purple liquid drink with no top. The tray of food had liquid spilled all over it. A napkin was soaked with brown liquid and the diet sheet was also stained with brown liquid. Resident #1 grabbed the hard toast, took a bite, and a crunch noise was heard. The resident put the bread down. This survey asked Resident #1 if the bread was too hard and Resident #1 nodded his head yes. Resident #1 lifted his fork with his left hand. Resident #1's hand was shaking, and food fell off the fork. The Resident #1 put the fork down on the tray. Resident #1 grabbed a handful of spaghetti and began to shove it in his mouth. Resident #1 ate quickly. No straws, condiments, or cheesecake were noted on the tray of food. There was a diet sheet from the kitchen which showed Resident #1's name, stated he was on a regular mechanical soft diet with thin liquids, no allergies were listed, adaptive equipment: divided plate, entr&eacute;e: meat sauce, starch: spaghetti noodles, vegetable: zucchini, bread garlic toast, dessert: cheesecake, condiment salt/pepper/margarine, and beverage: choice of beverage and water. <BR/>During an observation on 04/11/24 at 11:30 Resident #1 was delivered a meal tray by an unidentified male staff. The staff exited the room right after delivering the tray. Resident #1 was eating in his room alone. At 11:38 a.m. an unidentified female staff went into his room. The resident's plate had no food left. The staff lifted a utensil with the last bite of food for the resident to eat. The staff stated Resident #1 can eat on his own, but she will go in to help him because he made a mess. Resident #1 again had a regular plate. The staff stated the resident chose to eat with his hands. <BR/>During an interview on 04/12/24 at 9:12 a.m. the Speech Therapist stated Resident #1 was evaluated in March. The SP stated she was working with the Resident due to history of stroke and he had dysphagia. The SP stated if Resident #1 was presented food he would not take it and preferred to eat with his hands. The SP stated in March she recommended Resident #1 eat in the dining room per her notes because he could not communicate to staff and in case of an emergency he needed to be with in sight. The SP stated she they attempted to take Resident #1 to the dining room for meals in March after her recommendation but the Resident had a panic attack. The SP stated her recommendations were given to the rehab director and to the DON. The SP stated the Resident should have a divided plate with meals and his cups should have plastic lids and a straw. The SP stated she did go in the room to assist the resident with meals because she also helped with other residents and could not always be in the room with him. <BR/>During an interview on 04/12/24 at 12:35 a.m. the DON stated the Rehab director would usually let them know what findings they had from an evaluation. The DON stated Resident #1 was supervised only for meals, he was able to feed himself, he could use utensils, staff would set the tray up uncover everything for him, give him the spoon, he would pick it up and feed himself, and she did not see him shake or have tremors. The DON stated they were notified Resident #1 needed to eat in the dining room for queuing (prompting to eat) and or if he dropped his silverware. The DON stated the resident was very contracted and he refused to go to the dining room because it was painful for him to move. The DON stated staff would set the resident up at 90 degrees in bed, would set up his tray, and would go in and out of his room to supervise him during meals in his room. The DON stated they did not document or care plan the resident's refusals to go to the dining room. The DON stated staff would attempt 3 times to get the resident up and then would notify the nurse if he refused. The DON stated the SP would go in the room to sit with the resident and help him eat. The DON stated she had not read the SP evaluation and plan of care for Resident #1. The DON read the POC and stated she did not agree that staff would not be able to assist the resident in an emergency because the staff was CPR certified and could also perform the Heimlich maneuver. The DON stated she had never been notified that the resident would cough or choke while eating and the SP should have reported this to nursing. <BR/>During a joint interview on 04/12/24 at 4:37 p.m. with Rehab director and SP stated it was the RD's responsibility to communicate any evaluations and recommendations at clinical meetings to the nursing staff. They stated they were unable to get the resident to the recommended barium swallow study because the resident refused to cooperate. The SP stated the resident did not want to get into the wheelchair and he had no signs or symptoms of choking such as a pneumonia. The RD stated the evaluation was done in March of 2024 and since then the resident had progressed. The RD stated the resident did not need supervision with meals. The RD stated he would not get supervision from staff they would just check in on him when he ate. The RD stated the doctor signed the SP evaluation on 03/19/24 with no further recommendations. The RD stated she was never notified or told the resident was coughing while eating or choking.<BR/>2. Record review of Resident #5's face sheet dated 4/12/24 revealed a [AGE] year-old female, admitted on [DATE] and readmitted on [DATE] with diagnoses of cerebral infarction (stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood.), Alzheimer's disease late onset (disease that affects memory), insomnia (inability to sleep or stay asleep), unsteadiness on feet, and history of falling. <BR/>Record review of Resident #5's quarterly MDS dated [DATE] revealed Resident #5 was severely impaired for daily decision making, had 1 fall with no injury, and 1 fall with injury (except major) since admission/entry or reentry or admission. <BR/>Record review of Resident #5's comprehensive person-centered care plan, dated 04/10/24, revealed the Resident #5 had a history of falls related to Alzheimer's with intervention to ensure proper footwear, staff to increase activities, wedge cushion ordered for chair, staff to ensure resident is positioned at nurses station, staff to provide frequent rounds, keep bed in lowest position with brakes locked, and staff to provide hand activities for resident while up. <BR/>During an observation on 04/11/24 at 10:33 a.m. Resident #5 was lying in bed. There was a single fall mat folded into a stack of three layers on the ground, aligned on one side of the bed. The mat did not cover the side of the bed because it was folded up. <BR/>During an observation on 04/11/24 at 11:36 a.m. the mat was observed in the same position and the resident was still laying in the bed. <BR/>During an interview on 04/12/24 at 12:14 p.m. the DON stated Resident #5 had memory issues and would often get out of bed and kick everything out of the way. The DON stated she had fall matts in her room and they had brought up that the resident would kick them out of the way at a care plan meeting before. The DON stated they should care plan the fall matts. <BR/>Record review of document titled Speech Therapy Plan of Care - 03/13/2024, dated 03/13/2024, revealed profound language impairments and mild pharyngeal swallow function impairments (71-85% ability). Section titled Underlying Impairments listed Verbal Expression- Automatic speech severe impairment, Auditory Comprehension- 1 step commands severe impairment, Auditory Comprehension- wh questions- Severe Impairment, and Pharyngeal Swallow Deficits- after swallow. The reasons for referral were without therapeutic intervention patient at risk for: choking, aspiration, weight loss, inability to meet nutritional needs via PO intake of least restrictive diet .Bedside Swallowing Assessment .Pharyngeal phase: Patient demonstrated no signs or symptoms of aspiration during meal or when drinking . Patient demonstrated strong reflexive coughing episode &gt; 10 minutes after last PO intake with face reddening/eye tearing, suspected aspiration/penetration of secretions vs reflux material. Patient seized coughing and resumed normal breathing pattern within 20 seconds. Conclusion patient demonstrated grossly within functional limits oropharyngeal swallow at his current/baseline diet level however it is strongly recommended that the patient take meals in the dining room with staff supervision going forward, if he were to experience choking/aspiration during a meal in his room, staff would not be able to recognize the signs or help him in a timely manner, increasing his risk of an emergency event. Additionally patient shows signs that he may be aspirating/choking on reflux material after eating, and should be kept in an upright position, such as in his wheelchair and within close proximity to staff for supervision and assistance if necessary. SLP to provide skilled dysphasia intervention to provide staff education on choking/ reflux precautions and order/ complete MBSS to objectively assess for risk of aspiration, reflux, esophageal dysmotility, etc. <BR/>Record review of Speech Therapy daily notes 03/13/2024 through 04/12/2024 stated: <BR/>03/18/2024 patient taken for on site MBSS (Modified Barium Swallow Study (MBSS) is a specialized x-ray procedure that helps both the Radiologist (who specializes in using x-rays) and the Speech Language Pathologist (SLP) identify why someone is having trouble with swallowing). Patient presented with very high anxiety when SLP and transport aide attempted to bring him out- shaking, yelling, waving people away. Patient was briefly calmed while being taken to the van and set up. patient resumed elevated behavior when evaluating SLP presented trials. Patient accepted one teaspoon of thin liquid by cup and began to shout and rock back and forth violently before swallowing. Agitation continued across other trials/ consistencies attempted, and with multiple feeders. results inconclusive due to lack of patient participation, however no penetration/ aspiration observed with 1 swallow. Anatomy noted with cervical osteocytes and decreased lordodic curvature nearing pharyngeal space and creating pharyngeal pressure system deficit. Recommendations are to continue current diet (mechanical soft and thin liquid, crushed meds) while taking all meals upright and supervised with assistance as needed. <BR/>03/21/2024 SLP discussed with CNA recommendations for patient to be up in wheelchair in dining room for lunch period CNA reported patient becoming severely agitated (screaming, shaking, vehemently refusing) during attempts to get him out of bed. CNA attempted again today and reported similar behavior. SLP acknowledged and documented CNA's report.<BR/>03/29/2024 SLP assisted patient with lunch at bedside. Patient mostly self-fed with fingers, occasionally accepting prefilled spoons with help from SLP. Patient ate rapidly/ impulsively and was not responsive to verbal/ gestural cues to pace himself or alternate bites/sips. Patient refused liquid wash each time it was offered. No signs or symptoms aspiration T/ O meal, adequate oral clearance at the end of the meal.<BR/>04/09/2024 patient had 1/2 PBJ sandwich, unmodified, self-fed. Patient was able to take bites out of the sandwich. Ataxia (neurological sign consisting of lack of voluntary coordination of muscle movements that can include trouble eating and swallowing) evident during mastication but patient still able to manipulate and propel bolus effectively. Patient used liquid wash on his own. SLP checked oral cavity to ensure no pocketing/stasis after he finished. <BR/>Record review of the facility's care plan policy, dated 12/2017, stated policy: it is the policy of this home that staff must develop a comprehensive care plan to meet the needs of the resident .Note remember the residents care plan is a tool used to coordinate all care provided to the resident to be sure care is necessary, appropriate and planned to meet individual needs of the resident consonant with the physician's plan of care for the resident .12. Resident care plan documentation and use of the plan: a. the residents care plan is used to plan and assign care for all disciplines .c. The resident care plan must be kept current at all times .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 4 residents (Resident #1) reviewed for adequate supervision in that: <BR/>The facility failed to ensure Resident #1 received supervision during mealtimes to prevent choking or aspiration. <BR/>An IJ was identified on 4/12/24. The IJ template was provided to the facility on [DATE] at 6:19 PM. While the IJ was removed on 04/14/24 the facility remained out of compliance at a scope of isolated with a severity of potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>This failure could place residents at risk of choking, weight loss, decline in health, and death. <BR/>The findings included: <BR/>Record review of Resident #1's face sheet dated 4/10/24 revealed a [AGE] year-old male, admitted on [DATE] and readmitted on [DATE] with diagnoses of seizures, cerebrovascular disease, aphasia following cerebral infarction (a person may be unable to comprehend or unable to formulate language because of damage to specific brain regions), contracture right elbow (shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement), contracture right wrist, hemiplegia (weakness of one entire side of the body) and hemiparesis (complete paralysis of half of the body). The facesheet stated Resident #1 was allergic to morphine, mushrooms, and penicillins. <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was severely impaired for daily decision making, dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with ADLs in the areas of eating and drinking, and was on a mechanically altered diet. <BR/>Record review of Resident #1's comprehensive person-centered care plan, dated 02/20/24, revealed the resident's interventions for ADLs included REQUIRED***EATING: Resident requires set up assist. Resident #1 had unplanned/unexpected weight loss with interventions for ice cream as ordered, monitor and record food intake at each meal, notify the dietician of the weight loss upon their next visit, notify the physician, resident and family of the weight loss, provide verbal assistance and cues during meals, weigh the resident weekly for at least 4 weeks or until weight has stabilized. <BR/>Record review of Resident#1's Physician Order, dated 01/18/24 revealed an order for diet-regular, mechanical soft, and thin fluids. Special instructions FMP to all meals. Divided plate for every meal. The order was signed on 02/01/24 by the physician.<BR/>Record review of a nursing progress note, dated 02/12/2024, stated Patient eating breakfast and begins coughing episode directly after eating. Patient airway patent upon assessment. Patient sitting upright in bed, call light with reach. NP notified RP, MD and staff nurse. <BR/>Record review of document titled Speech Therapy Plan of Care - 03/13/2024, dated 03/13/2024, revealed profound language impairments and mild pharyngeal swallow function impairments (71-85% ability). Section titled Underlying Impairments listed Verbal Expression- Automatic speech severe impairment, Auditory Comprehension- 1 step commands severe impairment, Auditory Comprehension- wh questions- Severe Impairment, and Pharyngeal Swallow Deficits- after swallow. The reasons for referral were without therapeutic intervention patient at risk for: choking, aspiration, weight loss, inability to meet nutritional needs via PO intake of least restrictive diet .Bedside Swallowing Assessment .Pharyngeal phase: Patient demonstrated no signs or symptoms of aspiration during meal or when drinking . Patient demonstrated strong reflexive coughing episode &gt; 10 minutes after last PO intake with face reddening/eye tearing, suspected aspiration/penetration of secretions vs reflux material. Patient seized coughing and resumed normal breathing pattern within 20 seconds. Conclusion patient demonstrated grossly within functional limits oropharyngeal swallow at his current/baseline diet level however it is strongly recommended that the patient take meals in the dining room with staff supervision going forward, if he were to experience choking/aspiration during a meal in his room, staff would not be able to recognize the signs or help him in a timely manner, increasing his risk of an emergency event. Additionally patient shows signs that he may be aspirating/choking on reflux material after eating, and should be kept in an upright position, such as in his wheelchair and within close proximity to staff for supervision and assistance if necessary. SLP to provide skilled dysphasia intervention to provide staff education on choking/ reflux precautions and order/ complete MBSS to objectively assess for risk of aspiration, reflux, esophageal dysmotility, etc. <BR/>Record review of Speech Therapy daily notes 03/13/2024 through 04/12/2024 stated: <BR/>03/18/2024 patient taken for on site MBSS (Modified Barium Swallow Study (MBSS) is a specialized x-ray procedure that helps both the Radiologist (who specializes in using x-rays) and the Speech Language Pathologist (SLP) identify why someone is having trouble with swallowing). Patient presented with very high anxiety when SLP and transport aide attempted to bring him out- shaking, yelling, waving people away. Patient was briefly calmed while being taken to the van and set up. patient resumed elevated behavior when evaluating SLP presented trials. Patient accepted one teaspoon of thin liquid by cup and began to shout and rock back and forth violently before swallowing. Agitation continued across other trials/ consistencies attempted, and with multiple feeders. results inconclusive due to lack of patient participation, however no penetration/ aspiration observed with 1 swallow. Anatomy noted with cervical osteocytes (Osteophytes are exostoses (bony projections) that form along joint margins) and decreased lordodic curvature nearing pharyngeal space and creating pharyngeal pressure system deficit (the decrease of the normal curvature, near the throat, can cause increased pressure in the airway causing partial or complete block). Recommendations are to continue current diet (mechanical soft and thin liquid, crushed meds) while taking all meals upright and supervised with assistance as needed. <BR/>03/21/2024 SLP discussed with CNA recommendations for patient to be up in wheelchair in dining room for lunch period CNA reported patient becoming severely agitated (screaming, shaking, vehemently refusing) during attempts to get him out of bed. CNA attempted again today and reported similar behavior. SLP acknowledged and documented CNA's report.<BR/>03/29/2024 SLP assisted patient with lunch at bedside. Patient mostly self-fed with fingers, occasionally accepting prefilled spoons with help from SLP. Patient ate rapidly/ impulsively and was not responsive to verbal/ gestural cues to pace himself or alternate bites/sips. Patient refused liquid wash each time it was offered. No signs or symptoms aspiration T/ O meal, adequate oral clearance at the end of the meal.<BR/>04/09/2024 patient had 1/2 PBJ sandwich, unmodified, self-fed. Patient was able to take bites out of the sandwich. Ataxia (neurological sign consisting of lack of voluntary coordination of muscle movements that can include trouble eating and swallowing) evident during mastication but patient still able to manipulate and propel bolus effectively. Patient used liquid wash on his own. SLP checked oral cavity to ensure no pocketing/stasis after he finished. <BR/>During an observation on 04/10/24 at 11:13 a.m. Resident #1 was in his room alone in bed. Resident #1 was sitting up in bed. Resident #1 had a regular plate (not a divided plate as indicated in the resident's order) with spaghetti, cooked squash, a hard brown piece of toast, a dessert dish with watery gelatin snack, a coffee cup with no top, and a clear cup with a purple liquid drink with no top. The tray of food had liquid spilled all over it. A napkin was soaked with brown liquid and the diet sheet was also stained with brown liquid. Resident #1 grabbed the hard toast, took a bite, and a crunch noise was heard. The resident put the bread down. This survey asked Resident #1 if the bread was too hard and Resident #1 nodded his head yes. Resident #1 lifted his fork with his left hand. Resident #1's hand was shaking, and food fell off the fork. The Resident #1 put the fork down on the tray. Resident #1 grabbed a handful of spaghetti and began to shove it in his mouth. Resident #1 ate quickly. No straws, condiments, or cheesecake were noted on the tray of food. There was a diet sheet from the kitchen which showed Resident #1's name, stated he was on a regular mechanical soft diet with thin liquids, no allergies were listed, adaptive equipment: divided plate, entr&eacute;e: meat sauce, starch: spaghetti noodles, vegetable: zucchini, bread garlic toast, dessert: cheesecake, condiment salt/pepper/margarine, and beverage: choice of beverage and water. <BR/>During an observation on 04/11/24 at 11:30 Resident #1 was delivered a meal tray by an unidentified male staff. The staff exited the room right after delivering the tray. Resident #1 was eating in his room alone. At 11:38 a.m. an unidentified female staff went into his room. The resident's plate had no food left. The staff lifted a utensil with the last bite of food for the resident to eat. The staff stated Resident #1 can eat on his own, but she will go in to help him because he made a mess. Resident #1 again had a regular plate. The staff stated the resident chose to eat with his hands. <BR/>During an interview on 04/11/24 at 2:40 p.m. the Dietary Manager (DM) stated she had a binder of forms with dietary preferences and allergies for some residents but not all. The DM stated if a resident had an allergy, nursing would notify them with a paper . The DM stated she did not have a form in her binder for Resident #1. The DM stated they were not aware of Resident #1's food allergy to mushrooms and the spaghetti did not have mushrooms in it. The DM stated the kitchen did not have any mushrooms in it and it had been a while since the kitchen had any mushrooms. The DM stated the facility had divided plates available. The DM stated Resident #1 was supposed to receive a divided plate and staff needed to pay attention to what the diet sheet showed the resident needed for adaptive equipment. The DM stated the divided plate was needed to help the resident get his food better. The DM stated the cooks had over cooked the bread and needed to pay attention because residents would not be able to eat hard bread especially if they are on a mechanical soft diet. The DM stated the gelatin snack was not made right and was too watery. The DM stated the cooks had substituted the cheesecake with the gelatin snack but the resident should not have been served the watery gelatin snack. <BR/>During an interview on 04/12/24 at 9:12 a.m. the Speech Therapist stated Resident #1 was evaluated in March. The SP stated she was working with the Resident due to history of stroke and he had dysphagia. The SP stated if Resident #1 was presented food he would not take it and preferred to eat with his hands. The SP stated in March she recommended Resident #1 eat in the dining room per her notes because he could not communicate to staff and in case of an emergency he needed to be with in sight. The SP stated she they attempted to take Resident #1 to the dining room for meals in March after her recommendation but the Resident had a panic attack. The SP stated her recommendations were given to the rehab director and to the DON. The SP stated the Resident should have a divided plate with meals and his cups should have plastic lids and a straw. The SP stated she did go in the room to assist the resident with meals because she also helped with other residents and could not always be in the room with him. <BR/>During an interview on 04/12/24 at 12:35 a.m. the DON stated the Rehab director would usually let them know what findings they had from an evaluation. The DON stated Resident #1 was supervised only for meals, he was able to feed himself, he could use utensils, staff would set the tray up uncover everything for him, give him the spoon, he would pick it up and feed himself, and she did not see him shake or have tremors. The DON stated they were notified Resident #1 needed to eat in the dining room for queuing (prompting to eat) and or if he dropped his silverware. The DON stated the resident was very contracted and he refused to go to the dining room because it was painful for him to move. The DON stated staff would set the resident up at 90 degrees in bed, would set up his tray, and would go in and out of his room to supervise him during meals in his room. The DON stated they did not document or care plan the resident's refusals to go to the dining room. The DON stated staff would attempt 3 times to get the resident up and then would notify the nurse if he refused. The DON stated the SP would go in the room to sit with the resident and help him eat. The DON stated she had not read the SP evaluation and plan of care for Resident #1. The DON read the POC and stated she did not agree that staff would not be able to assist the resident in an emergency because the staff was CPR certified and could also perform the Heimlich maneuver. The DON stated she had never been notified that the resident would cough or choke while eating and the SP should have reported this to nursing. <BR/>During a joint interview on 04/12/24 at 4:37 p.m. with Rehab director and SP stated it was the RD's responsibility to communicate any evaluations and recommendations at clinical meetings to the nursing staff. They stated they were unable to get the resident to the recommended barium swallow study because the residents refused cooperate. The SP stated the resident did not want to get into the wheelchair and he had no signs or symptoms of choking such as a pneumonia. The RD stated the evaluation was done in March of 2024 and since then the resident had progressed. The RD stated the resident did not need supervision with meals. The RD stated he would not get supervision from staff they would just check in on him when he ate. The RD stated the doctor signed the SP evaluation on 03/19/24 with no further recommendations. The RD stated she was never notified or told the resident was coughing while eating or choking.<BR/>Record review of the facility's policy titled 'Nutritional Recommendations, dated 12/2017, stated policy: it is the policy of this home that the deal in/ DON will address recommendations by the console dietitian within three working days, if possible, of the exit of the dietician consult. Procedure: 1. the consultation will complete the nutritional recommendation form and/ or enteral feeding recommendations, sign, and date. 2. The consult dietitian will discuss the recommendations and exit conference with the administrator, director of nursing, and dietary service manager for clarification. After completion of the discussion, each will sign the form. 3. The dietitian will keep one copy of the form and give the other copy to the director of nursing. 4. The director of nursing or designee will contact the physician for orders or denial of the recommendation. The director of nursing or designee will write the physician's response and date and the follow up section. A note should be made regarding the reason for refusal if the physician denies the recommendation. 5. when recommendations have been completed and follow up column filled in, the director of nursing gave a copy to the administrator and dietary service manager. 6. The director of nursing/ designee will write orders in the medical records to initiate the approval recommendations. 7. The [nursing/ dietary communication form] will be completed regarding any diet or supplement changes. The original copy will be placed in dietary section of the medical record and the copy will be given to the dietary. 8. On the console dietitian next visit, the completed recommendations will be reviewed, and if indicated, follow up will be made in the clinical software. 9. It is the administrator's responsibility to see that recommendations are addressed within three business days, if possible, of the consulting dietitians exit conference.<BR/>The Administrator was given the IJ template and was notified of the IJ on 4/12/24 at 6:19 PM and a POR was requested.<BR/>On 04/14/24 at 1:35 PM, the POR was accepted. It was documented as follows:<BR/>4/12/2024<BR/>Plan of Removal - F 689 <BR/>Immediate Action Taken <BR/>Resident Specific <BR/>Resident #1 will be supervised by staff during all 3 meals daily beginning on 4/12/2024 at 7:00 pm.<BR/>Resident #1 had the appropriate care plan updates completed on 4/13/2024 at 11:20 am.<BR/>System Changes<BR/>On 4/12/2024 at 7:00 pm a facility audit took place to ensure that all residents requiring supervision for meals will receive appropriate supervision.<BR/>On 4/12/2024 at 7:00 pm DON and therapy reviewed all residents who require supervision for meals have had their care plans audited to ensure that the care plans accurately reflect the residents need for supervision with meals. <BR/>Starting on 4/12/2024 and ongoing therapy will be present in morning meetings to ensure that all orders are communicated directly between nursing and therapy to ensure that residents requiring supervision with meals will have recommendations reviewed and carried out appropriately. <BR/>Starting on 4/12/2024 and ongoing the DON will monitor two meals daily x 5 days a week to ensure staff compliance with meal supervision for those residents requiring supervision. <BR/>Starting on 4/12/2024 and ongoing residents dietary and supervision statuses will be audited upon change of condition, appropriate MDS cycles or anytime necessary. <BR/>Starting 4/13/2024 at 11:00 am the facility's mechanism for ensuring correct diet texture for the residents is that all trays will be compared to the actual plated meal for the resident by a licensed staff member prior to being served to the resident. The meal ticket/diet order will be compared for accuracy.<BR/>Education <BR/>On 4/12/2024 at 7:00 pm the Assistant Director of Nursing provided education to all staff regarding residents needing to have supervision at meals to ensure those residents will be supervised at mealtimes. Staff on future shifts will be educated prior to taking the floor. This will be accomplished by having a designated staff member in the building for that purpose and with that specific assignment. Licensed staff will be assigned by the DON to ensure that all trays/plates are correct prior to being served to the residents. Diet orders will match correctly to what is being served to the residents. This assigned licensed staff member will ensure specifically that texture, larger utensils, cup covers etc are being utilized for the residents.<BR/>On 4/12/2024 at 7:00 pm the Regional Clinical Consultant provided education to Administrator and Director of Nursing regarding residents needing supervision for meals. <BR/>On 4/12/2024 at 7:15 pm the Regional Clinical Consultant will educate DOR and clinical team as to communication and follow up during morning meetings. <BR/>Starting on 4/12/2024 at 7:00 pm the regional clinical consultant will be responsible for ensuring that staff receive the in-service/training regarding residents needing supervision during meals.<BR/>Starting on 4/12/2024 the residents dietary and supervision status will be communicated to facility staff directly by the DON and ADON. This process will be accomplished through photocopy and written communication.<BR/>Starting on 4/12/2024 the DON will be responsible for ensuring that the residents who require supervision during meals receive supervision.<BR/>Starting on 4/12/2024 at 7:00 pm during the daily stand up process all recommendations and orders will be audited by the clinical team in consultation with the therapy team to ensure compliance and follow up for all residents with orders and recommendations. The clinical consultant will review orders and recommendations daily x 4 weeks as a tool for oversight to ensure compliance.<BR/>100% Staff education compliance of the above mentioned by noon 4/14/24.<BR/>Verification of Plan of Removal:<BR/>Confirmed via Observation of lunch and dinner meals on 04/13/2024.<BR/>Confirmed via Record Review of Resident #1's care plan . <BR/>Confirmed via Interview with Regional Clinical Consultant and DON. They each had a list of all staff with check marks. Interviewed about their process for identifying residents who needed supervision and how they ensured no one was falling through the cracks. Interviewed each independently and they both said they went through each clinical record looking at: therapy notes and recommendations, physician notes, POC notes from CNAs, progress notes from LVNs and RNs, MDS assessments, and care plans. <BR/>On 4/12/2024 at 7:00 pm DON and therapy reviewed all residents who require supervision for meals have had their care plans audited.<BR/>Confirmed via Interview with Dir of Rehab and DON.<BR/>Record review of the care plans for all eight of the residents (Resident #1 and additional seven who require assistance). Five care plans had been updated - edits were observed - and the updates clarified and added more specific language. For example, instead of saying supervision as needed the language was updated to read supervision at all times by nursing staff. The two that were not updated were already very precise and specific in their wording. <BR/>Confirmed via Interview with Dir of Rehab DON, and Administrator <BR/>Confirmed via Interview with DON.<BR/>Record review of chart of items to check for each resident identified and had filled in the chart for each meal served since IJ was called. <BR/>Confirmed via Interview with Regional Clinical Consultant, DON, MDS/Care Plan Coordinator, and Administrator. <BR/>There were 52 total staff members 41 of the 52 staff have received in-service. Interview in person or by phone with 32 of the 52 staff members and confirmed they received the trainings and could verbalize understanding of the training. Of the 11 staff who did not receive the training: 1 FMLA, 1 vacation, and 9 PRN. Observation of a sign on the time clock stated for staff not to clock in for shift until they received in-service trainings dated 04/12/2024. <BR/>Observation of both lunch and dinner service on 04/13/2024 revealed each meal had an assigned licensed nurse to check meal tickets against trays. Observation of weekend RN meal tickets and trays revealed checking tickets for 15 residents versus what they had been served were completed and all were correct. The DON stated she would personally check two meals per day M-F, and weekend RN would check all three weekend meals (The DON and weekend RN work 6 am to 6 pm ). <BR/>Observation of the residents who required assistance in dining hall revealed staff were treating them with dignity, their tickets and meals were correct, and assistive devices(e.g. divided plate, built up utensils) were in place. <BR/>Observation of Resident #1 dining in his room revealed his ticket and meal were correct, a divided plate was in place, covered cups in place, and a member of nursing staff was providing 1 on 1 supervision. <BR/>Interviews conducted on 4/13/24 from 3:42 p.m. to 7:45 p.m. and on 4/14/24 from 9:03 a.m. to 1:30 p.m. revealed there were 14 nurses on staff, and interviewed 12 of them and all have received the in-service trainings (more detail on trainings below). <BR/>Interviews conducted on 4/13/24 from 3:42 p.m. to 7:45 p.m. and on 4/14/24 from 9:03 a.m. to 1:30 p.m. revealed there are 17 CNAs on staff, 13 of them were interviewed and all received the in-service trainings.<BR/>Confirmed via Interview with Regional Clinical Consultant and Record Review of in-service training.<BR/>Confirmed via Interview with DON and with ADON.<BR/>Record review of the in-services. One of the in-services which was given to all nursing staff identified all eight residents who require supervision and/or assistance for dining. <BR/>Confirmed via Interview with DON.<BR/>Observation of lunch and dinner comparison of their care plans and meal tickets against the meal, assistive devices, and level of supervision for the eight residents who required assistance received during both lunch and dinner, revealed each was correct. <BR/>Confirmed via Interview with Regional Clinical Consultant and DON, MDS/Care Plan Coordinator, and Administrator. <BR/>During interviews staff confirmed abuse and neglect training was done in general and every staff member confirmed ANE trainings are provided at least monthly. <BR/>Regional Clinical Consultant confirmed via interview that she was personally ensuring that all staff received in-service trainings. She was onsite today and planned to stay to catch the oncoming night shift. She provided her documentation via a staff list with check offs. <BR/>An IJ was identified on 4/12/24. While the IJ was removed on 04/14/24, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 1 of 3 residents (Residents #1) reviewed for food and nutrition services.<BR/>The facility failed to ensure Resident #1 received a mechanical soft diet in the proper consistency.<BR/>This deficient practice could place residents who received pureed meals at risk of dissatisfaction, poor intake, choking, and/or weight loss.<BR/>The findings included:<BR/>Record review of Resident #1's face sheet dated 4/10/24 revealed a [AGE] year-old male, admitted on [DATE] and readmitted on [DATE] with diagnoses of seizures, cerebrovascular disease, aphasia following cerebral infarction (a person may be unable to comprehend or unable to formulate language because of damage to specific brain regions), contracture right elbow (shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement), contracture right wrist, hemiplegia (weakness of one entire side of the body) and hemiparesis (complete paralysis of half of the body). The facesheet stated Resident #1 was allergic to morphine, mushrooms, and penicillins. The facesheet stated Resident #1 was allergic to morphine, mushrooms, and penicillins. <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was severely impaired for daily decision making, dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with ADLs in the areas of eating and drinking, and was on a mechanically altered diet. <BR/>Record review of Resident #1's comprehensive person-centered care plan, dated 02/20/24, revealed the resident's interventions for ADLs included REQUIRED***EATING: Resident requires set up assist. Resident #1 had unplanned/unexpected weight loss with interventions for ice cream as ordered, monitor and record food intake at each meal, notify the dietician of the weight loss upon their next visit, notify the physician, resident and family of the weight loss, provide verbal assistance and cues during meals, weigh the resident weekly for at least 4 weeks or until weight has stabilized. <BR/>Record review of Resident#1's Physician Order, dated 01/18/24 revealed an order for diet-regular, mechanical soft, and thin fluids. Special instructions FMP to all meals. Divided plate for every meal. The order was signed on 02/01/24 by the physician.<BR/>During an observation on 04/10/24 at 11:13 a.m. Resident #1 was in his room alone in bed. Resident #1 was sitting up in bed. Resident #1 was served a hard brown piece of toast with his lunch meal. Resident #1 grabbed the hard toast, took a bite, and a crunch noise was heard. The Resident put the bread down. This survey asked Resident #1 if the bread was too hard and Resident #1 nodded his head yes. Resident #1 lifted his fork with his left hand. Resident #1's hand was shaking, and food fell off the fork. The Resident #1 put the fork down on the tray. Resident #1 grabbed a handful of spaghetti and began to shove it in his mouth. Resident #1 ate quickly. No straws, condiments, or cheesecake were noted on the tray of food. There was a diet sheet from the kitchen which showed Resident #1's name, stated he was on a regular mechanical soft diet. <BR/>During an interview on 04/11/24 at 2:40 p.m. the Dietary Manager (DM) stated the cooks had over cooked the bread and needed to pay attention because residents would not be able to eat hard bread especially if they are on a mechanical soft diet. The DM stated the gelatin snack was not made right and was too watery. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to accommodate residents' food preferences and allergies for 1 of 3 (Resident #1) residents reviewed for food preferences and allergies, in that:<BR/>The facility failed to ensure that Resident #1's daily dietary form reflected the residents allergy to mushrooms. <BR/>These failures could cause an allergic reaction, a decrease in resident choices, and diminished interest in meals. <BR/>The findings were:<BR/>The findings included: <BR/>Record review of Resident #1's face sheet dated 4/10/24 revealed a [AGE] year-old male, admitted on [DATE] and readmitted on [DATE] with diagnoses of seizures, cerebrovascular disease, aphasia following cerebral infarction (a person may be unable to comprehend or unable to formulate language because of damage to specific brain regions), contracture right elbow (shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement), contracture right wrist, hemiplegia (weakness of one entire side of the body) and hemiparesis (complete paralysis of half of the body). The facesheet stated Resident #1 was allergic to morphine, mushrooms, and penicillins. The facesheet stated Resident #1 was allergic to morphine, mushrooms, and penicillins. <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was severely impaired for daily decision making, dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with ADLs in the areas of eating and drinking, and was on a mechanically altered diet. <BR/>Record review of Resident #1's comprehensive person-centered care plan, dated 02/20/24, revealed the resident's interventions for ADLs included REQUIRED***EATING: Resident requires set up assist. Resident #1 had unplanned/unexpected weight loss with interventions for ice cream as ordered, monitor and record food intake at each meal, notify the dietician of the weight loss upon their next visit, notify the physician, resident and family of the weight loss, provide verbal assistance and cues during meals, weigh the resident weekly for at least 4 weeks or until weight has stabilized. <BR/>Record review of Resident#1's Physician Order, dated 01/18/24 revealed an order for diet-regular, mechanical soft, and thin fluids. Special instructions FMP to all meals. Divided plate for every meal. The order was signed on 02/01/24 by the physician.<BR/>During an observation on 04/10/24 at 11:13 a.m. Resident #1 was in his room alone in bed. Resident #1 was sitting up in bed. The resident was eating from a food tray. There was a diet sheet from the kitchen with the food tray which showed Resident #1's name, stated he was on a regular mechanical soft diet with thin liquids, no allergies were listed.<BR/>During an interview on 04/11/24 at 2:40 p.m. the Dietary Manager (DM) stated she had a binder of forms with dietary preferences and allergies for some residents but not all. The DM stated if a resident had an allergy nursing would notify them with a paper. The DM stated she did not have a form in her binder for Resident #1. The DM stated they were not aware of Resident #1's food allergy to mushrooms an the spaghetti did not have mushrooms in it. The DM stated the kitchen did not have any mushrooms in it and it had been a while since the kitchen had any mushroom. <BR/>During an interview on 04/12/24 at 12:35 a.m. The DON stated she was pretty sure the mushroom allergy was more of a dislike but could not be sure so they would treat it as an allergy. The DON stated if the resident ate something he was allergic to his throat could close up. <BR/>Record review of the facility's policy titled 'Nutritional Recommendations, dated 12/2017, stated policy: it is the policy of this home that the deal in/ DON will address recommendations by the console dietitian within three working days, if possible, of the exit of the dietician consult. Procedure: 1. the consultation will complete the nutritional recommendation form and/ or enteral feeding recommendations, sign, and date. 2. The consult dietitian will discuss the recommendations and exit conference with the administrator, director of nursing, and dietary service manager for clarification. After completion of the discussion, each will sign the form. 3. The dietitian will keep one copy of the form and give the other copy to the director of nursing. 4. The director of nursing or designee will contact the physician for orders or denial of the recommendation. The director of nursing or designee will write the physician's response and date and the follow up section. A note should be made regarding the reason for refusal if the physician denies the recommendation. 5. when recommendations have been completed and follow up column filled in, the director of nursing gave a copy to the administrator and dietary service manager. 6. The director of nursing/ designee will write orders in the medical records to initiate the approval recommendations. 7. The [nursing/ dietary communication form] will be completed regarding any diet or supplement changes. The original copy will be placed in dietary section of the medical record and the copy will be given to the dietary. 8. On the console dietitian next visit, the completed recommendations will be reviewed, and if indicated, follow up will be made in the clinical software. 9. It is the administrator's responsibility to see that recommendations are addressed within three business days, if possible, of the consulting dietitians exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide drinks, including, water and other liquids, consistent with resident needs and preferences for 1 (Resident #1) of 4 Residents observed for meal service.<BR/>The facility failed to provide water during lunch on 04/10/24 for Resident #1. <BR/>This failure could place residents at risk for thirst, dehydration, and decreased quality of life. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 4/10/24 revealed a [AGE] year-old male, admitted on [DATE] and readmitted on [DATE] with diagnoses of seizures, cerebrovascular disease, aphasia following cerebral infarction (a person may be unable to comprehend or unable to formulate language because of damage to specific brain regions), contracture right elbow (shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement), contracture right wrist, hemiplegia (weakness of one entire side of the body) and hemiparesis (complete paralysis of half of the body). The facesheet stated Resident #1 was allergic to morphine, mushrooms, and penicillins. The facesheet stated Resident #1 was allergic to morphine, mushrooms, and penicillins. <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was severely impaired for daily decision making, dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with ADLs in the areas of eating and drinking, and was on a mechanically altered diet. <BR/>Record review of Resident #1's comprehensive person-centered care plan, dated 02/20/24, revealed the resident's interventions for ADLs included REQUIRED***EATING: Resident requires set up assist. Resident #1 had unplanned/unexpected weight loss with interventions for ice cream as ordered, monitor and record food intake at each meal, notify the dietician of the weight loss upon their next visit, notify the physician, resident and family of the weight loss, provide verbal assistance and cues during meals, weigh the resident weekly for at least 4 weeks or until weight has stabilized. <BR/>Record review of Resident#1's Physician Order, dated 01/18/24 revealed an order for diet-regular, mechanical soft, and thin fluids. Special instructions FMP to all meals. Divided plate for every meal. The order was signed on 02/01/24 by the physician.<BR/>During an observation on 04/10/24 at 11:13 a.m. Resident #1 had a coffee cup with no top, and a clear cup with a purple liquid drink with no top. The tray of food had liquid spilled all over it. A napkin was soaked with brown liquid and the diet sheet was also stained with brown liquid Resident #1's hand was shaking. There was no straws noted on the tray of food. There was a diet sheet from the kitchen which showed Resident #1's name and beverage: choice of beverage and water. <BR/>During an observation on 04/13/2024 during lunch and dinner service Resident #1 was dining in his room revealed his ticket and meal was correct, a divided plate was in place, covered cups in place, and a member of nursing staff was providing 1 on 1 supervision. <BR/>During an interview on 04/12/24 at 9:12 a.m. the Speech Therapist stated Resident #1 was evaluated in March. The SP stated she was working with the Resident due to history of stroke and he had dysphagia. The SP stated if Resident #1 was presented food he would not take it and preferred to eat with his hands. The SP stated the Resident should have a divided plate with meals and his cups should have plastic lids and a straw. The SP stated she did go in the room to assist the resident with meals but she also had to assist other residents and could not always be in the room with him.<BR/>Record review of the facility's policy titled 'Nutritional Recommendations, dated 12/2017, stated policy: it is the policy of this home that the deal in/ DON will address recommendations by the console dietitian within three working days, if possible, of the exit of the dietician consult. Procedure: 1. the consultation will complete the nutritional recommendation form and/ or enteral feeding recommendations, sign, and date. 2. The consult dietitian will discuss the recommendations and exit conference with the administrator, director of nursing, and dietary service manager for clarification. After completion of the discussion, each will sign the form. 3. The dietitian will keep one copy of the form and give the other copy to the director of nursing. 4. The director of nursing or designee will contact the physician for orders or denial of the recommendation. The director of nursing or designee will write the physician's response and date and the follow up section. A note should be made regarding the reason for refusal if the physician denies the recommendation. 5. when recommendations have been completed and follow up column filled in, the director of nursing gave a copy to the administrator and dietary service manager. 6. The director of nursing/ designee will write orders in the medical records to initiate the approval recommendations. 7. The [nursing/ dietary communication form] will be completed regarding any diet or supplement changes. The original copy will be placed in dietary section of the medical record and the copy will be given to the dietary. 8. On the console dietitian next visit, the completed recommendations will be reviewed, and if indicated, follow up will be made in the clinical software. 9. It is the administrator's responsibility to see that recommendations are addressed within three business days, if possible, of the consulting dietitians exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals for 1 (Resident #1) of 3 residents reviewed for special eating equipment and assistance when consuming meals, in that:<BR/>The dietary staff failed to provide Resident #1 with a divided plate to meet Resident #1's need for assistance with eating. <BR/>This failure could place residents at risk for harm by weight loss, diminished independence, and self-esteem.<BR/>The findings included:<BR/>. Record review of Resident #1's face sheet dated 4/10/24 revealed a [AGE] year-old male, admitted on [DATE] and readmitted on [DATE] with diagnoses of seizures, cerebrovascular disease, aphasia following cerebral infarction (a person may be unable to comprehend or unable to formulate language because of damage to specific brain regions), contracture right elbow (shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement), contracture right wrist, hemiplegia (weakness of one entire side of the body) and hemiparesis (complete paralysis of half of the body). The facesheet stated Resident #1 was allergic to morphine, mushrooms, and penicillins. <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was severely impaired for daily decision making, dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with ADLs in the areas of eating and drinking, and was on a mechanically altered diet. <BR/>Record review of Resident #1's comprehensive person-centered care plan, dated 02/20/24, revealed the resident's interventions for ADLs included REQUIRED***EATING: Resident requires set up assist. Resident #1 had unplanned/unexpected weight loss with interventions for ice cream as ordered, monitor and record food intake at each meal, notify the dietician of the weight loss upon their next visit, notify the physician, resident and family of the weight loss, provide verbal assistance and cues during meals, weigh the resident weekly for at least 4 weeks or until weight has stabilized. <BR/>Record review of Resident#1's Physician Order, dated 01/18/24 revealed an order for diet-regular, mechanical soft, and thin fluids. Special instructions FMP to all meals. Divided plate for every meal. The order was signed on 02/01/24 by the physician.<BR/>During an observation on 04/10/24 at 11:13 a.m. Resident #1 was in his room alone in bed. Resident #1's meal was served on a regular plate, not a divided plate, a coffee cup with no top, and a clear cup with a purple liquid drink with no top. The tray of food had liquid spilled all over it. A napkin was soaked with brown liquid and the diet sheet was also stained with brown liquid. Resident #1 lifted his fork with his left hand. Resident #1's hand was shaking, and food fell off the fork. The Resident #1 put the fork down on the tray. Resident #1 grabbed a handful of spaghetti and began to shove it in his mouth. Resident #1 ate quickly. No straws were noted on the tray of food. There was a diet sheet from the kitchen which showed Resident #1's name, adaptive equipment: divided plate.<BR/>During an observation on 04/11/24 at 11:30 Resident #1 lunch meal was delivered on a regular plate.<BR/>During an interview on 04/11/24 at 2:40 p.m. the Dietary Manager (DM) stated the facility had divided plates available. The DM stated Resident #1 was supposed to receive a divided plate and staff needed to pay attention to what the diet sheet showed the resident needed for adaptive equipment. The DM stated the divided plate was needed to help the resident get his food better. <BR/>During an interview on 04/12/24 at 9:12 a.m. the Speech Therapist stated Resident #1 was evaluated in March. The SP stated she was working with the Resident due to history of stroke and he had dysphagia. The SP stated if Resident #1 was presented food he would not take it and preferred to eat with his hands. The SP stated the Resident should have a divided plate with meals and his cups should have plastic lids and a straw. The SP stated she did go in the room to assist the resident with meals but she also helped with other residents and could not always be in the room with him. <BR/>Record review of the facility's policy titled 'Nutritional Recommendations, dated 12/2017, stated policy: it is the policy of this home that the deal in/ DON will address recommendations by the console dietitian within three working days, if possible, of the exit of the dietician consult. Procedure: 1. the consultation will complete the nutritional recommendation form and/ or enteral feeding recommendations, sign, and date. 2. The consult dietitian will discuss the recommendations and exit conference with the administrator, director of nursing, and dietary service manager for clarification. After completion of the discussion, each will sign the form. 3. The dietitian will keep one copy of the form and give the other copy to the director of nursing. 4. The director of nursing or designee will contact the physician for orders or denial of the recommendation. The director of nursing or designee will write the physician's response and date and the follow up section. A note should be made regarding the reason for refusal if the physician denies the recommendation. 5. when recommendations have been completed and follow up column filled in, the director of nursing gave a copy to the administrator and dietary service manager. 6. The director of nursing/ designee will write orders in the medical records to initiate the approval recommendations. 7. The [nursing/ dietary communication form] will be completed regarding any diet or supplement changes. The original copy will be placed in dietary section of the medical record and the copy will be given to the dietary. 8. On the console dietitian next visit, the completed recommendations will be reviewed, and if indicated, follow up will be made in the clinical software. 9. It is the administrator's responsibility to see that recommendations are addressed within three business days, if possible, of the consulting dietitians exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 4 residents (Resident #1 and Resident #5) reviewed for care plans.<BR/>1. The facility failed to care plan Resident #1's refusal eating in the dining room for supervision with meals.<BR/>2. The facility failed to care plan Resident #5's use or refusal to use fall mats. <BR/>This failure could place residents at risk of not having their needs met. <BR/>Finding Included:<BR/>1. Record review of Resident #1's face sheet dated 4/10/24 revealed a [AGE] year-old male, admitted on [DATE] and readmitted on [DATE] with diagnoses of seizures, cerebrovascular disease, aphasia following cerebral infarction (a person may be unable to comprehend or unable to formulate language because of damage to specific brain regions), contracture right elbow (shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement), contracture right wrist, hemiplegia (weakness of one entire side of the body) and hemiparesis (complete paralysis of half of the body). <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was severely impaired for daily decision making, dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with ADLs in the areas of eating and drinking, and was on a mechanically altered diet. <BR/>Record review of Resident #1's comprehensive person-centered care plan, dated 02/20/24, revealed the resident's interventions for ADLs included REQUIRED***EATING: Resident requires set up assist. Resident #1 had unplanned/unexpected weight loss with interventions for ice cream as ordered, monitor and record food intake at each meal, notify the dietician of the weight loss upon their next visit, notify the physician, resident and family of the weight loss, provide verbal assistance and cues during meals, weigh the resident weekly for at least 4 weeks or until weight has stabilized. <BR/>Record review of Resident#1's Physician Order, dated 01/18/24 revealed an order for diet-regular, mechanical soft, and thin fluids. Special instructions FMP to all meals. Divided plate for every meal. The order was signed on 02/01/24 by the physician.<BR/>During an observation on 04/10/24 at 11:13 a.m. Resident #1 was in his room alone in bed. Resident #1 was sitting up in bed. Resident #1 had a regular plate (not a divided plate as indicated in the resident's order) with spaghetti, cooked squash, a hard brown piece of toast, a dessert dish with watery gelatin snack, a coffee cup with no top, and a clear cup with a purple liquid drink with no top. The tray of food had liquid spilled all over it. A napkin was soaked with brown liquid and the diet sheet was also stained with brown liquid. Resident #1 grabbed the hard toast, took a bite, and a crunch noise was heard. The resident put the bread down. This survey asked Resident #1 if the bread was too hard and Resident #1 nodded his head yes. Resident #1 lifted his fork with his left hand. Resident #1's hand was shaking, and food fell off the fork. The Resident #1 put the fork down on the tray. Resident #1 grabbed a handful of spaghetti and began to shove it in his mouth. Resident #1 ate quickly. No straws, condiments, or cheesecake were noted on the tray of food. There was a diet sheet from the kitchen which showed Resident #1's name, stated he was on a regular mechanical soft diet with thin liquids, no allergies were listed, adaptive equipment: divided plate, entr&eacute;e: meat sauce, starch: spaghetti noodles, vegetable: zucchini, bread garlic toast, dessert: cheesecake, condiment salt/pepper/margarine, and beverage: choice of beverage and water. <BR/>During an observation on 04/11/24 at 11:30 Resident #1 was delivered a meal tray by an unidentified male staff. The staff exited the room right after delivering the tray. Resident #1 was eating in his room alone. At 11:38 a.m. an unidentified female staff went into his room. The resident's plate had no food left. The staff lifted a utensil with the last bite of food for the resident to eat. The staff stated Resident #1 can eat on his own, but she will go in to help him because he made a mess. Resident #1 again had a regular plate. The staff stated the resident chose to eat with his hands. <BR/>During an interview on 04/12/24 at 9:12 a.m. the Speech Therapist stated Resident #1 was evaluated in March. The SP stated she was working with the Resident due to history of stroke and he had dysphagia. The SP stated if Resident #1 was presented food he would not take it and preferred to eat with his hands. The SP stated in March she recommended Resident #1 eat in the dining room per her notes because he could not communicate to staff and in case of an emergency he needed to be with in sight. The SP stated she they attempted to take Resident #1 to the dining room for meals in March after her recommendation but the Resident had a panic attack. The SP stated her recommendations were given to the rehab director and to the DON. The SP stated the Resident should have a divided plate with meals and his cups should have plastic lids and a straw. The SP stated she did go in the room to assist the resident with meals because she also helped with other residents and could not always be in the room with him. <BR/>During an interview on 04/12/24 at 12:35 a.m. the DON stated the Rehab director would usually let them know what findings they had from an evaluation. The DON stated Resident #1 was supervised only for meals, he was able to feed himself, he could use utensils, staff would set the tray up uncover everything for him, give him the spoon, he would pick it up and feed himself, and she did not see him shake or have tremors. The DON stated they were notified Resident #1 needed to eat in the dining room for queuing (prompting to eat) and or if he dropped his silverware. The DON stated the resident was very contracted and he refused to go to the dining room because it was painful for him to move. The DON stated staff would set the resident up at 90 degrees in bed, would set up his tray, and would go in and out of his room to supervise him during meals in his room. The DON stated they did not document or care plan the resident's refusals to go to the dining room. The DON stated staff would attempt 3 times to get the resident up and then would notify the nurse if he refused. The DON stated the SP would go in the room to sit with the resident and help him eat. The DON stated she had not read the SP evaluation and plan of care for Resident #1. The DON read the POC and stated she did not agree that staff would not be able to assist the resident in an emergency because the staff was CPR certified and could also perform the Heimlich maneuver. The DON stated she had never been notified that the resident would cough or choke while eating and the SP should have reported this to nursing. <BR/>During a joint interview on 04/12/24 at 4:37 p.m. with Rehab director and SP stated it was the RD's responsibility to communicate any evaluations and recommendations at clinical meetings to the nursing staff. They stated they were unable to get the resident to the recommended barium swallow study because the resident refused to cooperate. The SP stated the resident did not want to get into the wheelchair and he had no signs or symptoms of choking such as a pneumonia. The RD stated the evaluation was done in March of 2024 and since then the resident had progressed. The RD stated the resident did not need supervision with meals. The RD stated he would not get supervision from staff they would just check in on him when he ate. The RD stated the doctor signed the SP evaluation on 03/19/24 with no further recommendations. The RD stated she was never notified or told the resident was coughing while eating or choking.<BR/>2. Record review of Resident #5's face sheet dated 4/12/24 revealed a [AGE] year-old female, admitted on [DATE] and readmitted on [DATE] with diagnoses of cerebral infarction (stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood.), Alzheimer's disease late onset (disease that affects memory), insomnia (inability to sleep or stay asleep), unsteadiness on feet, and history of falling. <BR/>Record review of Resident #5's quarterly MDS dated [DATE] revealed Resident #5 was severely impaired for daily decision making, had 1 fall with no injury, and 1 fall with injury (except major) since admission/entry or reentry or admission. <BR/>Record review of Resident #5's comprehensive person-centered care plan, dated 04/10/24, revealed the Resident #5 had a history of falls related to Alzheimer's with intervention to ensure proper footwear, staff to increase activities, wedge cushion ordered for chair, staff to ensure resident is positioned at nurses station, staff to provide frequent rounds, keep bed in lowest position with brakes locked, and staff to provide hand activities for resident while up. <BR/>During an observation on 04/11/24 at 10:33 a.m. Resident #5 was lying in bed. There was a single fall mat folded into a stack of three layers on the ground, aligned on one side of the bed. The mat did not cover the side of the bed because it was folded up. <BR/>During an observation on 04/11/24 at 11:36 a.m. the mat was observed in the same position and the resident was still laying in the bed. <BR/>During an interview on 04/12/24 at 12:14 p.m. the DON stated Resident #5 had memory issues and would often get out of bed and kick everything out of the way. The DON stated she had fall matts in her room and they had brought up that the resident would kick them out of the way at a care plan meeting before. The DON stated they should care plan the fall matts. <BR/>Record review of document titled Speech Therapy Plan of Care - 03/13/2024, dated 03/13/2024, revealed profound language impairments and mild pharyngeal swallow function impairments (71-85% ability). Section titled Underlying Impairments listed Verbal Expression- Automatic speech severe impairment, Auditory Comprehension- 1 step commands severe impairment, Auditory Comprehension- wh questions- Severe Impairment, and Pharyngeal Swallow Deficits- after swallow. The reasons for referral were without therapeutic intervention patient at risk for: choking, aspiration, weight loss, inability to meet nutritional needs via PO intake of least restrictive diet .Bedside Swallowing Assessment .Pharyngeal phase: Patient demonstrated no signs or symptoms of aspiration during meal or when drinking . Patient demonstrated strong reflexive coughing episode &gt; 10 minutes after last PO intake with face reddening/eye tearing, suspected aspiration/penetration of secretions vs reflux material. Patient seized coughing and resumed normal breathing pattern within 20 seconds. Conclusion patient demonstrated grossly within functional limits oropharyngeal swallow at his current/baseline diet level however it is strongly recommended that the patient take meals in the dining room with staff supervision going forward, if he were to experience choking/aspiration during a meal in his room, staff would not be able to recognize the signs or help him in a timely manner, increasing his risk of an emergency event. Additionally patient shows signs that he may be aspirating/choking on reflux material after eating, and should be kept in an upright position, such as in his wheelchair and within close proximity to staff for supervision and assistance if necessary. SLP to provide skilled dysphasia intervention to provide staff education on choking/ reflux precautions and order/ complete MBSS to objectively assess for risk of aspiration, reflux, esophageal dysmotility, etc. <BR/>Record review of Speech Therapy daily notes 03/13/2024 through 04/12/2024 stated: <BR/>03/18/2024 patient taken for on site MBSS (Modified Barium Swallow Study (MBSS) is a specialized x-ray procedure that helps both the Radiologist (who specializes in using x-rays) and the Speech Language Pathologist (SLP) identify why someone is having trouble with swallowing). Patient presented with very high anxiety when SLP and transport aide attempted to bring him out- shaking, yelling, waving people away. Patient was briefly calmed while being taken to the van and set up. patient resumed elevated behavior when evaluating SLP presented trials. Patient accepted one teaspoon of thin liquid by cup and began to shout and rock back and forth violently before swallowing. Agitation continued across other trials/ consistencies attempted, and with multiple feeders. results inconclusive due to lack of patient participation, however no penetration/ aspiration observed with 1 swallow. Anatomy noted with cervical osteocytes and decreased lordodic curvature nearing pharyngeal space and creating pharyngeal pressure system deficit. Recommendations are to continue current diet (mechanical soft and thin liquid, crushed meds) while taking all meals upright and supervised with assistance as needed. <BR/>03/21/2024 SLP discussed with CNA recommendations for patient to be up in wheelchair in dining room for lunch period CNA reported patient becoming severely agitated (screaming, shaking, vehemently refusing) during attempts to get him out of bed. CNA attempted again today and reported similar behavior. SLP acknowledged and documented CNA's report.<BR/>03/29/2024 SLP assisted patient with lunch at bedside. Patient mostly self-fed with fingers, occasionally accepting prefilled spoons with help from SLP. Patient ate rapidly/ impulsively and was not responsive to verbal/ gestural cues to pace himself or alternate bites/sips. Patient refused liquid wash each time it was offered. No signs or symptoms aspiration T/ O meal, adequate oral clearance at the end of the meal.<BR/>04/09/2024 patient had 1/2 PBJ sandwich, unmodified, self-fed. Patient was able to take bites out of the sandwich. Ataxia (neurological sign consisting of lack of voluntary coordination of muscle movements that can include trouble eating and swallowing) evident during mastication but patient still able to manipulate and propel bolus effectively. Patient used liquid wash on his own. SLP checked oral cavity to ensure no pocketing/stasis after he finished. <BR/>Record review of the facility's care plan policy, dated 12/2017, stated policy: it is the policy of this home that staff must develop a comprehensive care plan to meet the needs of the resident .Note remember the residents care plan is a tool used to coordinate all care provided to the resident to be sure care is necessary, appropriate and planned to meet individual needs of the resident consonant with the physician's plan of care for the resident .12. Resident care plan documentation and use of the plan: a. the residents care plan is used to plan and assign care for all disciplines .c. The resident care plan must be kept current at all times .

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that:<BR/>1. A plastic bag of cheese in the refrigerator was not labeled or dated.<BR/>2. A plastic bag of beets in the refrigerator was not labeled or dated.<BR/>3-A one gallon plastic container of pudding was not labeled or dated<BR/>4. The temperature gauge on the dish machine in the dish room was not working as the temperature reading would not advance on the gauge.<BR/>5. Snacks in the Nourishment Rooms were not labeled or dated.<BR/>These deficient practices could place residents who received meals and snacks from the kitchen at risk for food borne illness from improper infection control, from a lack of food label date monitoring, from a lack of equipment maintenance, and improper sanitation in the kitchen area.<BR/>The findings included:<BR/>Observation on 06/04/24 from 9:10 am to 9:40 am, during the kitchen tour with the Dietary Manager revealed the following:<BR/>a. There was a plastic bag of cheese in the refrigerator that was not labeled or dated.<BR/>b. There was a plastic bag of beets in the refrigerator that was not labeled or dated.<BR/>c. There was a one- gallon plastic container of pudding that was not labeled or dated.<BR/>d. The temperature gauge on the dish machine in the dish room was not working.<BR/>During an interview with the Dietary Manager on 06/04/24 at 9:45 am, she stated the food in the refrigerators must be dated and labeled to determine the food expiration date. She stated the temperature gauge on the dish machine in the dish room had not been working for about one month. The Dietary Manager stated she had informed the Maintenance Director along with the dish machine service representative of the problem. She stated dietary staff had to use a manual thermometer to check for proper cleaning temperature and having a working temperature gauge on the dish machine was important for sanitation purposes. The Dietary Manager stated a working temperature gauge would be installed on 06/04/24.<BR/>During an interview with the DON on 06/06/24 at 12:40 pm, issues mentioned during the resident meeting were discussed. One of the issues was residents do not consistently get snacks, especially at night. The DON stated snacks are given on a first come first served basis and if a resident has a doctor's order for a snack, then the resident's name is placed on the snack. The DON then showed surveyor a small refrigerator in the nourishment room where facility snacks and personal resident snacks are kept. A tray on the counter in this room revealed a few items that may have been snacks such as cookies but they were not labeled or dated and did not have a resident's name on them. The DON stated these were the snacks that were available but they should have been given to or at least offered to residents unless they were the ones that were just left over. The DON stated she would ensure that snacks were being offered to residents especially at night.<BR/>On 06/06/24 at 1:30 pm an interview with Dietary Manager revealed snacks are taken to the nourishment rooms at 10:00 am, 2:00 pm and 8:00 pm. The Dietary Manager stated nursing was then responsible to hand out the snacks.<BR/>During an interview with the Administrator on 06/06/24 at 4:45 pm, he stated having the food labeled and dated was important to determine the food expiration time period. He stated having a working temperature gauge on the dish machine was important for sanitation purposes.<BR/>During an interview and observation on 06/07/24 at 11:02 am with the Housekeeping Supervisor, the nourishment rooms were discussed along with the lack of cleaning of the refrigerators. The freezer part of the refrigerator in the Nourishment Room on the 100-200 Halls had been observed with a a large build-up of ice and there was a white melted spot of some substance in the bottom of the freezer. There were also spilled liquids on several shelves of the refrigerator part of the device. The Nourishment Room on the 300-400 Halls was observed during this interview and a large full size refrigerator was observed in that room. A tray of snacks were noted on the top shelf of the refrigerator but they were not dated or labeled. The Housekeeping Supervisor stated she had heard that snacks had been delivered about an hour ago so assumed this was the tray that was delivered. The Housekeeping Supervisor stated she and the housekeepers were responsible for keeping the Nourishment Rooms and the refrigerators clean. <BR/>During an interview with the Dietary Manager on 06/07/24 at 11:30 am, the snack delivery system was discussed and she was asked to view the snacks in the refrigerator in the 300-400 Hall Nourishment Room. The snacks were noted to contain a couple of bowls of pudding, crackers, baggies of cookies, and a couple of baggies of cereal. None of the items were dated or labeled with the name of the item. The Dietary Manager stated when they brought in new snacks, any snacks left over from the previous distribution were taken out and discarded. When asked how anyone would know when these snacks were brought out, she stated she needed to put a date and time they were brought out on each snack so someone would know if it was safe to eat. <BR/>Record review of the facility's policy on Food Storage, policy number 03.003 dated 2018 revealed food in refrigerators is to be dated and labeled in containers that are approved for food storage.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (A) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5&ordm;C (41&ordm;F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.<BR/>Record review of facility's policy on General Kitchen Safety Guidelines, policy number 05.001 dated 2018 revealed all equipment is to be kept in working order and malfunctions reported to the Maintenance Department.<BR/>Record review of facility's Maintenance Log Book for the months of April and May 2024 revealed no work order for repair of the dish machine temperature gauge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide evidence that all alleged violations of neglect, abuse, misappropriation of property were thoroughly investigated in order to prevent further potential neglect, abuse, misappropriation while the investigation was in progress for 1 of 6 resident (Resident #1) reviewed for neglect, in that:<BR/>The facility did not thoroughly investigate an incident that Resident #1 choked and died after receiving routine medications. <BR/>This deficient practice could place residents at risk for harm to include death.<BR/>The findings were: <BR/>Record review of facility's Abuse/Reportable Events policy dated [DATE] read: .Neglect: is the failure of the facility .to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .Investigation: Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated . <BR/>Record review of Resident #1's Nurse note dated [DATE] revealed: resident was re-admitted to the facility for long term care directly from a local hospital. Hospital diagnoses included: advanced dementia, depression, altered mental state, and a subdural hematoma (bleeding in the brain).<BR/>Record review of Resident#1's face sheet, dated [DATE], and EMR (electronic medical record) revealed, the resident was admitted on [DATE] with diagnoses that included: traumatic subdural hemorrhage (brain bleed-primary), pneumonia (acquired at the facility on [DATE]) and dementia. Resident was a female; age [AGE]. Advanced Directive was DNR (do not resuscitate). RP (responsible party) was listed as: a family member.<BR/>Record review of Resident# 1's Care Plan, dated [DATE], revealed goals and interventions that included: Pneumonia. Interventions included: monitor for signs of symptoms of pneumonia. Another goal was administration of psychotropic drugs. Interventions included: behavior management.<BR/>Record review of Resident#1's admission MDS (minimum data set), dated [DATE], revealed: <BR/> BIMS (brief interview of mental status) Score was 2 (meaning the resident had severe impairments in cognition). The Resident's ADLs (activities of daily living) revealed: resident was incontinent of bowel and bladder. The resident required assistance with transfer by one staff; and bed mobility required two staff assistance. The resident had no range of motion impairment. <BR/>Record review of Resident #1's Dietary Flow Sheet revealed a diet order with a start date of [DATE] and an end date of [DATE] for a diet order being regular and thin liquids. <BR/>Record review of Resident#1's MAR (medication administration record), dated [DATE], revealed, the resident received the following medications prior to the choking incident:<BR/>*Vitamin C 500 mg daily<BR/>*Divalproex 500 mg daily (for seizures)<BR/>*Folic acid 1 mg (vitamin)<BR/>*Multi-vitamin 0.4 mg daily<BR/>*Wellbutrin (for depression) 150 mg daily <BR/>Record review of Resident#1's Nurse Note, dated [DATE], authored by Nurse B, read: <BR/>at 0705 [7:05 AM] this nurse raises HOB {Head of bed board} and gives pt [patient] water using straw, when pt ready admin meds [medications] po [by mouth] individually, pt sipping between meds. Pt takes meds then nods when asked if would like more water, pt finishes water quickly and at 0712 [7:12 AM] pt sputters water from mouth, pt noted with tongue thrusting, this nurse laid HOB flat rolled pt to L [left] side and cleared water, pt cont [continued]with tongue thrusting, called to LVN [Nurse C] for assistance came to room assist with positioning abd [abdominal] thrust and back thrusting. 0715 [7:15 AM] LVN activate 911, sx [crash cart/suctioning] machine retrieved by this nurse. Additional airway clearing by resident at 0720 [7:20 AM], pulse is weakly noted by LVN, sent RN supervisor to door to allow access for EMS. SX cleared some med residual that had been coughed out, pt lips noted blue tinged with no reading from pulse . 0725 [7:25 AM] EMS arrives sets up leads, 0729 [7:29 AM] SAFD Doc [physician] called with TOD [time of death] 0729 [7:29 AM] . <BR/>Record review of resident #1's SBAR dated [DATE], authored by Nurse B, read: sputters water, tongue thrusting at 7:12 AM.<BR/>Record review of Resident #1's DNR was dated [DATE], signed by MD and witnessed; and signed by RP. <BR/>During an interview on [DATE] at 3:33 PM, Nurse A stated: they read in the progress notes and Nurse D said that Resident #1 was deceased due to choking on pills after the resident was given medications by Nurse B. Nurse A stated that Heimlich maneuver was attempted by Nurse B and Nurse C but with no success. [Nurse A had no knowledge as to whether the facility investigated the choking death of Resident #1.] <BR/>During an interview on [DATE] at 3:49 PM, the Administrator stated: he did not know what caused Resident #1 to die on [DATE]. The Administrator trusted the information given to him by nurse management (DON) that the death was no suspicious. Therefore, the Administrator stated he did not investigate the incident; and did not report the death to HHS. The Administrator added that the facility did contact law enforcement on [DATE]; and law enforcement released the resident's body back to the facility. <BR/>During an interview on [DATE] at 5:02 PM, Nurse B stated: . I went in at 7:05 AM on [DATE] ; placed the head of the bed at 50 degrees; gave her (Resident #1) the pills in a med cup ; and gave her water with the straw in a cup; she took the medicine; I asked whether she wanted more water; she started sputtering and then water came out of her mouth; tongue started thrusting out of the mouth .I put the bed flat and she started coughing .I called for help .[Nurse C] came in and we attempted abdominal thrust [which was a modified Heimlich maneuver] . I got the crash cart and [Nurse C] was calling 911 (7:15 AM) .we always maintained observation of the resident .I was setting up the suction machine in the room and EMS arrived at 7:25 AM .they hooked resident to the EKG .I gave them the out-hospital DNR form .resident was no incubated .MD called and resident pronounced deceased by MD (Fire Department) .RP and facility MD called .cause of death was unknown .medication did not require crushing or to be put in a liquid form .I gave her one pill at a time .she got all the pills down .7:12 AM was when the resident started sputtering .DON notified .incident was spontaneous .Fire Department called Law Enforcement . Homicide Unit investigated (Case #2309920)- .Homicide Unit did not suspect that a crime was committed and the resident was released to the funeral home. Nurse B stated the Administrator and DON did not submit a self-report to HHS. Nurse B stated that Resident #1 did not have a history of aspiration. CPR was not done by nursing staff because the resident was DNR. Nurse B stated that she gave a verbal accounting of the incident to Nurse D and the DON; and documented the timeline in a nurse note dated [DATE]. [Nurse B had no knowledge as to whether the facility investigated the choking death of Resident #1.] <BR/>During an interview on [DATE] at 5:28 PM, Nurse C stated: I arrived around 7:10 AM and at 7:15 AM called 911 .because the resident was turning blue .resident was DNR .I started a modified Heimlich (pushing down on the stomach) .putting pressure on the abdomen in upward .she [Resident #1] would spit up water .once the suctioning machine arrived we hooked her up and started suctioning her month and was able to clear one pill. Nurse C did not know how many pills were given to the resident. Nurse B got a copy of the out-of- hospital DNR for EMS. Nurse B she took over the suctioning while Nurse C listened for a heartbeat and heard none and then EMS arrived around at 7:25 AM. The resident was pronounced at 7:27 by the Fire Department physician. Nurse C commented that Law Enforcement and the Homicide Unit arrived and conducted a brief investigation and released the body to the facility. Nurse C expressed the opinion that there might have been a delay in starting the Heimlich maneuver when the resident was choking [ 7:12 AM to 7:13 AM]. Nurse C added that the Resident (#1) had no history of aspiration or choking. [Nurse C had no knowledge as to whether the facility investigated the choking death of Resident #1.]<BR/>During an interview on [DATE] at 8:26 AM, Nurse B stated: the timeline of the incident on [DATE] involving the choking death of Resident #1 was as follows:<BR/>*7:05 AM-entered residence's room to dispense medications<BR/>*7:12 AM-Resident #1 started spurting. Nurse B laid resident flat in bed, turned resident to the side, and started back trusts (striking resident on the back). Called for help.<BR/>*7:13 AM- Nurse C arrived in the room and started abdominal trusts (modified Heimlich maneuver)<BR/>*7:15 AM- Nurse C called 911<BR/>*7:15 AM- Nurse B left to get the crash cart<BR/>*7:17 AM-crash cart present and suctioning started<BR/>*7:20 AM-low pulse and resident turning blue<BR/>*7:25 AM- EMS arrived<BR/>*7:27 AM-Resident #1 pronounced deceased by Fire Department MD<BR/> Regarding the 7-minute gap between 7:05 AM to 7:12 AM, Nurse B stated, they dispensed the medication slowly to the Resident (#1) so as to allow the resident to drink between each pill given. Nurse B stated that the choking incident started at 7:12 AM and not sooner.<BR/>During an interview on [DATE] at 8:40 AM, Nurse C stated (regarding the timeline).<BR/>*At 7:13 AM- [Resident #1 started spurting water and was choking. Nurse B laid the resident flat in bed, turned the resident to the side, and started back trusts (striking resident on the back. Nurse B Called for help.) Nurse C saw the resident flat in bed to the side when they arrived at 7:13 AM. Nurse C restated, . she (resident #1) was choking when I entered the room .<BR/>During an interview on [DATE] at 9:15 AM facility MD stated: putting Resident #1 on the side was appropriate and a safe position. It was a stressful situation and Nurse (B) did her best .in hindsight starting the Heimlich sooner might have been another intervention .but Nurse (B) did call for help . The facility MD added that doing a modified Heimlich early in a crisis does not necessarily result in the resident not choking and not dying. Likewise, in a crisis, the intervention by another professional staff helps in the assessment of the resident and what further interventions are needed. Facility MD said the nurses [Nurse B and Nurse C] did the right procedures and CPR was never given because the Resident was DNR. In the crisis, the facility MD stated, the nurses attempted different interventions; and the resident had symptoms of choking and was alive for a period of time. EMS was also guiding the nurses (Nurse B and C) before their arrival. The facility MD saw no neglect in the tragic death of Resident #1. [The facility MD had no knowledge as to whether the facility investigated of the incident.] <BR/>During an interview on [DATE] at 9:43 AM, The DON stated: an investigation was not done because the facts were known and the death was not suspicious. HHS was not contacted because the death was not suspicious. Nursing staff performed as they were trained and in-serviced, according to the DON. <BR/>During an interview on [DATE] at 9:52 AM, the Administrator stated: there was no suspicion regarding the death of the resident and therefore no need to investigate or to report to the state (HHS). The Administrator relied on the nursing staff for guidance on whether to investigate and to report to HHS. As stated by the Administrator, I did not suspect neglect existed in the death of Resident (#1). The Administrator stated that law enforcement was called and the Homicide Unit released the body of Resident #1 back to the facility. The Administrator did not report the unexpected death of Resident #1 from choking on routine medications because there was no neglect. However, the Administrator was not certain of the timeline involving the choking and nursing interventions given. He and the DON did not conduct a formal investigation and document their findings.<BR/>Record review of facility's Incident Log from March-[DATE] revealed, the medication choking incident on [DATE] involving Resident #1 was not recorded or investigated. <BR/>Record review of facility's Heimlich Maneuver policy dated 12/2017 read: Resident becomes unconscious .Position resident on back, face up, and delegate a person to call 911 .Give 4 abdominal thrusts as described for resident lying down .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 4 residents (Resident #1 and Resident #5) reviewed for care plans.<BR/>1. The facility failed to care plan Resident #1's refusal eating in the dining room for supervision with meals.<BR/>2. The facility failed to care plan Resident #5's use or refusal to use fall mats. <BR/>This failure could place residents at risk of not having their needs met. <BR/>Finding Included:<BR/>1. Record review of Resident #1's face sheet dated 4/10/24 revealed a [AGE] year-old male, admitted on [DATE] and readmitted on [DATE] with diagnoses of seizures, cerebrovascular disease, aphasia following cerebral infarction (a person may be unable to comprehend or unable to formulate language because of damage to specific brain regions), contracture right elbow (shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement), contracture right wrist, hemiplegia (weakness of one entire side of the body) and hemiparesis (complete paralysis of half of the body). <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was severely impaired for daily decision making, dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with ADLs in the areas of eating and drinking, and was on a mechanically altered diet. <BR/>Record review of Resident #1's comprehensive person-centered care plan, dated 02/20/24, revealed the resident's interventions for ADLs included REQUIRED***EATING: Resident requires set up assist. Resident #1 had unplanned/unexpected weight loss with interventions for ice cream as ordered, monitor and record food intake at each meal, notify the dietician of the weight loss upon their next visit, notify the physician, resident and family of the weight loss, provide verbal assistance and cues during meals, weigh the resident weekly for at least 4 weeks or until weight has stabilized. <BR/>Record review of Resident#1's Physician Order, dated 01/18/24 revealed an order for diet-regular, mechanical soft, and thin fluids. Special instructions FMP to all meals. Divided plate for every meal. The order was signed on 02/01/24 by the physician.<BR/>During an observation on 04/10/24 at 11:13 a.m. Resident #1 was in his room alone in bed. Resident #1 was sitting up in bed. Resident #1 had a regular plate (not a divided plate as indicated in the resident's order) with spaghetti, cooked squash, a hard brown piece of toast, a dessert dish with watery gelatin snack, a coffee cup with no top, and a clear cup with a purple liquid drink with no top. The tray of food had liquid spilled all over it. A napkin was soaked with brown liquid and the diet sheet was also stained with brown liquid. Resident #1 grabbed the hard toast, took a bite, and a crunch noise was heard. The resident put the bread down. This survey asked Resident #1 if the bread was too hard and Resident #1 nodded his head yes. Resident #1 lifted his fork with his left hand. Resident #1's hand was shaking, and food fell off the fork. The Resident #1 put the fork down on the tray. Resident #1 grabbed a handful of spaghetti and began to shove it in his mouth. Resident #1 ate quickly. No straws, condiments, or cheesecake were noted on the tray of food. There was a diet sheet from the kitchen which showed Resident #1's name, stated he was on a regular mechanical soft diet with thin liquids, no allergies were listed, adaptive equipment: divided plate, entr&eacute;e: meat sauce, starch: spaghetti noodles, vegetable: zucchini, bread garlic toast, dessert: cheesecake, condiment salt/pepper/margarine, and beverage: choice of beverage and water. <BR/>During an observation on 04/11/24 at 11:30 Resident #1 was delivered a meal tray by an unidentified male staff. The staff exited the room right after delivering the tray. Resident #1 was eating in his room alone. At 11:38 a.m. an unidentified female staff went into his room. The resident's plate had no food left. The staff lifted a utensil with the last bite of food for the resident to eat. The staff stated Resident #1 can eat on his own, but she will go in to help him because he made a mess. Resident #1 again had a regular plate. The staff stated the resident chose to eat with his hands. <BR/>During an interview on 04/12/24 at 9:12 a.m. the Speech Therapist stated Resident #1 was evaluated in March. The SP stated she was working with the Resident due to history of stroke and he had dysphagia. The SP stated if Resident #1 was presented food he would not take it and preferred to eat with his hands. The SP stated in March she recommended Resident #1 eat in the dining room per her notes because he could not communicate to staff and in case of an emergency he needed to be with in sight. The SP stated she they attempted to take Resident #1 to the dining room for meals in March after her recommendation but the Resident had a panic attack. The SP stated her recommendations were given to the rehab director and to the DON. The SP stated the Resident should have a divided plate with meals and his cups should have plastic lids and a straw. The SP stated she did go in the room to assist the resident with meals because she also helped with other residents and could not always be in the room with him. <BR/>During an interview on 04/12/24 at 12:35 a.m. the DON stated the Rehab director would usually let them know what findings they had from an evaluation. The DON stated Resident #1 was supervised only for meals, he was able to feed himself, he could use utensils, staff would set the tray up uncover everything for him, give him the spoon, he would pick it up and feed himself, and she did not see him shake or have tremors. The DON stated they were notified Resident #1 needed to eat in the dining room for queuing (prompting to eat) and or if he dropped his silverware. The DON stated the resident was very contracted and he refused to go to the dining room because it was painful for him to move. The DON stated staff would set the resident up at 90 degrees in bed, would set up his tray, and would go in and out of his room to supervise him during meals in his room. The DON stated they did not document or care plan the resident's refusals to go to the dining room. The DON stated staff would attempt 3 times to get the resident up and then would notify the nurse if he refused. The DON stated the SP would go in the room to sit with the resident and help him eat. The DON stated she had not read the SP evaluation and plan of care for Resident #1. The DON read the POC and stated she did not agree that staff would not be able to assist the resident in an emergency because the staff was CPR certified and could also perform the Heimlich maneuver. The DON stated she had never been notified that the resident would cough or choke while eating and the SP should have reported this to nursing. <BR/>During a joint interview on 04/12/24 at 4:37 p.m. with Rehab director and SP stated it was the RD's responsibility to communicate any evaluations and recommendations at clinical meetings to the nursing staff. They stated they were unable to get the resident to the recommended barium swallow study because the resident refused to cooperate. The SP stated the resident did not want to get into the wheelchair and he had no signs or symptoms of choking such as a pneumonia. The RD stated the evaluation was done in March of 2024 and since then the resident had progressed. The RD stated the resident did not need supervision with meals. The RD stated he would not get supervision from staff they would just check in on him when he ate. The RD stated the doctor signed the SP evaluation on 03/19/24 with no further recommendations. The RD stated she was never notified or told the resident was coughing while eating or choking.<BR/>2. Record review of Resident #5's face sheet dated 4/12/24 revealed a [AGE] year-old female, admitted on [DATE] and readmitted on [DATE] with diagnoses of cerebral infarction (stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood.), Alzheimer's disease late onset (disease that affects memory), insomnia (inability to sleep or stay asleep), unsteadiness on feet, and history of falling. <BR/>Record review of Resident #5's quarterly MDS dated [DATE] revealed Resident #5 was severely impaired for daily decision making, had 1 fall with no injury, and 1 fall with injury (except major) since admission/entry or reentry or admission. <BR/>Record review of Resident #5's comprehensive person-centered care plan, dated 04/10/24, revealed the Resident #5 had a history of falls related to Alzheimer's with intervention to ensure proper footwear, staff to increase activities, wedge cushion ordered for chair, staff to ensure resident is positioned at nurses station, staff to provide frequent rounds, keep bed in lowest position with brakes locked, and staff to provide hand activities for resident while up. <BR/>During an observation on 04/11/24 at 10:33 a.m. Resident #5 was lying in bed. There was a single fall mat folded into a stack of three layers on the ground, aligned on one side of the bed. The mat did not cover the side of the bed because it was folded up. <BR/>During an observation on 04/11/24 at 11:36 a.m. the mat was observed in the same position and the resident was still laying in the bed. <BR/>During an interview on 04/12/24 at 12:14 p.m. the DON stated Resident #5 had memory issues and would often get out of bed and kick everything out of the way. The DON stated she had fall matts in her room and they had brought up that the resident would kick them out of the way at a care plan meeting before. The DON stated they should care plan the fall matts. <BR/>Record review of document titled Speech Therapy Plan of Care - 03/13/2024, dated 03/13/2024, revealed profound language impairments and mild pharyngeal swallow function impairments (71-85% ability). Section titled Underlying Impairments listed Verbal Expression- Automatic speech severe impairment, Auditory Comprehension- 1 step commands severe impairment, Auditory Comprehension- wh questions- Severe Impairment, and Pharyngeal Swallow Deficits- after swallow. The reasons for referral were without therapeutic intervention patient at risk for: choking, aspiration, weight loss, inability to meet nutritional needs via PO intake of least restrictive diet .Bedside Swallowing Assessment .Pharyngeal phase: Patient demonstrated no signs or symptoms of aspiration during meal or when drinking . Patient demonstrated strong reflexive coughing episode &gt; 10 minutes after last PO intake with face reddening/eye tearing, suspected aspiration/penetration of secretions vs reflux material. Patient seized coughing and resumed normal breathing pattern within 20 seconds. Conclusion patient demonstrated grossly within functional limits oropharyngeal swallow at his current/baseline diet level however it is strongly recommended that the patient take meals in the dining room with staff supervision going forward, if he were to experience choking/aspiration during a meal in his room, staff would not be able to recognize the signs or help him in a timely manner, increasing his risk of an emergency event. Additionally patient shows signs that he may be aspirating/choking on reflux material after eating, and should be kept in an upright position, such as in his wheelchair and within close proximity to staff for supervision and assistance if necessary. SLP to provide skilled dysphasia intervention to provide staff education on choking/ reflux precautions and order/ complete MBSS to objectively assess for risk of aspiration, reflux, esophageal dysmotility, etc. <BR/>Record review of Speech Therapy daily notes 03/13/2024 through 04/12/2024 stated: <BR/>03/18/2024 patient taken for on site MBSS (Modified Barium Swallow Study (MBSS) is a specialized x-ray procedure that helps both the Radiologist (who specializes in using x-rays) and the Speech Language Pathologist (SLP) identify why someone is having trouble with swallowing). Patient presented with very high anxiety when SLP and transport aide attempted to bring him out- shaking, yelling, waving people away. Patient was briefly calmed while being taken to the van and set up. patient resumed elevated behavior when evaluating SLP presented trials. Patient accepted one teaspoon of thin liquid by cup and began to shout and rock back and forth violently before swallowing. Agitation continued across other trials/ consistencies attempted, and with multiple feeders. results inconclusive due to lack of patient participation, however no penetration/ aspiration observed with 1 swallow. Anatomy noted with cervical osteocytes and decreased lordodic curvature nearing pharyngeal space and creating pharyngeal pressure system deficit. Recommendations are to continue current diet (mechanical soft and thin liquid, crushed meds) while taking all meals upright and supervised with assistance as needed. <BR/>03/21/2024 SLP discussed with CNA recommendations for patient to be up in wheelchair in dining room for lunch period CNA reported patient becoming severely agitated (screaming, shaking, vehemently refusing) during attempts to get him out of bed. CNA attempted again today and reported similar behavior. SLP acknowledged and documented CNA's report.<BR/>03/29/2024 SLP assisted patient with lunch at bedside. Patient mostly self-fed with fingers, occasionally accepting prefilled spoons with help from SLP. Patient ate rapidly/ impulsively and was not responsive to verbal/ gestural cues to pace himself or alternate bites/sips. Patient refused liquid wash each time it was offered. No signs or symptoms aspiration T/ O meal, adequate oral clearance at the end of the meal.<BR/>04/09/2024 patient had 1/2 PBJ sandwich, unmodified, self-fed. Patient was able to take bites out of the sandwich. Ataxia (neurological sign consisting of lack of voluntary coordination of muscle movements that can include trouble eating and swallowing) evident during mastication but patient still able to manipulate and propel bolus effectively. Patient used liquid wash on his own. SLP checked oral cavity to ensure no pocketing/stasis after he finished. <BR/>Record review of the facility's care plan policy, dated 12/2017, stated policy: it is the policy of this home that staff must develop a comprehensive care plan to meet the needs of the resident .Note remember the residents care plan is a tool used to coordinate all care provided to the resident to be sure care is necessary, appropriate and planned to meet individual needs of the resident consonant with the physician's plan of care for the resident .12. Resident care plan documentation and use of the plan: a. the residents care plan is used to plan and assign care for all disciplines .c. The resident care plan must be kept current at all times .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 4 residents (Resident #1) reviewed for adequate supervision in that: <BR/>The facility failed to ensure Resident #1 received supervision during mealtimes to prevent choking or aspiration. <BR/>An IJ was identified on 4/12/24. The IJ template was provided to the facility on [DATE] at 6:19 PM. While the IJ was removed on 04/14/24 the facility remained out of compliance at a scope of isolated with a severity of potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>This failure could place residents at risk of choking, weight loss, decline in health, and death. <BR/>The findings included: <BR/>Record review of Resident #1's face sheet dated 4/10/24 revealed a [AGE] year-old male, admitted on [DATE] and readmitted on [DATE] with diagnoses of seizures, cerebrovascular disease, aphasia following cerebral infarction (a person may be unable to comprehend or unable to formulate language because of damage to specific brain regions), contracture right elbow (shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement), contracture right wrist, hemiplegia (weakness of one entire side of the body) and hemiparesis (complete paralysis of half of the body). The facesheet stated Resident #1 was allergic to morphine, mushrooms, and penicillins. <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was severely impaired for daily decision making, dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with ADLs in the areas of eating and drinking, and was on a mechanically altered diet. <BR/>Record review of Resident #1's comprehensive person-centered care plan, dated 02/20/24, revealed the resident's interventions for ADLs included REQUIRED***EATING: Resident requires set up assist. Resident #1 had unplanned/unexpected weight loss with interventions for ice cream as ordered, monitor and record food intake at each meal, notify the dietician of the weight loss upon their next visit, notify the physician, resident and family of the weight loss, provide verbal assistance and cues during meals, weigh the resident weekly for at least 4 weeks or until weight has stabilized. <BR/>Record review of Resident#1's Physician Order, dated 01/18/24 revealed an order for diet-regular, mechanical soft, and thin fluids. Special instructions FMP to all meals. Divided plate for every meal. The order was signed on 02/01/24 by the physician.<BR/>Record review of a nursing progress note, dated 02/12/2024, stated Patient eating breakfast and begins coughing episode directly after eating. Patient airway patent upon assessment. Patient sitting upright in bed, call light with reach. NP notified RP, MD and staff nurse. <BR/>Record review of document titled Speech Therapy Plan of Care - 03/13/2024, dated 03/13/2024, revealed profound language impairments and mild pharyngeal swallow function impairments (71-85% ability). Section titled Underlying Impairments listed Verbal Expression- Automatic speech severe impairment, Auditory Comprehension- 1 step commands severe impairment, Auditory Comprehension- wh questions- Severe Impairment, and Pharyngeal Swallow Deficits- after swallow. The reasons for referral were without therapeutic intervention patient at risk for: choking, aspiration, weight loss, inability to meet nutritional needs via PO intake of least restrictive diet .Bedside Swallowing Assessment .Pharyngeal phase: Patient demonstrated no signs or symptoms of aspiration during meal or when drinking . Patient demonstrated strong reflexive coughing episode &gt; 10 minutes after last PO intake with face reddening/eye tearing, suspected aspiration/penetration of secretions vs reflux material. Patient seized coughing and resumed normal breathing pattern within 20 seconds. Conclusion patient demonstrated grossly within functional limits oropharyngeal swallow at his current/baseline diet level however it is strongly recommended that the patient take meals in the dining room with staff supervision going forward, if he were to experience choking/aspiration during a meal in his room, staff would not be able to recognize the signs or help him in a timely manner, increasing his risk of an emergency event. Additionally patient shows signs that he may be aspirating/choking on reflux material after eating, and should be kept in an upright position, such as in his wheelchair and within close proximity to staff for supervision and assistance if necessary. SLP to provide skilled dysphasia intervention to provide staff education on choking/ reflux precautions and order/ complete MBSS to objectively assess for risk of aspiration, reflux, esophageal dysmotility, etc. <BR/>Record review of Speech Therapy daily notes 03/13/2024 through 04/12/2024 stated: <BR/>03/18/2024 patient taken for on site MBSS (Modified Barium Swallow Study (MBSS) is a specialized x-ray procedure that helps both the Radiologist (who specializes in using x-rays) and the Speech Language Pathologist (SLP) identify why someone is having trouble with swallowing). Patient presented with very high anxiety when SLP and transport aide attempted to bring him out- shaking, yelling, waving people away. Patient was briefly calmed while being taken to the van and set up. patient resumed elevated behavior when evaluating SLP presented trials. Patient accepted one teaspoon of thin liquid by cup and began to shout and rock back and forth violently before swallowing. Agitation continued across other trials/ consistencies attempted, and with multiple feeders. results inconclusive due to lack of patient participation, however no penetration/ aspiration observed with 1 swallow. Anatomy noted with cervical osteocytes (Osteophytes are exostoses (bony projections) that form along joint margins) and decreased lordodic curvature nearing pharyngeal space and creating pharyngeal pressure system deficit (the decrease of the normal curvature, near the throat, can cause increased pressure in the airway causing partial or complete block). Recommendations are to continue current diet (mechanical soft and thin liquid, crushed meds) while taking all meals upright and supervised with assistance as needed. <BR/>03/21/2024 SLP discussed with CNA recommendations for patient to be up in wheelchair in dining room for lunch period CNA reported patient becoming severely agitated (screaming, shaking, vehemently refusing) during attempts to get him out of bed. CNA attempted again today and reported similar behavior. SLP acknowledged and documented CNA's report.<BR/>03/29/2024 SLP assisted patient with lunch at bedside. Patient mostly self-fed with fingers, occasionally accepting prefilled spoons with help from SLP. Patient ate rapidly/ impulsively and was not responsive to verbal/ gestural cues to pace himself or alternate bites/sips. Patient refused liquid wash each time it was offered. No signs or symptoms aspiration T/ O meal, adequate oral clearance at the end of the meal.<BR/>04/09/2024 patient had 1/2 PBJ sandwich, unmodified, self-fed. Patient was able to take bites out of the sandwich. Ataxia (neurological sign consisting of lack of voluntary coordination of muscle movements that can include trouble eating and swallowing) evident during mastication but patient still able to manipulate and propel bolus effectively. Patient used liquid wash on his own. SLP checked oral cavity to ensure no pocketing/stasis after he finished. <BR/>During an observation on 04/10/24 at 11:13 a.m. Resident #1 was in his room alone in bed. Resident #1 was sitting up in bed. Resident #1 had a regular plate (not a divided plate as indicated in the resident's order) with spaghetti, cooked squash, a hard brown piece of toast, a dessert dish with watery gelatin snack, a coffee cup with no top, and a clear cup with a purple liquid drink with no top. The tray of food had liquid spilled all over it. A napkin was soaked with brown liquid and the diet sheet was also stained with brown liquid. Resident #1 grabbed the hard toast, took a bite, and a crunch noise was heard. The resident put the bread down. This survey asked Resident #1 if the bread was too hard and Resident #1 nodded his head yes. Resident #1 lifted his fork with his left hand. Resident #1's hand was shaking, and food fell off the fork. The Resident #1 put the fork down on the tray. Resident #1 grabbed a handful of spaghetti and began to shove it in his mouth. Resident #1 ate quickly. No straws, condiments, or cheesecake were noted on the tray of food. There was a diet sheet from the kitchen which showed Resident #1's name, stated he was on a regular mechanical soft diet with thin liquids, no allergies were listed, adaptive equipment: divided plate, entr&eacute;e: meat sauce, starch: spaghetti noodles, vegetable: zucchini, bread garlic toast, dessert: cheesecake, condiment salt/pepper/margarine, and beverage: choice of beverage and water. <BR/>During an observation on 04/11/24 at 11:30 Resident #1 was delivered a meal tray by an unidentified male staff. The staff exited the room right after delivering the tray. Resident #1 was eating in his room alone. At 11:38 a.m. an unidentified female staff went into his room. The resident's plate had no food left. The staff lifted a utensil with the last bite of food for the resident to eat. The staff stated Resident #1 can eat on his own, but she will go in to help him because he made a mess. Resident #1 again had a regular plate. The staff stated the resident chose to eat with his hands. <BR/>During an interview on 04/11/24 at 2:40 p.m. the Dietary Manager (DM) stated she had a binder of forms with dietary preferences and allergies for some residents but not all. The DM stated if a resident had an allergy, nursing would notify them with a paper . The DM stated she did not have a form in her binder for Resident #1. The DM stated they were not aware of Resident #1's food allergy to mushrooms and the spaghetti did not have mushrooms in it. The DM stated the kitchen did not have any mushrooms in it and it had been a while since the kitchen had any mushrooms. The DM stated the facility had divided plates available. The DM stated Resident #1 was supposed to receive a divided plate and staff needed to pay attention to what the diet sheet showed the resident needed for adaptive equipment. The DM stated the divided plate was needed to help the resident get his food better. The DM stated the cooks had over cooked the bread and needed to pay attention because residents would not be able to eat hard bread especially if they are on a mechanical soft diet. The DM stated the gelatin snack was not made right and was too watery. The DM stated the cooks had substituted the cheesecake with the gelatin snack but the resident should not have been served the watery gelatin snack. <BR/>During an interview on 04/12/24 at 9:12 a.m. the Speech Therapist stated Resident #1 was evaluated in March. The SP stated she was working with the Resident due to history of stroke and he had dysphagia. The SP stated if Resident #1 was presented food he would not take it and preferred to eat with his hands. The SP stated in March she recommended Resident #1 eat in the dining room per her notes because he could not communicate to staff and in case of an emergency he needed to be with in sight. The SP stated she they attempted to take Resident #1 to the dining room for meals in March after her recommendation but the Resident had a panic attack. The SP stated her recommendations were given to the rehab director and to the DON. The SP stated the Resident should have a divided plate with meals and his cups should have plastic lids and a straw. The SP stated she did go in the room to assist the resident with meals because she also helped with other residents and could not always be in the room with him. <BR/>During an interview on 04/12/24 at 12:35 a.m. the DON stated the Rehab director would usually let them know what findings they had from an evaluation. The DON stated Resident #1 was supervised only for meals, he was able to feed himself, he could use utensils, staff would set the tray up uncover everything for him, give him the spoon, he would pick it up and feed himself, and she did not see him shake or have tremors. The DON stated they were notified Resident #1 needed to eat in the dining room for queuing (prompting to eat) and or if he dropped his silverware. The DON stated the resident was very contracted and he refused to go to the dining room because it was painful for him to move. The DON stated staff would set the resident up at 90 degrees in bed, would set up his tray, and would go in and out of his room to supervise him during meals in his room. The DON stated they did not document or care plan the resident's refusals to go to the dining room. The DON stated staff would attempt 3 times to get the resident up and then would notify the nurse if he refused. The DON stated the SP would go in the room to sit with the resident and help him eat. The DON stated she had not read the SP evaluation and plan of care for Resident #1. The DON read the POC and stated she did not agree that staff would not be able to assist the resident in an emergency because the staff was CPR certified and could also perform the Heimlich maneuver. The DON stated she had never been notified that the resident would cough or choke while eating and the SP should have reported this to nursing. <BR/>During a joint interview on 04/12/24 at 4:37 p.m. with Rehab director and SP stated it was the RD's responsibility to communicate any evaluations and recommendations at clinical meetings to the nursing staff. They stated they were unable to get the resident to the recommended barium swallow study because the residents refused cooperate. The SP stated the resident did not want to get into the wheelchair and he had no signs or symptoms of choking such as a pneumonia. The RD stated the evaluation was done in March of 2024 and since then the resident had progressed. The RD stated the resident did not need supervision with meals. The RD stated he would not get supervision from staff they would just check in on him when he ate. The RD stated the doctor signed the SP evaluation on 03/19/24 with no further recommendations. The RD stated she was never notified or told the resident was coughing while eating or choking.<BR/>Record review of the facility's policy titled 'Nutritional Recommendations, dated 12/2017, stated policy: it is the policy of this home that the deal in/ DON will address recommendations by the console dietitian within three working days, if possible, of the exit of the dietician consult. Procedure: 1. the consultation will complete the nutritional recommendation form and/ or enteral feeding recommendations, sign, and date. 2. The consult dietitian will discuss the recommendations and exit conference with the administrator, director of nursing, and dietary service manager for clarification. After completion of the discussion, each will sign the form. 3. The dietitian will keep one copy of the form and give the other copy to the director of nursing. 4. The director of nursing or designee will contact the physician for orders or denial of the recommendation. The director of nursing or designee will write the physician's response and date and the follow up section. A note should be made regarding the reason for refusal if the physician denies the recommendation. 5. when recommendations have been completed and follow up column filled in, the director of nursing gave a copy to the administrator and dietary service manager. 6. The director of nursing/ designee will write orders in the medical records to initiate the approval recommendations. 7. The [nursing/ dietary communication form] will be completed regarding any diet or supplement changes. The original copy will be placed in dietary section of the medical record and the copy will be given to the dietary. 8. On the console dietitian next visit, the completed recommendations will be reviewed, and if indicated, follow up will be made in the clinical software. 9. It is the administrator's responsibility to see that recommendations are addressed within three business days, if possible, of the consulting dietitians exit conference.<BR/>The Administrator was given the IJ template and was notified of the IJ on 4/12/24 at 6:19 PM and a POR was requested.<BR/>On 04/14/24 at 1:35 PM, the POR was accepted. It was documented as follows:<BR/>4/12/2024<BR/>Plan of Removal - F 689 <BR/>Immediate Action Taken <BR/>Resident Specific <BR/>Resident #1 will be supervised by staff during all 3 meals daily beginning on 4/12/2024 at 7:00 pm.<BR/>Resident #1 had the appropriate care plan updates completed on 4/13/2024 at 11:20 am.<BR/>System Changes<BR/>On 4/12/2024 at 7:00 pm a facility audit took place to ensure that all residents requiring supervision for meals will receive appropriate supervision.<BR/>On 4/12/2024 at 7:00 pm DON and therapy reviewed all residents who require supervision for meals have had their care plans audited to ensure that the care plans accurately reflect the residents need for supervision with meals. <BR/>Starting on 4/12/2024 and ongoing therapy will be present in morning meetings to ensure that all orders are communicated directly between nursing and therapy to ensure that residents requiring supervision with meals will have recommendations reviewed and carried out appropriately. <BR/>Starting on 4/12/2024 and ongoing the DON will monitor two meals daily x 5 days a week to ensure staff compliance with meal supervision for those residents requiring supervision. <BR/>Starting on 4/12/2024 and ongoing residents dietary and supervision statuses will be audited upon change of condition, appropriate MDS cycles or anytime necessary. <BR/>Starting 4/13/2024 at 11:00 am the facility's mechanism for ensuring correct diet texture for the residents is that all trays will be compared to the actual plated meal for the resident by a licensed staff member prior to being served to the resident. The meal ticket/diet order will be compared for accuracy.<BR/>Education <BR/>On 4/12/2024 at 7:00 pm the Assistant Director of Nursing provided education to all staff regarding residents needing to have supervision at meals to ensure those residents will be supervised at mealtimes. Staff on future shifts will be educated prior to taking the floor. This will be accomplished by having a designated staff member in the building for that purpose and with that specific assignment. Licensed staff will be assigned by the DON to ensure that all trays/plates are correct prior to being served to the residents. Diet orders will match correctly to what is being served to the residents. This assigned licensed staff member will ensure specifically that texture, larger utensils, cup covers etc are being utilized for the residents.<BR/>On 4/12/2024 at 7:00 pm the Regional Clinical Consultant provided education to Administrator and Director of Nursing regarding residents needing supervision for meals. <BR/>On 4/12/2024 at 7:15 pm the Regional Clinical Consultant will educate DOR and clinical team as to communication and follow up during morning meetings. <BR/>Starting on 4/12/2024 at 7:00 pm the regional clinical consultant will be responsible for ensuring that staff receive the in-service/training regarding residents needing supervision during meals.<BR/>Starting on 4/12/2024 the residents dietary and supervision status will be communicated to facility staff directly by the DON and ADON. This process will be accomplished through photocopy and written communication.<BR/>Starting on 4/12/2024 the DON will be responsible for ensuring that the residents who require supervision during meals receive supervision.<BR/>Starting on 4/12/2024 at 7:00 pm during the daily stand up process all recommendations and orders will be audited by the clinical team in consultation with the therapy team to ensure compliance and follow up for all residents with orders and recommendations. The clinical consultant will review orders and recommendations daily x 4 weeks as a tool for oversight to ensure compliance.<BR/>100% Staff education compliance of the above mentioned by noon 4/14/24.<BR/>Verification of Plan of Removal:<BR/>Confirmed via Observation of lunch and dinner meals on 04/13/2024.<BR/>Confirmed via Record Review of Resident #1's care plan . <BR/>Confirmed via Interview with Regional Clinical Consultant and DON. They each had a list of all staff with check marks. Interviewed about their process for identifying residents who needed supervision and how they ensured no one was falling through the cracks. Interviewed each independently and they both said they went through each clinical record looking at: therapy notes and recommendations, physician notes, POC notes from CNAs, progress notes from LVNs and RNs, MDS assessments, and care plans. <BR/>On 4/12/2024 at 7:00 pm DON and therapy reviewed all residents who require supervision for meals have had their care plans audited.<BR/>Confirmed via Interview with Dir of Rehab and DON.<BR/>Record review of the care plans for all eight of the residents (Resident #1 and additional seven who require assistance). Five care plans had been updated - edits were observed - and the updates clarified and added more specific language. For example, instead of saying supervision as needed the language was updated to read supervision at all times by nursing staff. The two that were not updated were already very precise and specific in their wording. <BR/>Confirmed via Interview with Dir of Rehab DON, and Administrator <BR/>Confirmed via Interview with DON.<BR/>Record review of chart of items to check for each resident identified and had filled in the chart for each meal served since IJ was called. <BR/>Confirmed via Interview with Regional Clinical Consultant, DON, MDS/Care Plan Coordinator, and Administrator. <BR/>There were 52 total staff members 41 of the 52 staff have received in-service. Interview in person or by phone with 32 of the 52 staff members and confirmed they received the trainings and could verbalize understanding of the training. Of the 11 staff who did not receive the training: 1 FMLA, 1 vacation, and 9 PRN. Observation of a sign on the time clock stated for staff not to clock in for shift until they received in-service trainings dated 04/12/2024. <BR/>Observation of both lunch and dinner service on 04/13/2024 revealed each meal had an assigned licensed nurse to check meal tickets against trays. Observation of weekend RN meal tickets and trays revealed checking tickets for 15 residents versus what they had been served were completed and all were correct. The DON stated she would personally check two meals per day M-F, and weekend RN would check all three weekend meals (The DON and weekend RN work 6 am to 6 pm ). <BR/>Observation of the residents who required assistance in dining hall revealed staff were treating them with dignity, their tickets and meals were correct, and assistive devices(e.g. divided plate, built up utensils) were in place. <BR/>Observation of Resident #1 dining in his room revealed his ticket and meal were correct, a divided plate was in place, covered cups in place, and a member of nursing staff was providing 1 on 1 supervision. <BR/>Interviews conducted on 4/13/24 from 3:42 p.m. to 7:45 p.m. and on 4/14/24 from 9:03 a.m. to 1:30 p.m. revealed there were 14 nurses on staff, and interviewed 12 of them and all have received the in-service trainings (more detail on trainings below). <BR/>Interviews conducted on 4/13/24 from 3:42 p.m. to 7:45 p.m. and on 4/14/24 from 9:03 a.m. to 1:30 p.m. revealed there are 17 CNAs on staff, 13 of them were interviewed and all received the in-service trainings.<BR/>Confirmed via Interview with Regional Clinical Consultant and Record Review of in-service training.<BR/>Confirmed via Interview with DON and with ADON.<BR/>Record review of the in-services. One of the in-services which was given to all nursing staff identified all eight residents who require supervision and/or assistance for dining. <BR/>Confirmed via Interview with DON.<BR/>Observation of lunch and dinner comparison of their care plans and meal tickets against the meal, assistive devices, and level of supervision for the eight residents who required assistance received during both lunch and dinner, revealed each was correct. <BR/>Confirmed via Interview with Regional Clinical Consultant and DON, MDS/Care Plan Coordinator, and Administrator. <BR/>During interviews staff confirmed abuse and neglect training was done in general and every staff member confirmed ANE trainings are provided at least monthly. <BR/>Regional Clinical Consultant confirmed via interview that she was personally ensuring that all staff received in-service trainings. She was onsite today and planned to stay to catch the oncoming night shift. She provided her documentation via a staff list with check offs. <BR/>An IJ was identified on 4/12/24. While the IJ was removed on 04/14/24, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 1 of 3 Residents (Resident #1) reviewed for injuries of unknown origin, in that:<BR/>The facility discovered an injury of unknown origin for Resident #1 and did not report the injury of unknown origin to the abuse, neglect, exploitation coordinator, the Administrator, and/or the state agency.<BR/>This failure could place residents at risk for further abuse, neglect, exploitation, and/or injuries of unknown origin. <BR/>The findings included :<BR/>A record review of Resident #1's face sheet, dated 03/07/2023, revealed an admission date of 12/29/2023 with diagnoses which included dependence on renal dialysis [a blood purifying treatment given when kidney function is not optimum], end stage renal disease [a term for any condition that damages the kidneys, the organs that filter waste and excess fluid from the blood], morbid severe obesity, and chronic pain. <BR/>A record review of Resident #1's re-entry MDS , dated 01/16/2023, revealed Resident #1 was a [AGE] year-old female who was diagnosed as medically complex. Resident #1 was assessed as a severely morbidly obese person who was non-ambulatory, bedfast, chairfast, and needed assistance with transfers and required dialysis services. Resident #1 was assessed with a Brief Interview for Mental Status with a score of 15 out of 15 indicating no mental cognition impairment. <BR/>A record review of Resident #1's care plan, dated 03/07/2023, revealed, Resident #1 needs dialysis .encourage Resident to go to dialysis appointments .transport to [dialysis facility] every Monday, Wednesday, Friday with [name of transport contractor], pick up time 1315 [01:15 PM] in wheelchair with Hoyer sling under [a Hoyer lift is a hydraulic lift device which uses a sling for caregivers that transition those with limited mobility to or from a chair, bed, toilet, or a standing position].<BR/>A record review of Resident #1's nursing progress notes revealed a note, dated 01/08/2023, authored by LVN A, resident gets anxious at times, making moaning noises when sleeping. this nurse went to check on her and ask if she is OK. resident verbalized she is OK and wanted pain medicine for her legs. pain medicine given; we'll continue to monitor for any changes.<BR/>A record review of Resident #1's nursing progress notes revealed a note, dated 01/09/2023, authored by LVN B, CNA noted to this nurse large open area with some bleeding. Upon assessment, noted type 2 skin tear 11.5 centimeters by 11.0 centimeters partial flap intact, with scant sanguineous drainage. Patient has no complaint of pain and is not sure what happened. Due to inclusion of open areas in intergluteal cleft, treatment to be close monitoring and use of barrier cream. At the time dialysis transport arrives they tell staff the resident had slid down in wheelchair on return from dialysis. [on Friday 01/06/2023].<BR/>A record review of Resident #1's skin integrity event document, dated 01/09/2023, authored by LVN B, revealed new physician's orders for barrier cream and skin tear monitoring for signs and symptoms of infection every shift until healed. <BR/>A record review of Resident #1's nursing progress notes revealed a note, dated 01/10/2023, authored by ex-DON, Spoke with [name of transport contractors office personnel] at [name of transport contractor] requested the dialysis transport be changed from wheelchair to stretcher van starting tomorrow. She was able to make that change.<BR/>During an interview on 03/07/2023 at 02:06 PM, Resident #1's Family Member stated Resident #1 was dropped on the floor, neglected, and declined in health. Resident #1's Family Member could not recall any specific dates and or times for the allegations made. <BR/>During an interview on 03/07/2023 at 04:00 PM, the ADON stated she was not sure of exact details but believed Resident #1 has slid out of her wheelchair during a return transport from dialysis. The ADON stated LVN A, on 01/08/2023, discovered Resident #1 had an injury to her lower back, did not report the incident to the physician, did not document the skin tear injury, but did call the wound care nurse, LVN B, and gave a report. The ADON stated LVN B assessed Resident #1 on 01/09/2023 and gave a report to the physician and received new orders for Resident #1's wound care. The ADON stated LVN B did not document the details of the report given to the doctor in Resident #1's nursing progress notes. The ADON stated the facility currently has a new adjunct DON and at the time of Resident #1's discovered skin-tear the DON was the ex-DON. <BR/>During an interview on 03/08/2023 at 1:00 PM, LVN A stated she assessed Resident #1 on 01/08/2023 for pain and discovered Resident #1 had a large skin tear and could not assess how the injury occurred. Resident #1 could not state how she received the injury. LVN A medicated Resident #1 for pain, but had not documented the skin injury discovery and supporting details in Resident #1's medical record. LVN A stated she had not called the physician to give a report. LVN A stated she did not give a report to the DON or the Administrator. LVN A stated she did not recognize the injury of unknown origin, where there were no witnesses, and the Resident could not explain the injury was an allegation of abuse and/or neglect and should be reported to the Administrator. LVN A stated she had received training for abuse, neglect, and exploitation prevention but still failed to recognize Resident #1's unwitnessed, unexplainable, skin injury was a reportable discovery. LVN A stated she understands she should have recognized the injury of unknown origin with Resident #1 inability to give an account for the injury, and reported the injury of unknown origin to the Administrator. <BR/>During an interview on 03/08/2023 the adjunct DON stated she had researched the incident where, on Friday, 01/06/2023, Resident #1 received a skin tear during a return trip from dialysis, via the facility's transportation contractor, where the van driver suddenly came to an abrupt stop, causing Resident #1 to slide down out of her wheelchair. The adjunct DON stated the transportation contractor's driver did not report the incident to anyone until Monday 01/09/2023, when he was questioned by the ex-DON. The driver stated Resident #1 slid out of the wheelchair upon arrival to the facility. The adjunct DON stated the ex-DON did not report the allegation of abuse/neglect to the Administrator and/or the state agency. The adjunct DON stated the expectation is for all staff that have a suspicion of abuse, neglect, exploitation, mistreatment, and injuries of unknown origin are to immediately report the suspicion to the Administrator and to the state agency. The adjunct DON stated the ex-DON was responsible for the failure of not reporting the suspicion of abuse and/or neglect, and as the DON the ex-DON was responsible to review all incidents and at a minimum should have recognized the injury of unknown origin, without Resident #1's ability to give an account for the injury, as a reportable incident and should have at a minimum given the Administrator a report. The adjunct DON stated the failure could have placed residents at risk for further abuse and/or neglect to include injuries. <BR/>During an interview on 03/08/2023 at 5:00 PM, the Administrator stated he was not aware of the incident on 01/06/2023 where Resident #1 slid out of her wheelchair while being transported by the transportation contractor from Resident #1's dialysis appointment. The Administrator stated the ex-DON did not provide a report or document the details of the incident. The Administrator stated the expectation was for the ex-DON to immediately report the injury and to provide sufficient documentation to support Resident #1's needs for care and safety. the Administrator stated LVN A, LVN B, and the ex-DON all had abuse, neglect, and exploitation, prevention training; all had knowledge of Resident #1's injury of unknown origin, and still no one reported the injury to me [the Administrator]. <BR/>Record review of the facility's Abuse / Reportable Events policy, dated 01/10/2017, revealed, All residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation .the facility will provide and ensure the promotion and protection of resident rights . it is everyone's responsibility to recognize, report, and promptly investigate actual or alleged abuse neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility . injury of unknown source, any injury to a resident where; the source of the injury was not observed by any person or the source of the injury could not be explained by the Resident; and the injury is suspicious because of the extent of the injury or the location of the injury for example the injury is located in an area not generally vulnerable to trauma or the number of injuries observed at one particular point in time or the incidence of injuries overtime .facility employees must report all allegations of; abuse, neglect, exploitation, mistreatment of residents, misappropriation of residence property or injury of unknown source to the facility Administrator. The facility administrator or designee will report the allegation to HHSC.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 1 of 3 Residents (Resident #1) reviewed for injuries of unknown origin, in that:<BR/>The facility discovered an injury of unknown origin for Resident #1 and did not report the injury of unknown origin to the abuse, neglect, exploitation coordinator, the Administrator, and/or the state agency.<BR/>This failure could place residents at risk for further abuse, neglect, exploitation, and/or injuries of unknown origin. <BR/>The findings included :<BR/>A record review of Resident #1's face sheet, dated 03/07/2023, revealed an admission date of 12/29/2023 with diagnoses which included dependence on renal dialysis [a blood purifying treatment given when kidney function is not optimum], end stage renal disease [a term for any condition that damages the kidneys, the organs that filter waste and excess fluid from the blood], morbid severe obesity, and chronic pain. <BR/>A record review of Resident #1's re-entry MDS , dated 01/16/2023, revealed Resident #1 was a [AGE] year-old female who was diagnosed as medically complex. Resident #1 was assessed as a severely morbidly obese person who was non-ambulatory, bedfast, chairfast, and needed assistance with transfers and required dialysis services. Resident #1 was assessed with a Brief Interview for Mental Status with a score of 15 out of 15 indicating no mental cognition impairment. <BR/>A record review of Resident #1's care plan, dated 03/07/2023, revealed, Resident #1 needs dialysis .encourage Resident to go to dialysis appointments .transport to [dialysis facility] every Monday, Wednesday, Friday with [name of transport contractor], pick up time 1315 [01:15 PM] in wheelchair with Hoyer sling under [a Hoyer lift is a hydraulic lift device which uses a sling for caregivers that transition those with limited mobility to or from a chair, bed, toilet, or a standing position].<BR/>A record review of Resident #1's nursing progress notes revealed a note, dated 01/08/2023, authored by LVN A, resident gets anxious at times, making moaning noises when sleeping. this nurse went to check on her and ask if she is OK. resident verbalized she is OK and wanted pain medicine for her legs. pain medicine given; we'll continue to monitor for any changes.<BR/>A record review of Resident #1's nursing progress notes revealed a note, dated 01/09/2023, authored by LVN B, CNA noted to this nurse large open area with some bleeding. Upon assessment, noted type 2 skin tear 11.5 centimeters by 11.0 centimeters partial flap intact, with scant sanguineous drainage. Patient has no complaint of pain and is not sure what happened. Due to inclusion of open areas in intergluteal cleft, treatment to be close monitoring and use of barrier cream. At the time dialysis transport arrives they tell staff the resident had slid down in wheelchair on return from dialysis. [on Friday 01/06/2023].<BR/>A record review of Resident #1's skin integrity event document, dated 01/09/2023, authored by LVN B, revealed new physician's orders for barrier cream and skin tear monitoring for signs and symptoms of infection every shift until healed. <BR/>A record review of Resident #1's nursing progress notes revealed a note, dated 01/10/2023, authored by ex-DON, Spoke with [name of transport contractors office personnel] at [name of transport contractor] requested the dialysis transport be changed from wheelchair to stretcher van starting tomorrow. She was able to make that change.<BR/>During an interview on 03/07/2023 at 02:06 PM, Resident #1's Family Member stated Resident #1 was dropped on the floor, neglected, and declined in health. Resident #1's Family Member could not recall any specific dates and or times for the allegations made. <BR/>During an interview on 03/07/2023 at 04:00 PM, the ADON stated she was not sure of exact details but believed Resident #1 has slid out of her wheelchair during a return transport from dialysis. The ADON stated LVN A, on 01/08/2023, discovered Resident #1 had an injury to her lower back, did not report the incident to the physician, did not document the skin tear injury, but did call the wound care nurse, LVN B, and gave a report. The ADON stated LVN B assessed Resident #1 on 01/09/2023 and gave a report to the physician and received new orders for Resident #1's wound care. The ADON stated LVN B did not document the details of the report given to the doctor in Resident #1's nursing progress notes. The ADON stated the facility currently has a new adjunct DON and at the time of Resident #1's discovered skin-tear the DON was the ex-DON. <BR/>During an interview on 03/08/2023 at 1:00 PM, LVN A stated she assessed Resident #1 on 01/08/2023 for pain and discovered Resident #1 had a large skin tear and could not assess how the injury occurred. Resident #1 could not state how she received the injury. LVN A medicated Resident #1 for pain, but had not documented the skin injury discovery and supporting details in Resident #1's medical record. LVN A stated she had not called the physician to give a report. LVN A stated she did not give a report to the DON or the Administrator. LVN A stated she did not recognize the injury of unknown origin, where there were no witnesses, and the Resident could not explain the injury was an allegation of abuse and/or neglect and should be reported to the Administrator. LVN A stated she had received training for abuse, neglect, and exploitation prevention but still failed to recognize Resident #1's unwitnessed, unexplainable, skin injury was a reportable discovery. LVN A stated she understands she should have recognized the injury of unknown origin with Resident #1 inability to give an account for the injury, and reported the injury of unknown origin to the Administrator. <BR/>During an interview on 03/08/2023 the adjunct DON stated she had researched the incident where, on Friday, 01/06/2023, Resident #1 received a skin tear during a return trip from dialysis, via the facility's transportation contractor, where the van driver suddenly came to an abrupt stop, causing Resident #1 to slide down out of her wheelchair. The adjunct DON stated the transportation contractor's driver did not report the incident to anyone until Monday 01/09/2023, when he was questioned by the ex-DON. The driver stated Resident #1 slid out of the wheelchair upon arrival to the facility. The adjunct DON stated the ex-DON did not report the allegation of abuse/neglect to the Administrator and/or the state agency. The adjunct DON stated the expectation is for all staff that have a suspicion of abuse, neglect, exploitation, mistreatment, and injuries of unknown origin are to immediately report the suspicion to the Administrator and to the state agency. The adjunct DON stated the ex-DON was responsible for the failure of not reporting the suspicion of abuse and/or neglect, and as the DON the ex-DON was responsible to review all incidents and at a minimum should have recognized the injury of unknown origin, without Resident #1's ability to give an account for the injury, as a reportable incident and should have at a minimum given the Administrator a report. The adjunct DON stated the failure could have placed residents at risk for further abuse and/or neglect to include injuries. <BR/>During an interview on 03/08/2023 at 5:00 PM, the Administrator stated he was not aware of the incident on 01/06/2023 where Resident #1 slid out of her wheelchair while being transported by the transportation contractor from Resident #1's dialysis appointment. The Administrator stated the ex-DON did not provide a report or document the details of the incident. The Administrator stated the expectation was for the ex-DON to immediately report the injury and to provide sufficient documentation to support Resident #1's needs for care and safety. the Administrator stated LVN A, LVN B, and the ex-DON all had abuse, neglect, and exploitation, prevention training; all had knowledge of Resident #1's injury of unknown origin, and still no one reported the injury to me [the Administrator]. <BR/>Record review of the facility's Abuse / Reportable Events policy, dated 01/10/2017, revealed, All residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation .the facility will provide and ensure the promotion and protection of resident rights . it is everyone's responsibility to recognize, report, and promptly investigate actual or alleged abuse neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility . injury of unknown source, any injury to a resident where; the source of the injury was not observed by any person or the source of the injury could not be explained by the Resident; and the injury is suspicious because of the extent of the injury or the location of the injury for example the injury is located in an area not generally vulnerable to trauma or the number of injuries observed at one particular point in time or the incidence of injuries overtime .facility employees must report all allegations of; abuse, neglect, exploitation, mistreatment of residents, misappropriation of residence property or injury of unknown source to the facility Administrator. The facility administrator or designee will report the allegation to HHSC.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized, for 1 of 3 Residents (Resident #1) reviewed for complete and accurate medical records, in that:<BR/>Resident #1 medical record did not reflect the communications and details surrounding Resident #1 needs for wound care per physician orders.<BR/>This failure could place residents at risk for inaccurate medical records. <BR/>The findings included:<BR/>A record review of Resident #1's face sheet, dated 03/07/2023, revealed an admission date of 12/29/2023 and a discharge date of 01/16/2023, with diagnoses which included dependence on renal dialysis [a blood purifying treatment given when kidney function is not optimum], end stage renal disease [a term for any condition that damages the kidneys, the organs that filter waste and excess fluid from the blood], morbid severe obesity, and chronic pain. <BR/>A record review of Resident #1's re-entry MDS, dated [DATE], revealed Resident #1 was a [AGE] year-old female who was diagnosed as medically complex. Resident #1 was assessed as a severely morbidly obese person who was non-ambulatory, bedfast, chairfast, and needed assistance with transfers and required dialysis services. <BR/>A record review of Resident #1's care plan, dated 03/07/2023, revealed, Resident #1 needs dialysis .encourage Resident to go to dialysis appointments .transport to [dialysis facility] every Monday, Wednesday, Friday with [name of transport contractor], pick up time 1315 [01:15 PM] in wheelchair with Hoyer sling under [a Hoyer lift is a hydraulic lift device which uses a sling for caregivers that transition those with limited mobility to or from a chair, bed, toilet, or a standing position].<BR/>A record review of Resident #1's nursing progress notes revealed a note, dated 01/08/2023, authored by LVN A, resident gets anxious at times, making moaning noises when sleeping. this nurse went to check on her and ask if she is OK. resident verbalized she is OK and wanted pain medicine for her legs. pain medicine given; we'll continue to monitor for any changes.<BR/>A record review of Resident #1's nursing progress notes revealed a note, dated 01/09/2023, authored by LVN B, CNA noted to this nurse large open area with some bleeding. Upon assessment, noted type 2 skin tear 11.5 centimeters by 11.0 centimeters partial flap intact, with scant sanguineous drainage. Patient has no complaint of pain and is not sure what happened. Due to inclusion of open areas in intergluteal cleft, treatment to be close monitoring and use of barrier cream. At the time dialysis transport arrives they tell staff the resident had slid down in wheelchair on return from dialysis. [on Friday 01/06/2023].<BR/>A record review of Resident #1's skin integrity event document, dated 01/09/2023, authored by LVN B, revealed new physician's orders for barrier cream and skin tear monitoring for signs and symptoms of infection every shift until healed. <BR/>During an interview on 03/07/2023 at 02:06 PM, Resident #1's Family Member stated Resident #1 was dropped on the floor, neglected, declined in health, and was admitted to the hospital. Resident #1's Family Member could not recall any specific dates and or times for the allegations made. Resident #1's Family Member stated the hospital RN reported Resident #1 had a pressure ulcer to her lower back. <BR/>During an interview on 03/07/2023 at 04:00 PM, the ADON stated she was not sure of exact details but believed Resident #1 has slid out of her wheelchair during a return transport from dialysis. The ADON stated LVN A, on 01/08/2023, discovered Resident #1 had an injury to her lower back, did not report the incident to the physician, did not document the skin tear injury, but did call the wound care nurse (LVN B), and gave a report. The ADON stated LVN B assessed Resident #1 on 01/09/2023 and gave a report to the physician and received new orders for Resident #1's wound care. The ADON stated LVN B did not document the details of the report to the doctor in Resident #1's nursing progress notes. The ADON stated the facility currently has a new DON and at the time of Resident #1's discovered skin-tear the DON was ex-DON. <BR/>During an interview on 03/08/2023 at 1:00 PM, LVN A stated she assessed Resident #1 on 01/08/2023 for pain and discovered Resident #1 had a large skin tear and could not assess how the injury occurred. Resident #1 could not state how she received the injury. LVN A medicated Resident #1 for pain, but had not documented the skin injury discovery and supporting details in Resident #1's medical record. LVN A stated she had not called the physician to give a report. LVN A stated she now understands she must document in residents progress notes any changes of condition and details of communications with residents, physicians, family representatives, and members of the interdisciplinary care team. <BR/>During an interview on 03/08/2023 the adjunct DON stated she had researched the incident where on Friday, 01/06/2023, Resident #1 received a skin tear during a return trip from dialysis , via the facility's transportation contractor, where the van driver suddenly came to an abrupt stop, causing Resident #1 to slide down out of her wheelchair. The adjunct DON stated the transportation contractor's driver did not report the incident to anyone until Monday 01/09/2023, when he was questioned by the ex-DON. The driver stated Resident #1 slid out of the wheelchair upon arrival to the facility. The adjunct DON stated the ex-DON did not document the details of the discovery in Resident #1's medical record / progress notes. The adjunct DON stated LVN B also did not document the details of her communications with the wound care physician in Resident #1's medical record / progress notes. The adjunct DON stated the expectation is for nurses to document in real time as close as possible with sufficient details to support interdisciplinary care team members continuity of quality care. The adjunct stated the ex-DON was responsible for the failure of accurate timely documentation and as the DON the ex-DON was responsible to review all incidents and verify the accuracy and completeness of documents. The adjunct DON stated the failure could have placed residents at risk for inaccuracy of medical records. <BR/>During an interview on 03/08/2023 at 5:00 PM, the Administrator stated he was not aware of the incident on 01/06/2023 where Resident #1 slid out of her wheelchair while being transported by the transportation contractor from Resident #1's dialysis appointment. The Administrator stated the ex-DON did not provide a report or document the details of the incident. The Administrator stated the expectation was for the ex-DON to immediately report the injury and to provide sufficient documentation to support Resident #1's needs for care and safety. <BR/>A record review of the facility's Skin - Treatment Guidelines for Pressure Ulcers, dated 12/2017, revealed, policy: it is the policy of this home to utilize treatment guidelines when providing care for residents with pressure injury and to prevent further deterioration of pressure injury . procedure: identify the underlying cause as pressure, sheer, friction, maceration, or a combination of these factors . reposition turn the resident at least every two hours day and night based on residence specific positioning needs per care plans and physician orders . confirm the resident and interested party of resident has been notified of the pressure injury and is aware of the current status document in the progress note . document dressing completion .

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services for 1 of 1 dietary manager reviewed for qualified dietary staff. <BR/>The facility failed to employ a certified dietary manager as required. <BR/>This failure could place residents who consumed food prepared by staff in the kitchen at increased risk of food borne illness and not receiving adequate nutrition.<BR/>The findings were:<BR/>Record Review of the Employee Service List, undated, revealed the Dietary Manager with an initial hire date of 06/17/21.<BR/>During an interview with the Human Resources Director on 06/06/24 at 10:00a.m., she stated she was not aware the Dietary Director had to have completed a certified Dietary manager course. She stated she along with the Administrator would have been responsible for ensuring the department heads met their certification requirements.<BR/>During an interview on 06/6/24 at 10:15a.m., the Dietary Manager revealed she had not taken the Dietary Manager Certification course and was unaware she needed to complete this course. She stated her current role as a Dietary Manager, which began in 01/24, was the only Dietary Manager position she had held. She stated all of her previous positions working in kitchens, had been working in the capacity of a cook.<BR/>During an interview on 06/6/24 at 1:00p.m., the Administrator stated he was not aware the Dietary Director had to have completed a dietary manager certification course. He stated completion of a certification course would help the Dietary Manager to better run the kitchen.<BR/>Record review of the facility's employee handbook dated 81/21 stated on page 27 all professionally registered, licensed, and certified staff are required to maintain current licensure, registration and/or certification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure 1 of 8 residents (Resident #2) received services in the facility reviewed for reasonable accommodation of resident needs related to call lights. The facility failed to ensure the call light was within reach for Resident #2. This deficient practice could affect any resident and place them at risk of not being able to ask for help as needed.The findings were: Record review of Resident #2's face sheet revealed she was admitted to the facility on [DATE] with diagnoses which included: catatonic disorder (person experiences significant disruptions in movement and behavior), Neoplasm of uncertain behavior of parathyroid gland (growth in the parathyroid gland), Sick sinus syndrome (heart's natural pacemaker doesn't work properly). Record review of Resident #2's MDS assessment, dated 05/07/2025, revealed the resident's BIMS score was 99, which indicated severe cognitive impairment. The MDS assessment further revealed Resident #2 required substantial/maximal assistance (helper does more than half the effort) for ADL assistance. Record review of Resident #2's care plan revealed Resident #2 is at risk for falls d/t impaired cognition, impaired mobility, no safety awareness and Keep call light within reachObservation on 07/22/2025 at 1:25 pm. revealed Resident #2 lying in bed with her call light lying on the floor under the head of the bed, out of view and reach of the resident. During an interview on 07/22/2025 at 1:28 pm LVN A she observed the call light was not visible to the resident and the resident was unable to reach it. She stated the potential for harm could be a lack of care due to the resident unable to call for help. During an interview on 07/22/2025 at 1:46 pm the DON stated that the call light should be within resident reach to be able to call for assistance. Record review of facility's Call Light- Use of policy, dated December 2017, showed, When providing care to residents, be sure to position the call light conveniently for the resident to use.

Based on observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys, for 1 of 2 medication carts (Medication Cart 2), reviewed for security, in that,<BR/>An unassigned medication cart was unattended and unlocked with medication blister packs inside of the medication cart. <BR/>This failure placed residents at risk for harm by misappropriation of property of their medications. <BR/>The findings included:<BR/>During an observation on 01/23/2025 at 10:51 AM, it was revealed that a medication cart near the nurses' station at the corner of the 100 and 200 hallways, was unattended and unlocked. The medication cart was observed to have the lock button unengaged and unlocked. <BR/>During an interview and observation on 01/23/2025 at 11:08 AM, LVN A stated he was not assigned to the med cart and was not sure why it was unlocked. LVN A stated that the medication cart should have been locked and that he had not gone into the med cart that day. Observation with LVN A confirmed there was medication being stored inside of the cart, and stated he had been looking for medication and that he did not realize it was in the medication cart. <BR/>During an interview and observation on 01/23/2025 at 2:16 PM, the DON stated that she was not sure why the med cart was unlocked and confirmed it was being used as medication storage at the time of the observation. The DON stated that the med cart was no longer used and they had planned to get rid of the medication cart but had not yet. The DON stated she also was not aware of the last time a staff member would have gone into the medication cart. The DON stated her expectation was that all medication carts would be locked if staff was not passing medications to residents. The DON stated no one was assigned to this medication cart, as it was only being used as storage for extra medications.<BR/>Record review of the facility policy titled, Medication Storage - in the Home, dated 10/2020, revealed, It is the policy of this home that medications will be stored appropriately as to be secure from tampering, exposure or misuse.

Based on observation, interview, and record review, the facility failed to establish and maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 6 residents (Resident #44) reviewed for infection control, in that:<BR/>CNA A failed to wash or sanitize his hands or change his gloves after touching the bed's remote and head of the bed and before starting incontinent care. <BR/>This deficient practice could place residents at-risk for infection due to improper care practices. <BR/>The findings include:<BR/>Record review of Resident #44's face sheet, dated 04/27/2023, revealed an admission date of 04/24/2023, with diagnoses which included: Atelectasis (collapse or closure of a lung), Bipolar disorder(mental disorder characterized by periods of depression and periods of abnormally elevated mood) and, Guillain-Barre syndrome( rare disorder in which the body's immune system attacks the nerves).<BR/>Record review of Resident #44's MDS Log revealed there was no completed MDS. <BR/>Record review of Resident #44's care plan, dated 04/25/2023, revealed a problem of has urinary incontinence, with an intervention of Monitor/document for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.<BR/>Observation on 04/27/23 at 02:20 p.m. revealed while providing incontinent care for Resident #44, CNA A washed his hands and put on gloves. CNA A touched the resident's bed's remote and the head of the bed with his gloved hands, then without changing gloves or sanitizing his hands started providing care for the resident. <BR/>During an interview on 04/27/2023 at 02:30 p.m. with CNA A, he confirmed the environment around the resident was considered dirty and he should have changed his gloves and sanitized his hands prior to providing care. He confirmed he received infection control training within the year. <BR/>During an interview with the Regional Nurse on 04/28/23 at 10:08 a.m., she confirmed the environment around the resident was considered dirty and the staff should change their gloves and wash. Staff should sanitize their hands after touching anything in the environment, before touching the resident and at the start of care. She confirmed the staff were inserviced in infection control and incontinent care and skills were checked annually and as needed by management <BR/>Record review of the annual skills check for CNA A revealed CNA A passed competency for Infection control on 08/22/2022. <BR/>Record review of the facility policy, titled infection control-prevention and control program, dated 12/2017, revealed [ .] 4. Implement hand hygiene (hand washing) practices consistent with accepted standards of practice to reduce the spread of infections and prevent cross-contamination [ .] The director of nursing or designee will perform infection control audits to review staff procedure in observation of standard precautions, infection control and isolation procedures

Based on observation, interview, and record review, the facility failed to establish and maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 6 residents (Resident #44) reviewed for infection control, in that:<BR/>CNA A failed to wash or sanitize his hands or change his gloves after touching the bed's remote and head of the bed and before starting incontinent care. <BR/>This deficient practice could place residents at-risk for infection due to improper care practices. <BR/>The findings include:<BR/>Record review of Resident #44's face sheet, dated 04/27/2023, revealed an admission date of 04/24/2023, with diagnoses which included: Atelectasis (collapse or closure of a lung), Bipolar disorder(mental disorder characterized by periods of depression and periods of abnormally elevated mood) and, Guillain-Barre syndrome( rare disorder in which the body's immune system attacks the nerves).<BR/>Record review of Resident #44's MDS Log revealed there was no completed MDS. <BR/>Record review of Resident #44's care plan, dated 04/25/2023, revealed a problem of has urinary incontinence, with an intervention of Monitor/document for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.<BR/>Observation on 04/27/23 at 02:20 p.m. revealed while providing incontinent care for Resident #44, CNA A washed his hands and put on gloves. CNA A touched the resident's bed's remote and the head of the bed with his gloved hands, then without changing gloves or sanitizing his hands started providing care for the resident. <BR/>During an interview on 04/27/2023 at 02:30 p.m. with CNA A, he confirmed the environment around the resident was considered dirty and he should have changed his gloves and sanitized his hands prior to providing care. He confirmed he received infection control training within the year. <BR/>During an interview with the Regional Nurse on 04/28/23 at 10:08 a.m., she confirmed the environment around the resident was considered dirty and the staff should change their gloves and wash. Staff should sanitize their hands after touching anything in the environment, before touching the resident and at the start of care. She confirmed the staff were inserviced in infection control and incontinent care and skills were checked annually and as needed by management <BR/>Record review of the annual skills check for CNA A revealed CNA A passed competency for Infection control on 08/22/2022. <BR/>Record review of the facility policy, titled infection control-prevention and control program, dated 12/2017, revealed [ .] 4. Implement hand hygiene (hand washing) practices consistent with accepted standards of practice to reduce the spread of infections and prevent cross-contamination [ .] The director of nursing or designee will perform infection control audits to review staff procedure in observation of standard precautions, infection control and isolation procedures

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 facility reviewed for environmental concerns.<BR/>The facility failed to secure a resident's bathroom ceiling fan, replace a resident's bedroom light, fix a resident's window blinds, repair a penetration in a resident's bedroom wall, replace a hallway ceiling panel cover, repair water discoloration marks around a hallway ceiling vent, fix a section of resident hallway floor molding, and replace the light bulbs in a hallway ceiling light unit. <BR/>This deficient practice could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.<BR/>The findings included:<BR/>During an observation on 06/4/24 from 10:20 a.m. to 11:10 a.m. revealed the following the following:<BR/>1. Resident room [ROOM NUMBER] had a bathroom ceiling fan which measured approximately 1 foot in diameter which was disconnected from the ceiling on one side.<BR/>2. Resident room [ROOM NUMBER] had a broken circular light fixture which measured approximately 5 inches in diameter located on the wall above the bed headboard.<BR/>3. Resident room [ROOM NUMBER] had 4 broken window shade vents.<BR/>4. Resident room [ROOM NUMBER] had a round penetration which measured approximately 4 inches in diameter located on the bedroom wall adjacent to the bathroom.<BR/>5-Resident corridor hall 100 corridor had a missing ceiling panel which measured approximately 4x2 feet located in front of room [ROOM NUMBER].<BR/>6. Resident corridor hall 100 had a ceiling fan which measured approximately 1 foot by 6 inches located in front of room [ROOM NUMBER] that had signs of visible water penetration around the perimeter.<BR/>7. Resident corridor hall had missing floor molding which measured approximately 2 feet by 4 inches located in front of room [ROOM NUMBER].<BR/>8-Resident corridor hall had a ceiling light which measured approximately 2x3 feet located in front of room [ROOM NUMBER] which had non-working light bulbs.<BR/>During an interview with the Administrator on 6/4/24 at 10:20a.m., he stated that the Maintenance Director had self- terminated his position on 6/4/24, The Administrator stated that any broken light fixtures could negatively impact resident safety. He stated that all of the other observed building concerns could negatively impact resident satisfaction and would be addressed immediately for repair.<BR/>During an interview with the Administrator on 6/5/24 at 9:00a.m., he stated that there was not a facility policy on preventative maintenance but the Maintenance Director had maintained a work order communication log for pending and completed work projects on the resident units.<BR/> Record review of facility's Maintenance Log Book for the months of February, March, April and May 2024 revealed no work orders for repair of resident bathroom ceiling fans, resident bedroom lights, resident window blinds, resident room penetrations, missing ceiling panels on the resident hall corridors, water damage on the ceiling panel in the resident corridors, missing resident hallway floor molding, or broken ceiling light bulbs in resident hall corridors.<BR/>Record review of the facility's Maintenance Director's job description date 4/12/19 revealed the Maintenance Director was responsible for ensuring that the facility and equipment were properly maintained for patient/resident comfort and convenience.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure 1 of 8 residents (Resident #2) received services in the facility reviewed for reasonable accommodation of resident needs related to call lights. The facility failed to ensure the call light was within reach for Resident #2. This deficient practice could affect any resident and place them at risk of not being able to ask for help as needed.The findings were: Record review of Resident #2's face sheet revealed she was admitted to the facility on [DATE] with diagnoses which included: catatonic disorder (person experiences significant disruptions in movement and behavior), Neoplasm of uncertain behavior of parathyroid gland (growth in the parathyroid gland), Sick sinus syndrome (heart's natural pacemaker doesn't work properly). Record review of Resident #2's MDS assessment, dated 05/07/2025, revealed the resident's BIMS score was 99, which indicated severe cognitive impairment. The MDS assessment further revealed Resident #2 required substantial/maximal assistance (helper does more than half the effort) for ADL assistance. Record review of Resident #2's care plan revealed Resident #2 is at risk for falls d/t impaired cognition, impaired mobility, no safety awareness and Keep call light within reachObservation on 07/22/2025 at 1:25 pm. revealed Resident #2 lying in bed with her call light lying on the floor under the head of the bed, out of view and reach of the resident. During an interview on 07/22/2025 at 1:28 pm LVN A she observed the call light was not visible to the resident and the resident was unable to reach it. She stated the potential for harm could be a lack of care due to the resident unable to call for help. During an interview on 07/22/2025 at 1:46 pm the DON stated that the call light should be within resident reach to be able to call for assistance. Record review of facility's Call Light- Use of policy, dated December 2017, showed, When providing care to residents, be sure to position the call light conveniently for the resident to use.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 residents (Resident #44) reviewed for incontinent care, in that: <BR/>CNA A failed to separate Resident #44's labia to clean between the labia during incontinent care. <BR/>This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. <BR/>The findings were:<BR/>Record review of Resident #44's face sheet, dated 04/27/2023, revealed an admission date of 04/24/2023, with diagnoses which included: Atelectasis (collapse or closure of a lung), Bipolar disorder(mental disorder characterized by periods of depression and periods of abnormally elevated mood) and, Guillain-Barre syndrome( rare disorder in which the body's immune system attacks the nerves).<BR/>Record review of Resident #44's MDS Log revealed there was no completed MDS. <BR/>Record review of Resident #44's care plan, dated 04/25/2023, revealed a problem of has urinary incontinence, with an intervention of Monitor/document for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.<BR/>Observation on 04/27/23 at 02:20 p.m. revealed while providing incontinent care for Resident #44, CNA A did not separate the resident's labia to clean the center, left and right. <BR/>During an interview on 04/27/2023 at 02:30 p.m. with CNA A, he confirmed he had wiped the center on top of the resident's labia but did not separate the labia. He confirmed he received training in incontinent care. He thought he was using the right technique. <BR/>During an interview with the Regional Nurse on 04/28/23 at 10:08 a.m., she confirmed the female resident's labia must be separated to properly clean the center and the urethral opening. She confirmed the staff were inserviced in infection control and incontinent care and skills were checked annually and as needed by management.<BR/>Record review of the annual skills check for CNA A revealed CNA A passed competency for Perineal care/incontinent care on 08/22/2022. <BR/>Record review of the facility's policy titled incontinent care/perineal care with or without a catheter, dated 11/2021, revealed spread labia and clean center, left and right.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a baseline care plan which includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 8 residents (Resident #5) reviewed for baseline care plans in that:<BR/>The facility did not develop a baseline care plan for Resident #5.<BR/>This deficient practice could affect all residents and place them at risk of a care or services not being provided as needed.<BR/>The findings were:<BR/>Record review of Resident #5's face sheet, dated 5/5/23, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Major Depressive Disorder, recurrent severe without psychotic features, hereditary [genetic] and idiopathic [spontaneous] neuropathy [nerve damage], unspecified, other muscle spasm, pain, unspecified, and schizophrenia [a chronic mental illness characterized by delusions, hallucinations, and disordered thinking], unspecified. <BR/>Record review of Resident #5's EHR revealed Resident #5 did not have a baseline care plan. <BR/>During an interview and record review on 5/7/23 at 9:46 a.m., MDS LVN F stated baseline care plans should be created by the admitting nurse within the first 48 hours of a resident's admission. When asked who ensured the baseline care plans were created within 48 hours, MDS LVN F stated, it's an IDT, but really it's the nursing department. MDS LVN F stated the baseline care plan should contain, Name, diagnosis, admitting diagnosis, general allergies, code status, just basic things. Resident #5's EHR was reviewed at this time and MDS LVN F stated she did not see Resident #5's baseline care plan. When asked what negative effects could occur for the resident if the resident did not have a baseline care plan, MDS LVN F stated, It kind of gives us something to go on until we have something-that comprehensive care plan. A synopsis of what's going on with the resident and it's something that we need to know.<BR/>During an interview with the DON on 5/7/23 at 8:55 a.m., a policy on baseline care plans and comprehensive care plans was requested. The DON stated the facility had only one policy on care plans. At this time the DON provided a policy titled, Care Plan - Resident, dated 12/2017.<BR/>During an interview with the DON on 5/7/23 at 10:14 a.m., when asked how she provided oversight to the baseline care plan, the DON stated, We do go over them in the morning meeting and ensure the baseline care plan is done for new admissions. When asked what negative effects could occur to the resident if the resident did not have a baseline care plan, the DON stated, staff doesn't know how to care for the patient if there's no care plan.<BR/>Record review of a facility policy titled, Care Plan - Resident, dated 12/2017, revealed no verbiage regarding the creation of a baseline care plan.

Based on observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys, for 1 of 2 medication carts (Medication Cart 2), reviewed for security, in that,<BR/>An unassigned medication cart was unattended and unlocked with medication blister packs inside of the medication cart. <BR/>This failure placed residents at risk for harm by misappropriation of property of their medications. <BR/>The findings included:<BR/>During an observation on 01/23/2025 at 10:51 AM, it was revealed that a medication cart near the nurses' station at the corner of the 100 and 200 hallways, was unattended and unlocked. The medication cart was observed to have the lock button unengaged and unlocked. <BR/>During an interview and observation on 01/23/2025 at 11:08 AM, LVN A stated he was not assigned to the med cart and was not sure why it was unlocked. LVN A stated that the medication cart should have been locked and that he had not gone into the med cart that day. Observation with LVN A confirmed there was medication being stored inside of the cart, and stated he had been looking for medication and that he did not realize it was in the medication cart. <BR/>During an interview and observation on 01/23/2025 at 2:16 PM, the DON stated that she was not sure why the med cart was unlocked and confirmed it was being used as medication storage at the time of the observation. The DON stated that the med cart was no longer used and they had planned to get rid of the medication cart but had not yet. The DON stated she also was not aware of the last time a staff member would have gone into the medication cart. The DON stated her expectation was that all medication carts would be locked if staff was not passing medications to residents. The DON stated no one was assigned to this medication cart, as it was only being used as storage for extra medications.<BR/>Record review of the facility policy titled, Medication Storage - in the Home, dated 10/2020, revealed, It is the policy of this home that medications will be stored appropriately as to be secure from tampering, exposure or misuse.

Based on observation and interview, the facility failed to maintain an effective pest control program for 1 of 1 facility in that: <BR/>1. Numerous gnats were observed in a resident room on the 200 hall.<BR/>2. Numerous flies were observed on the 200 hall.<BR/>3. Observed a cockroach in the conference room <BR/>This deficient practice could place residents at risk of residing in an environment with pests. <BR/>The findings were: <BR/>1. Observation on 06/04/2024 at 9:34 a.m. revealed the presence of numerous flies on the 200 hall. <BR/>2. Observation on 06/04/2024 at 9:39 a.m. revealed the presence of gnats in and around residents' room in the 200 hall. <BR/>3. Observation on 06/05/2024 at 3:21 pm revealed the presence of a cockroach in the conference room. <BR/>Records review revealed that the pest control company had been to the facility twice in May 2024 to treat for ants and insects. <BR/>During an Interview on 06/06/2024 at 1:14 pm with the Administrator stated the maintenance person for the facility quit on 06/04/2024. He stated the facility should not have pests. He stated the facility does have a contract with a pest control company and the company services the facility at least once a month or sooner as needed. He stated it was the maintenance persons responsibility to maintain their pest control program. He stated the facility was utilizing the maintenance supervisor from a sister facility to resume pest control. He also said that he had ordered four blue lights for pest control and that he would have the interim maintenance personnel install them.

Based on observation, interview, and record review, the facility failed to establish and maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 6 residents (Resident #44) reviewed for infection control, in that:<BR/>CNA A failed to wash or sanitize his hands or change his gloves after touching the bed's remote and head of the bed and before starting incontinent care. <BR/>This deficient practice could place residents at-risk for infection due to improper care practices. <BR/>The findings include:<BR/>Record review of Resident #44's face sheet, dated 04/27/2023, revealed an admission date of 04/24/2023, with diagnoses which included: Atelectasis (collapse or closure of a lung), Bipolar disorder(mental disorder characterized by periods of depression and periods of abnormally elevated mood) and, Guillain-Barre syndrome( rare disorder in which the body's immune system attacks the nerves).<BR/>Record review of Resident #44's MDS Log revealed there was no completed MDS. <BR/>Record review of Resident #44's care plan, dated 04/25/2023, revealed a problem of has urinary incontinence, with an intervention of Monitor/document for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.<BR/>Observation on 04/27/23 at 02:20 p.m. revealed while providing incontinent care for Resident #44, CNA A washed his hands and put on gloves. CNA A touched the resident's bed's remote and the head of the bed with his gloved hands, then without changing gloves or sanitizing his hands started providing care for the resident. <BR/>During an interview on 04/27/2023 at 02:30 p.m. with CNA A, he confirmed the environment around the resident was considered dirty and he should have changed his gloves and sanitized his hands prior to providing care. He confirmed he received infection control training within the year. <BR/>During an interview with the Regional Nurse on 04/28/23 at 10:08 a.m., she confirmed the environment around the resident was considered dirty and the staff should change their gloves and wash. Staff should sanitize their hands after touching anything in the environment, before touching the resident and at the start of care. She confirmed the staff were inserviced in infection control and incontinent care and skills were checked annually and as needed by management <BR/>Record review of the annual skills check for CNA A revealed CNA A passed competency for Infection control on 08/22/2022. <BR/>Record review of the facility policy, titled infection control-prevention and control program, dated 12/2017, revealed [ .] 4. Implement hand hygiene (hand washing) practices consistent with accepted standards of practice to reduce the spread of infections and prevent cross-contamination [ .] The director of nursing or designee will perform infection control audits to review staff procedure in observation of standard precautions, infection control and isolation procedures