Every finding on record at Adviniacare Newburyport

Based on record review and interview the facility failed to ensure treatment and care was provided in accordance with professional standards of practice for one Resident (#87) out of a total sample of 21 residents. Specifically, for Resident #87 the facility failed to ensure timely treatment was provided when the Resident experienced a change in condition following a fall, that resulted in a fractured femur. Findings include:The facility policy titled Change in Condition, dated 7/2019, indicated the following:-Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an):a. accident or incident involving the resident;d. significant change in the resident's physical/emotional/medical condition;g. need to transfer the resident to a hospital/treatment center.2. A significant change of condition is a major decline or improvement in the resident's status that:a. will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self limiting);d. ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. Resident #87 was admitted to the facility in October 2023 and has diagnoses that include displaced midcervical fracture of the right femur, repeated falls and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/17/25, indicated that on the Brief Interview for Mental Status exam Resident #87 scored a 11 out of a possible 15, indicating moderately impaired cognition. The MDS further indicated Resident #87 requires partial to moderate assistance with Activities of Daily Living (ADLs). Review of the falls care plan for Resident #87, indicated Resident #87 is at risk for falls. R/T (related to) Decrease mobility, Poor Safety awareness, Impaired Balance, Use of assistive devices, legal blindness. (sic). Review of the assessment titled FALL-Initial Occurrence Note, dated 7/28/25 at 19:44 P.M., indicated Resident #87 sustained an unwitnessed fall on 7/28/25 at 17:00 P.M. The assessment indicated that Resident #87 complained of no pain and no change in range of motion from normal baseline. Review of the assessment titled Occurrence F/U Charting, dated 7/29/25 at 7:48 A.M., indicated the following:-Resident #87 reported 8/10 pain in the right hip and that this pain was new;-Resident #87 was demonstrating a change in ROM (range of motion) and that he/she was guarding the right hip;-That the writer called the on-call MD after 2am with no return call. Review of Resident #87's clinical progress notes indicated the following:-A note dated 7/28/25 at 19:43 P.M.: This nurse heard a loud bang as she left the room, rushed back and the patient was observed lying on the floor near the door with his/her wheelchair behind him/her. When asked what happened, he/she stated he/she is not in pain, he/she just slid off the chair The patient was assessed while on the floor, no injuries noted at this time. Denied hitting his/her head. Was assisted off the floor to his/her wheelchair by two nursing staff. Neuros initiated, WNL (within normal limits). The patient was reminded to use his/her call light whenever he/she required assistance. -A note dated 7/29/25 at 7:48 A.M., indicated the following: *The resident is experiencing pain. Pain rating is 8. Right Hip. This is a new complaint of pain. Pain medication administered. *New limitations noted in ROM. Resident guarding hip area. New interventions added following occurrence. Refer to care plan. New intervention(s) are effective. *MD notified of new change in condition @ Writer called on call after 2 am, No return call Writer called on call after 2 am, No return call (sic). -A note dated 7/29/25 at 8:38 A.M.: Call placed to on call service again after 8 am. Writer spoke with NP (name redacted). Order obtained to assess vitals and update. Resident has stable vitals but s/s of right hip pain continues. NP made aware and gave new orders for STAT Chest X-Ray 2 views and STAT X-RAY of R/HIP (right hip). -A note dated 7/29/25 at 11:36 A.M.: Pt. sent out to (name redacted) Hospital d/t (due to) stat x-ray results, acute impacted right femoral fracture, NP in building and gave order to send out, HCP Daughter aware. Review of the x-ray report dated 7/29/25 at 10:32 A.M., indicated: There is a fracture involving right femoral neck with impaction without displacement. The joint shows no dislocation. Pubic rami are intact. There is mild osteoporosis. During an interview with the Nurse Practitioner (NP) #1 on 9/17/2025 at 10:43 A.M., she said that the Physician's on-call system is in effect from 6:00 P.M., until 7:00 A.M. NP #1 said that if a call is placed to the on-call system at 2:00 A.M., technically the facility should hear back within the hour. NP #1 said that if a call was placed when Resident #87 had a change in condition that resulted in a new fracture later being identified, and the facility never received a call back from the on call physician, that is a problem. During a telephone interview with the Nurse #3 on 9/17/2025 at 11:45 A.M., she said that she was the Resident #87's nurse on 7/29/25. Nurse #3 said that during the middle of the night Resident #87 was having increased pain and a change in condition, so she called the on-call physician at 2:00 A.M., but never got a call back. Nurse #3 said that she gave Resident #87 Tylenol but cannot remember if it was effective and that she passed the concern on to the 7-3 shift nurse's to follow-up further. During an interview with the Director of Nursing on 9/18/2025 at 8:44 A.M., she said that it is her expectation that if a resident has a change of status several hours following a fall, that includes new pain reported at 8/10, a change in range of motion and guarding the hip, and it is 2:00 A.M., and the nurse is unable to reach the on-call provider, that the patient should be sent to the emergency room and the nurse should notify the provider as soon as they are able to reach them.

Based on record review and interview, the facility failed to follow up on a significant weight change for two Residents (#21 and #98) out of a total sample of 21 residents. Specifically, the facility failed to assess two Residents with significant weight changes in a timely manner, as indicated in the facility policy.Findings include: Review of the facility policy titled Weight Assessment and Interventions, revised 05/2019, indicated the following: Monthly weights will be obtained each month or as ordered by physician. Weights will be recorded in the medical record (electronic health record where available) for each resident. Any weight change of 5lb in a month and 3lbs in a week since their last assessment should be retaken within 72 hours for confirmation and verified by nursing. Licensed nurse should notify dietitian of identified weight change once reviewed. Dietitian notification should be documented within resident's medical record. Dietitian or diet technician should respond within 72 hours of receipt of notification. The threshold for significant and undesired weight changes will be based on the following criteria: 1 month- 5% weight change is significant; greater than 5% is severe. 3 months- 7.5% weight change is significant; greater than 7.5% is severe. 6 months- 10% weight change is significant; greater than 10% is severe. 1. Resident #98 was admitted in May 2016 with diagnoses including cerebral palsy, anxiety, and protein calorie malnutrition. Review of the Minimum Data Set (MDS) assessment, dated 8/7/25, indicated Resident #98 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. Review of the plan of care related to nutrition, dated 3/20/24, indicated: Monitor/record/report to physician as need for signs and symptoms of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs. in 1 week, > 5% in 1 month, >7.5% in 3 months, >10% in 6 months. Review of the weight record for Resident #98 indicated the following weights: 1/21/25: 147.0 pounds (lbs.) 3/17/25: 136.0 lbs. 4/2/25: 127.7 lbs. 5/9/25: 128.0 lbs. 6/3/25: 139.0 lbs. 8/7/25: 142.3 lbs. 9/5/25: 130.0 lbs. Review of the weight record indicated that from 1/21/25 to 4/2/25, Resident #98 lost 19.3 lbs. in three months, which is a 13.1% significant weight loss. Review of the physician progress notes and nutrition progress notes failed to indicate that either were made aware of the significant weight loss or followed up on the weight loss. Review of the medical record indicated that on 5/9/25, a quarterly nutrition assessment was completed, one month after a significant weight loss was identified, indicating that Resident #98 had gradual weight loss, but weight was within range and no additional nutrition intervention indicated at this time. Review of the weight record indicated that from 5/9/25 to 6/3/25, Resident #98 gained 11.0 lbs. in one month, which is a 7.9% significant weight gain. Review of the physician progress notes, and nutrition progress notes failed to indicate that either were made aware of the significant gain or assessed the Resident after the significant weight gain. Review of the medical record indicated that on 8/7/25, a quarterly nutrition assessment was completed, two months after the significant weight gain was identified, indicating that Resident #98 had gradual weight loss, but weight was within range and no additional nutrition intervention indicated at this time. Review of the weight record indicated that from 8/7/25 to 9/5/25, Resident #98 lost 12.3 lbs. in one month, which is an 8.6 % significant weight loss. Review of the physician progress notes, and nutrition progress notes failed to indicate that either were made aware of the significant loss or assessed the Resident after the significant weight loss. Review of Resident #98's physician orders dated 9/17/25 indicated a daily 237 milliliter supplement had been added on 12/29/23 and that there had not been any nutrition interventions implemented since then. During an interview on 9/17/25 at 12:23 P.M., the Dietitian said that she would expect that nursing would notify her of notable discrepancies in resident weights. She would put in an order to confirm the discrepancy or establish if the change is a new baseline for that resident. She said that if a resident had weight loss, either she or nursing can add supplements or other interventions to improve weight. She said that Resident #98's significant weight changes are consistent with his/her known overall decline and the reason she had not added any additional supplements. The Dietitian acknowledged that she had just noted on 9/17/25 the weight loss of 12 lbs. over the past month and that there was a lag time from the weight being obtained on 9/5/25 until 9/17/25. She said the weight loss should have been identified sooner and that interventions should have been put in place within 72 hours or at the most a week after the weight change being identified. She said residents should be assessed with any significant weight changes and at least quarterly. During an interview on 9/17/25 at 12:45 P.M., Nurse #1 said that significant changes in weights would be discussed during morning report which is attended by the Director of Nursing and that also it would be reported to the Dietitian and Nurse Practitioner. She said Resident #98's weight loss was expected because of his/her fluctuations in behaviors. During an interview on 9/17/25 at 10:22 A.M., the Director of Nursing said that she reviews monthly weights and that any other discrepancies in weights are discussed in morning rounds. She said the dietitian is in the building everyday so she will either discuss with her or send her an email to notify of weight changes. She would have expected a follow up or assessment from the dietitian or physician if a significant weight loss occurs within a week at the most after the weight change was identified. She said that Resident #98's weight fluctuations were his/her usual status. 2. Resident #21 was admitted in April 2023 with diagnoses including dementia and dysphagia. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #21 is severely impaired and could not participate in the Brief Interview for Mental Status exam. Review of the weight record for Resident #21 indicated the following weights: 2/3/25: 173.6 pounds (lbs) 3/14/25: 174.2 lbs 4/3/25: 161.2 lbs 5/3/25: 163.4 lbs 7/31/25: 161.1 lbs Review of the Nutrition progress notes indicated that Resident #21 was evaluated on 3/14/25 and had no acute nutrition concerns and would continue to monitor the Resident. Review of the weight record indicated that from 3/14/25 to 4/3/25, Resident #21 lost 13 lbs in one month, which is a 7.4% significant weight loss. Review of the physician progress notes and nutrition progress notes failed to indicate that either were made aware of the significant weight loss or addressed the significant weight loss for Resident #21. Resident #21 was signed onto hospice on 4/17/25. Review of the medical record failed to indicate that a comprehensive nutrition assessment was completed after the significant change with admission to hospice or after the significant weight loss. Review of the medical record indicated that on 7/14/25, a nutrition quarterly assessment was completed, 3 months after the significant weight loss and admission to hospice. During an interview on 9/17/25 at 12:23 P.M., the Dietitian said that she would expect that nursing would notify her of notable discrepancies in resident weights. She would put in an order to confirm the discrepancy or establish if the change is a new baseline for that resident. She said that if a resident had weight loss, either she or nursing can add supplements or other interventions to improve weight. She said that interventions should be put in place within 72 hours or at the most a week after a weight change is identified. She said residents should be assessed with any significant weight changes and at least quarterly. During an interview on 9/17/25 at 10:22 A.M., the Director of Nursing said that she would have expected a follow up from the dietitian or physician if a significant weight loss occurs and that weights are reviewed in morning meeting if there is a weight change.

Based on record review, and interview, the facility failed to provide care and services in accordance with professional standards of practice for one Resident (#109) out of a total sample of 21 residents, who required a vascular access device (device that provides access to the veins for the delivery of medications or fluids).Specifically, the facility failed to provide care and maintenance of Resident #109's midline catheter (a flexible tube inserted through a peripheral vein above the elbow that ends just below the axilla [armpit]) and monitor for catheter related complications. Findings include:Review of the facility policy titled 'Midline Dressing Change' dated January 2023, indicated the following:-Transparent dressings are changed every 7 days or sooner if the integrity of the dressing is compromised (wet, soiled, or loose).-Assessment is to include the absence or presence of erythema, drainage, swelling, induration, skin temperature at site, or complaint of tenderness at the site or along the vein tract.-Apply transparent dressing with insertion site centered in the dressing. Smooth dressing around catheter starting at insertion site and moving to periphery.-Label dressing with date, time, and initials of person performing dressing change.Resident #109 was admitted to the facility in September 2025 with diagnosis including other gram-negative sepsis.Review of Resident #109's Brief Interview for Mental Status (BIMS) score indicated the Resident scored a 15 out of possible 15 indicating intact cognition.On 9/16/25 at 8:51 A.M., the surveyor observed a right arm peripheral inserted catheter dressing undated, the bottom part dressing was lifting with hanging tape. The insertion site was not visible due to a disk and surrounding area was reddened. The Resident said the dressing had not been changed since he/she was at the hospital.Review of Resident #109's physician orders indicated the following orders initiated on 9/11/25: IV (intravenous) midline right arm transparent dressing change every day shift every Friday.-IV-midline right arm measure external catheter length with each dressing change, and as needed every day shift every Friday.9/15/25: Cefazolin Sodium Injection Solution Reconstituted 2 GM (Cefazolin Sodium) Use 2 gram intravenously three times a day for MSSA (methicillin-sensitive staphylococcus aureus) bacteremia for 10 Days until finished 2 gram/50 mL Piggyback - Infuse 50 mL stop date 9/26/25.Care plan date initiated 9/12/25: The resident has infection of the blood (septicemia)Intervention: Monitor site for placement signs/symptoms of infection every shift. -Change midline dressing every 7 days and PRN (as needed). Review of Resident #109's Medication Administration Record (MAR) indicated the midline dressing was changed on 9/12/25, the external catheter measuring 8cm.Review of the medical record hospital discharge paperwork infusion support systems, nurse visit record dated 8/31/25, indicated the midline external catheter measured zero centimeter.Review of Resident #109's progress notes failed to indicate the physician was notified due to possible midline migration. During an interview on 9/17/25 at 8:54 A.M., Nurse #2 said midline dressing changes are done weekly and should be dated when completed. She said every shift monitors for sign of infection but with the disk at the insertion site they are not able to visualize the insertion site.During an Interview on 9/17/25 at 9:54 A.M., the Director of Nursing said dressing changes are done weekly with measurements and documented in the MAR. Nurse responsible for changing the dressing should date and initial the dressing. During an interview on 9/17/25 at 10:53 A.M., Nurse #1 said she changed the midline dressing on 9/12/25 and measured from the insertion site to the end of the catheter. Nurse #1 said that during dressing changes they monitor for catheter migration, she said she assumed she dated the dressing.During an interview on 9/18/25 at 9:23 A.M., the Director of Nursing (DON) and the surveyor reviewed the photograph of Resident #109's midline. The DON said looking at it if the dressing was not changed that would be falsifying documentation.

Based on observations and interview the facility failed to 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 infections. Specifically, the facility failed to maintain Contact Precautions while administering medication to a resident. Findings include:Review of the Centers for Disease Control (CDC) website indicated the following, dated June 28, 2024:- Contact Precautions require the use of gown and gloves on every entry into a resident's room, regardless of the level of care being provided to the resident. Residents on Contact Precautions are recommended to be restricted to their rooms and restricted from participation in group activities. On 9/17/25 at 8:50 A.M., the surveyor observed Nurse #2 entering a resident's room to administer medications. Beside the entrance of the resident room was a sign that indicated:- Contact Precautions- Everyone must: - Clean their hands, including before entering and when leaving the room.- Providers and staff must also: - Put on gloves before room entry. Discard gloves before room exit. - Put on gown before room entry. Discard gown before room exit. The nurse entered the room and failed to put on gloves or a gown. After administering the oral medications, she had to administer an injection, so she put on gloves but did not put on a gown. Outside of the room was a drawer with gowns and gloves stocked in it. Prior to Nurse #2 entering the resident's room, there was another resident in the room visiting and that resident wheeled himself/herself out to hallway to ask Nurse #2 for medication and then wheeled back in to continue visiting with the resident in that room. The visiting resident was, at no time, wearing any personal protective equipment (PPE), nor did he/she wash or sanitize their hands. During an interview on 9/17/25 at 8:54 A.M., Nurse #2 said that residents with C-diff (a highly contagious bacterium that causes diarrhea and colitis) require the use of Contact Precautions. Nurse #2 said that she didn't think she needed to wear a gown and gloves if she was just giving meds to a resident on Contact Precautions and she didn't know what was necessary for precautions for another resident visiting a resident on Contact Precautions. During an interview on 9/18/25 at 8:54 A.M., the Director of Nurses said that any resident with C-diff would require the use of Contact Precautions but did not think PPE was required unless someone entering the resident room was providing direct care.

Based on observation, record review, policy review and interview, the facility failed to provide adequate supervision for one Resident (#49) out of a total sample of 27 Residents, and ensure an environment free from accidents and hazards in two resident rooms. Specifically, the facility failed to: 1. Ensure that Resident #49 was not left unattended in the dining room, subsequently the Resident sustained a fall resulting in nasal fracture. 2. Properly store oxygen cylinders in an upright and firmly secured manner on two out of three units. Findings Include: Review of the facility policy titled Accidents and Incidents, revised October 2022, indicated, but was not limited to, the following: - An incident is any occurrence not consistent with the routine operation of the center, normal care of the resident, a happening involving visitors, malfunctioning equipment, or observation of a condition which might be a safety hazard. The occurrence may be a fall, skin tear, bruise, new pressure ulcer and may involve abuse, neglect, and mistreatment or an injury of unknown origin. - All incidents and accidents will be evaluated by the interdisciplinary team. - The team will review the investigation and continue, if necessary, discuss and determine from the investigation the root causes, make recommendations for additional intervention, education and conclude the investigation. (sic.) Resident #49 was admitted to the facility in February 2024 with a diagnosis of dementia. Review of the most recent Minimum Data Set (MDS) Assessment, dated 8/7/24, indicated that Resident #49 scored a 0 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident has severe cognitive impairment. Further review of the MDS indicated the Resident was dependent on staff for all mobility, including sitting to standing and transferring. Review of the fall-unwitnessed report dated 4/7/24 indicated that Resident #49 had sustained an unwitnessed fall in the dining room, the Resident had fallen out of his/her wheelchair and sustained a skin tear on his/her left eyebrow and a hematoma. Further review of the incident report indicated that the Resident's plan of care was updated to not be left in the dining room area unattended, and that the Resident should be out to nursing station after meals. Review of the hospital paperwork dated 4/8/24, indicated Resident #49 had a laceration on his/her left eyelid with sutures in place. Review of Resident #49's care plan indicated the Resident was at risk for falls related to confusion, gait/balance problems, incontinence, unaware of safety needs, anxiety, restlessness, and impulsivity with the following intervention: - Ensure Resident is out in common area after meals, do not leave in dining area unattended, initiated 4/15/24. Review of Resident #49's incident reports indicated the Resident had also sustained falls on 8/16/24, 8/17/24, and 9/3/24. Review of Resident #49's incident report dated 9/11/24 indicated that Resident #49 had sustained a fall on 9/7/24 at 9:40 A.M. The incident report indicated that the nurse responded to a noise and observed Resident #49 on the floor with an abrasion on his/her forehead and bleeding from the left nostril; the Resident was subsequently sent to the hospital for evaluation and returned to the facility on the same day with a diagnosis of nasal fracture. Further review of the incident report indicated that per the certified Nursing Aides (CNA's) witness statements that the Resident was last seen sleeping in his/her wheelchair while staff were collecting breakfast trays and putting them in the food truck located outside of the dining room area. Review of four out of four witnesses' statements, including one that was completed by CNA #3, indicated that the fall was not witnessed and that the fall had occurred in the dining room. Review of Resident #49's fall with head injury report, dated 9/7/24, indicated that the nurse had heard a bang in the dining room and observed the resident lying on the floor; the Resident was bleeding from a gash in the middle of his/her forehead and left nostril. Further review of the report indicated that the incident was not witnessed. Review of the staffing schedule, dated 9/7/24, indicated that CNA #3 was working on Resident #49's unit at the time of the fall. During an interview on 10/10/24 at 7:55 A.M., CNA #3 said that she was working on 9/7/24 when the fall had occurred. CNA #3 said that while she was picking up breakfast trays and taking them to the food trucks located near the nurse's station and at the end of the hall Resident #49 had fallen in the dining room. CNA #3 said that all staff had left the dining room and that no staff or visiting family members were within eyesight of the dining room or witnessed Resident #49 fall. CNA#3 said the Resident was at risk for falls due to his/her progressive decline and that the Resident should have been taken out of the dining room after he/she had finished eating as the Resident required supervision. Review of the hospital paperwork, dated 9/7/24, indicated that Resident #49 arrived to the emergency department after sustaining a fall. The hospital paperwork indicated that Family Member #3 arrived with the Resident and helped provide the story. The hospital paperwork indicated that the Resident was in a wheelchair, fell forward, and that this was witnessed by facility staff. Further review of the hospital paperwork indicated that the Resident had sustained an abrasion over the nose and forehead, and that a CT (computed tomography) scan showed a nasal fracture. During an interview on 10/9/24 at 4:36 P.M., Family Member #3 said that Family member #2 had called her after being notified that Resident #49 had fallen. Family Member #3 said she had arrived to the facility before Resident #49 had left and had accompanied the Resident to the hospital. Family Member #3 said that she knew the Resident had fallen out of his/her chair in the dining room from speaking to Family Member #2 but had not spoken to staff about the fall and was unaware of any other details surrounding the fall. Family Member #3 said the hospital staff had asked her about the fall and that she did not know if staff were present at the time of the fall. Family Member #3 said that no family members were visiting the Resident at the time of the fall. During an interview on 10/9/24 at 1:45 P.M., Family Member #1 said that Family Member #2 was told by staff that Resident #49 had fallen in the dining room on 9/7/24 and that there were no staff present at the time of the fall, and that no staff witnessed the Resident fall. Family Member #2 said no family members were visiting at the time of the fall. During an interview on 10/9/24 at 2:01 P.M., Family Member #2 said she was initially contacted by the staff on 9/7/24 about Resident #49's fall and was told that the Resident fell while staff were picking up trays. During an interview on 10/10/24 at 9:23 A.M., Nurse #4 said that when a resident falls their care plan should be reviewed and updated with new interventions to prevent future falls. Nurse #4 said that the risk for not implementing a care plan created to prevent falls was injury or death and that she would expect the care plan to be implemented. Nurse #4 said Resident #49 was at high risk for falls due to dementia and incontinence and that the Resident had sustained injuries from previous falls; Nurse #4 said that Resident #49 should be near the nurse's station for supervision. During an interview on 10/10/24 at 9:56 A.M., the Director of Nursing (DON) said she wasn't in the building at the time of the fall but that based on the incident reports the fall on 9/7/24 was unwitnessed. The DON said the Resident should not be left in the dining room unattended. The DON said she would expect care plans created to prevent falls to be implemented. During a follow-up interview on 10/10/24 at 12:45 P.M. the DON said that the hospital paperwork from the 9/7/24 fall, which indicated the fall was witnessed by staff, was not accurate as the facility reports indicated the fall was unwitnessed. 49880 2a. Review of the National Fire Protection Association (NFPA) 99 section 11.6.2.3 (11) states that freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. During an observation on the first floor on 10/8/24 at 8:13 A.M. and 9:57 A.M., the surveyor observed two oxygen cylinders free standing in a resident room. The two oxygen cylinders were free standing without any chain, stand or cart supporting it. During the observation at 9:57 A.M., the Resident was up in his/her wheelchair and moving around the room. During an interview on 10/8/24 at 10:26 A.M., CNA #1 said that oxygen cylinders should be in a black carrier attached to a wheelchair or in a cart. He said they should not be just on the floor because they can fall over and explode or cause a fire. During an interview on 10/8/24 at 10:28 A.M., Nurse #1 said oxygen cylinders should be stored either in a black bag on the back of a wheelchair or in a metal rolling rack when in a resident's room. She said without proper storage it could fall over and potentially explode. Nurse #1 and the surveyor observed the two oxygen tanks in the resident's room, and she said they should absolutely not be stored like that. During an interview on 10/08/24 at 2:48 P.M., the Director of Nursing (DON) said oxygen cylinders should not be free standing on the floor and must be placed in the proper storage holders to prevent accidents or injuries. 48671 2b. During an observation on the second floor on 10/8/24 at 9:01 A.M. and 10:25 A.M., the surveyor observed one oxygen cylinder free standing in a resident room. The oxygen cylinder was free standing without any chain, stand or cart supporting it. During the observation at 9:01 A.M., the Resident was up and walking around the room. During an interview on 10/8/24 at 10:25 A.M., Certified Nursing Assistant (CNA) #4 said oxygen cylinders should not be on the floor in the room because they can fall over and explode. During an interview on 10/8/24 at 10:29 A.M., Nurse #2 said oxygen cylinders should not be stored directly on the floor because it is unsafe. Nurse #2 observed the oxygen cylinder with the surveyor and the oxygen cylinder was not empty. Nurse #2 said the oxygen cylinder should be placed in a holder and pointed to a metal oxygen cylinder container that was placed next to the oxygen cylinder. During an interview on 10/08/24 at 2:48 P.M., the Director of Nursing (DON) said oxygen cylinders should not be free standing on the floor and must be placed in the proper storage holders to prevent accidents or injuries.

Based on interviews and record review, the facility failed to ensure that sufficient staffing levels were maintained to safely and adequately meet each resident's personal care needs. Finding include: Review of the facility assessment indicated the following: -Our Resident Profile: 111 number of beds. Average daily census 89-94 residents -Staffing Plan: 1 DON (Director of Nurses) RN (Registered Nurse) full-time days; ASST (Assistant Director of Nurses) RN full-time days; RN or LPN (Licensed Practical Nurse): 2 for each shift 2-3 RN/LPN per shift; per unit Direct Care Staff: 3-4 CNA per shift; per unit Registered Nurses & LP Nurses total number needed 18. Number of weekly Hours 1008. Certified Nursing Assistants total number needed 33. Number of weekly Hours 1848. -Individual staff assignment is based on staff competency and preference to the type of care they like to provide and have experience providing i.e. residents with advanced dementia vs. short term rehab patients. The facility strives to maintain consistent assignments to ensure continuity of resident and care giver relationships. Assignments are reassessed when residents or staff leave the facility to maintain person centered care. -All staffing is primarily based on the daily census on each unit. Each resident's preference for schedule, waking times, naps, bathing, bedtime, etc. is reflected in their individual plan of care. Out staffing patterns allow for these needs to be met on an individual basis. Staffing patterns are increased based on acuity and behavior i.e., a resident requires 1:1 attention for a period of time or there is a need for two staff members to handle a transfer, such as with a resident that requires a hoyer lift. During an interview on 10/10/24 at 1:31 P.M., The Scheduler said the facility is having a difficult time finding dependable staff and said the facility is below the budgeted hours. Review of the actual working schedules provided to the surveyor for the past 30 days, the facility failed to meet the appropriate staffing levels for 30 out of 30 days. During an interview on 10/10/24 at 1:21 P.M., The Administrator said he expects the facility to staff according to the regulation and said the budgeted hours per patient per day (HPPD) for the facility census is 3.58. The Administrator said staffing has been an issue in the facility and they are working on recruiting more staff.

Based on observation and interview the facility failed to store and handle food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure food was labeled in the main kitchen and on the unit kitchenettes and that staff did not contaminate ready to eat food during service. Findings include: Review of the facility's policy titled Food Storage (Dry, Refrigerated, and Frozen), dated 2020, indicated, but was not limited to, the following: - All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. - Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration. - Leftover contents of cans and prepared food will be stored in covered, labeled, and dated containers in refrigerators and/or freezers. Review of the facility's policy titled HACCP (Hazard Analysis Critical Control Point) and Food Safety, dated 2013, indicated, but was not limited to, the following: - Food borne illness (FBI) is an illness that is transmitted to humans through food. A hazard is a food product that may cause a health risk to customers. These hazards may be biological, chemical, or physical. Physical hazards may include: foreign objects such as metal, glass, plastic or wood. Cross contamination occurs when harmful substances are transferred from one source (i.e., hands, food contact surfaces, unsanitary cleaning cloths, raw foods) to the food. - Be aware of sources of food-borne organisms in food service: o Humans (nose and throat, hands, infections, feces, and clothing): poor personal hygiene; poor handwashing practices. - Pay special attention to individuals at risk for FBI: older adults, children, pregnant women, immune-compromised individuals, those who had recent surgery or have chronic illness. - The lead cause of FBI is improperly cooled foods, followed by: o Food not thoroughly heated or cooked. o Infected employees/poor personal hygiene. o Food prepared a day or more in advance of serving. o Raw, contaminated ingredients added to food. o Food left too long at temperatures that favor bacterial growth. o Failure to reheat food to temperatures to kill bacteria. o Cross contamination - cooked food by raw food, equipment not properly. cleaned/sanitized, mishandling of food by employees. During the initial walk-through of the kitchen on 10/8/24 at 7:07 A.M., the surveyor observed an open water bottle stored with resident food and ingredients in the reach-in refrigerator. The kitchen staff said it was his water bottle. On 10/8/24 at 7:23 A.M., the surveyor made the following observations in the refrigerator of the third-floor kitchenette: - A container of prepared soup, undated and unlabeled. - A yogurt with an expiration date of 9/10/24, there was also a date of 9/9/24 written on the lid in marker. - A container of soy milk, open but undated. On the outside of the third-floor refrigerator the surveyor observed a sign, titled Kitchenette Food Storage, which indicated the following: - Please label all items with the date opened before placing items in the refrigerator. - All resident food/drinks need to be labeled with name, room number and date. - If anything is past the expiration date or is not labeled it will be thrown out. On 10/8/24 at 7:28 A.M., the surveyor made the following observations in the refrigerator of the second-floor kitchenette: - A lunch bag containing food was stored next to resident food. During an interview on 10/8/24 at 7:29 A.M., Nurse #5 said that it was her lunch bag and that it should be stored downstairs and not in the resident food refrigerator. On 10/8/24 at 7:31 A.M., the surveyor made the following observations in the refrigerator of the first-floor kitchenette: - A pizza box containing three slices of pizza, undated and unlabeled. The surveyor made the following observations during a continuous observation on 10/9/24 from 7:47 A.M. until 7:58 A.M. during the breakfast tray line: - An open bag of hard-boiled eggs in the reach in refrigerator, undated. - The container used to store serving utensils had visible debris in the bottom of the container where utensils were being stored. - The cook contaminated his gloves by touching the handles of tongs and serving utensils, the reach-in refrigerator door and the outside of a pan containing a cooked omelet. The cook then, with the same contaminated gloves, grabbed the cooked omelet and put it on a plate and into the microwave; the omelet was then served to a resident. - The cook's name-badge, which was hanging from his neck, made direct contact with ready-to-eat scrambled eggs when the cook leaned over on three separate occasions. - The cook contaminated his gloves by touching the handles of serving utensils then, with the same contaminated glove, grabbed a ready-to-eat muffin and placed it on a resident plate to be served. During an interview on 10/9/24 at 9:39 A.M., the Food Service Director (FSD) said that food service staff were expected to check the kitchenette refrigerators three times a day to ensure that food was not past expiration dates, and that food and drinks were labeled; the FSD said all food and drinks should be labeled and dated when prepared or opened. The FSD said employees should not store their own food or drinks with resident food or ingredients as this poses a risk for cross contamination, and that there was a designated employee refrigerator. The FSD said nurse or family were expected to date and label food brought in from outside of the facility which would be discarded after two days. The FSD said staff should not use contaminated gloves to touch ready-to-eat food.

Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) Assessments were accurately completed to reflect the status of one Resident (#25) out of a total sample of 27 residents. Specifically, the facility failed to document that Resident #25 is receiving antipsychotic medication. Findings Include: Resident #25 was admitted to the facility in September 2022 with diagnoses that include Major Depressive Disorder and Anxiety Disorder. Review of Resident #25's most recent Minimum Data Set (MDS) Assessment, dated 8/16/24, indicated a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating that Resident #25 has moderate cognitive impairment. The MDS failed to indicate receiving antipsychotic medication. Review of Resident #25's physician's orders indicated the following order dated 7/18/24: -Abilify (an antipsychotic medication) oral tablet 5 milligrams (mg) by mouth one time a day for mood depression. Review of Resident #25's August 2024 Medication Administration Record (MAR) indicated that the Resident received abilify once daily from 8/1/24 through 8/31/24. Review of Resident #52's plan of care dated as initiated 7/18/24 indicated that the Resident uses antipsychotic medications related to behavior management. Review of Resident #25's Psychiatric Evaluation and Consultation, dated 7/18/24, indicated he/she will start abilify tomorrow. Monitor for any adverse reactions of this antipsychotic. During an interview on 10/9/24 at 11:38 A.M., the MDS Nurse reviewed Resident #25's medical record and said that the MDS is coded incorrectly because the Resident has been receiving antipsychotic medication since July.

Based on record review and interviews, the facility failed to develop a comprehensive person-centered care plan for two Residents (#36 and #18) out of a sample of 27 residents. Specifically, 1(a) For Resident #36, the facility failed to develop comprehensive person-centered care plans for a history of alcohol abuse and, (b) a history of suicidal ideation. 2. For Resident #18, the facility failed to develop a comprehensive person-centered care plan for a history of alcohol abuse on admission. Findings include: Review of the facility policy titled 'Care Plan-Comprehensive' with a revision date of October 2022 indicated the following: -A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. -The Interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 1 (a) Resident #36 was admitted to the facility in February 2023 with diagnoses including major depressive disorder and anxiety disorder. Review of the Minimum Data Set (MDS) Assessment, dated 9/20/24, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating that Resident #36 is cognitively intact. Review of Resident #36's Admission Social History Evaluation, dated 2/8/23, indicated the following: -D. Smoking/Alcohol use Does the resident use any of the following (check all that apply): Alcohol-checked off. Does not currently use but has a known history of use-checked off. Review of the behavioral health group therapy progress notes, dated 4/30/24, indicated the following: -Substance Abuse/Addiction History: ETOH (alcohol) per chart-not currently. A review of the behavioral health group medication management progress notes dated 4/10/24 indicated the following: -Substance Abuse/Addiction History: ETOH (alcohol) per chart-not currently. A review of Resident #36's care plan failed to indicate that a comprehensive person-centered care plan was in place for a history of alcohol abuse. During an interview on 10/9/24 at 11:12 A.M., Resident #36 denied he/she has a history of alcohol abuse. During an interview on 10/9/24 at 4:51 P.M., Social Worker (SW) #1 said she would not be expected to develop a personalized care plan for Resident #36 because the history was not identified in his/her hospital discharge paperwork. During an interview on 10/9/24 at 6:02 P.M., the Regional Director of Clinical said Resident #36 does not need a personalized history of alcohol abuse care plan because he/she does not have a documented diagnosis of alcohol abuse. During a telephone interview on 10/11/24 at 1:34 P.M., Licensed Clinical Social Worker (LCSW) #2 said some residents with a history of alcohol abuse are very forthcoming with their alcohol abuse history, however, some of them are very cautious and will not reveal their alcohol abuse history easily. She said this could be based on first impressions, approach and how much rapport the person inquiring about the alcohol abuse history has with the Resident. LCSW #2 said residents with a history of alcohol abuse can be sober for years, but they can get triggered to start drinking alcohol again based on their mood at any point in time, therefore a personalized plan of care should be in place. (b) Resident #36 was admitted to the facility in February 2023 with diagnoses including major depressive disorder and anxiety disorder. Review of the Minimum Data Set (MDS) Assessment, dated 9/20/24, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating that Resident #36 is cognitively intact. Review of the hospital discharge clinical paperwork that accompanied Resident #36 at admission, dated 7/29/22, indicated the following: -[NAME] suicide severity/suicide rating scale: Wish to be dead (past month)-Yes Suicidal thoughts (past month)-Yes Suicidal thoughts with method without plan (past month)-Yes Review of the Resident #36's care plan failed to indicate that a comprehensive person- centered care plan was in place for a history of suicidal ideation. During an interview and chart review on 10/9/24 at 4:51 P.M., SW #1 and the Surveyor reviewed the clinical paperwork. SW #1 said she would not be expected to develop personalized care plans identifying Resident #36's history of suicidal ideation because the Resident eventually denied making those suicidal ideation statements. During an interview on 10/9/24 at 6:02 P.M., the Regional Director of clinical said Resident #36 did not need a personalized history of suicidal ideation care plan because the statements were a history and not happening in the present moment. During a telephone interview on 10/11/24 at 1:34 P.M., LCSW #2 said residents with a history of suicidal ideation can be re-triggered to have further suicidal ideations based on their mood at any point in time therefore a personalized plan of care should be in place. 2. Resident #18 was admitted to the facility in August 2024 with diagnoses including alcohol dependence with withdrawal delirium and cognitive communication deficit. Review of the Minimum Data Set (MDS) Assessment, dated 8/5/24, did not indicate a Brief Interview for Mental Status (BIMS) score. Review of Resident #18's care plan indicated a substance abuse care plan was initiated on 10/9/24. During an interview on 10/10/24 at 9:47 A.M., SW #1 said Resident #18 did not have a personalized substance abuse care plan, so she developed it on 10/9/24.

Based on observations, interview, and record review, the facility failed to meet professional standards of quality for one Resident (#52), out of a total sample of 27 residents. Specifically for Resident #52, the facility failed to assess the diet texture for Resident #52 after swallowing incident. Findings include: Resident #52 was admitted to the facility in October 2021 with diagnoses including major depressive disorder, diabetes, traumatic brain injury, and vitamin D deficiency. In June 2023, Resident #52 was diagnosed with dysphagia (difficulty chewing and swallowing). Review of the most recent Minimum Data Set (MDS) assessment, dated 9/24/24, indicated Resident #52 had a Brief Interview for Mental Status (BIMS) exam score of 3 out of a possible 15, which indicated he/she had severely impaired cognition. The MDS further indicated Resident #52 requires partial/moderate physical assistance with eating and is on a therapeutic diet. Review of Resident #52's medical record indicated he/she choked while eating chicken in July 2022, requiring the Heimlich maneuver (a first aid procedure to treat airway obstructions by a foreign object) and, at that time, physician orders were obtained to downgrade the Resident's diet to a Mechanical Soft Diet (an altered textured diet for individuals with difficulty chewing and swallowing). Further review of the medial record indicated a second choking incident that occurred in July 2023, resulting in Resident #52 being transferred to the hospital, and a third swallowing incident that occurred in August 2024. Review of Resident #52's Speech Therapy Discharge Summary dated 2/2/24 indicated the following recommendations: -Mechanical soft, thin liquids. To facilitate safety and efficiency, it is recommended the patient use the following strategies during oral intake: bolus size modifications including taking small bites. Review of Resident #52's Occupational Therapy Discharge Summary dated 1/24/24 indicated the following recommendations: -Patient is SU (set-up) and supervision for self-feeding. Supervision or touching assistance. -Assistance with ADL's. Dining / Swallowing Program. -Staff trained and 100% compliant with pt (patient) self-feeding supervised and SU. Review of Resident #52's Nurse Practitioner note dated 8/16/24, indicated: -Reason for appointment - Swallowing Issue. Being seen today related to nursing with reports of pt with trouble swallowing during his/her lunch. Upon encounter pt is sitting upright in wheelchair in the day room, awake and alert in NAD, pleasantly conversant. Pt verbalizes he/she was eating too fast and pasta got stuck in his/her throat. Currently denies any issues swallowing. Treatment: Choking sensation. Monitor for new or worsening s/sx (signs and symptoms). Speech therapy follow up, nursing aware. Review of Resident #52's Dietician Nutritional assessment dated [DATE], indicated: Regular diet, mechanical soft, thin liquids. recent choking sensation eating pasta noted, NP aware. Eating skills: Independent with set up, Supervision, Limited Assist and eating devices - lipped plate, sippy cup. -New/recent indications or complaints: Constipation, Swallowing. Review of Resident #52's Activities of Daily Living Care Plan last revised on 5/20/24, indicated the following: -Eating: Requires feeding assist at times, cueing. Lip Plate and sippy cups with meals. Cut up food to bite size, No bread products. -Supervision/touching. Review of the nutritional risk care plan dated 10/25/21 indicated the following interventions: - Increase initiation cues to help promote independence. Dated 10/27/23. -Resident to use lip plate and sippy cups to promote independence. Revised 2/16/24. -Supervised with meals. Dated 10/27/23. Review of the facility nutritional care manual indicate the following: Dental Soft (Mechanical Soft) Diet. This consistency modified diet is for individuals with limited or difficulty in chewing regular textured foods. This diet follows the Regular Diet planned and provides foods that can be easily chewed. The diet consists of food of nearly regular textures but eliminates very hard, sticky, crunchy or hard to chew foods. Foods should be moist and fork tender. This diet may also be used by a Speech Language Pathologist (SLP) in the treatment of dysphagia with individualization per recommendations by the SLP. This diet may be used for those experiencing mouth irritation and dentition problems including lack of teeth or poor fitting dentures. Individualization for specific food tolerances is required. For individuals that have any swallowing problems or dysphagia, it is recommended that a SLP be consulted and one of the Dysphagia Level Diets may need to be implemented. The diet consists of food of nearly regular textures but excludes very hard, sticky, crunchy or hard to chew foods. Foods should be moist and fork tender. Dry, hard crusty breads are excluded. Popcorn; dry, hard crusty breads. Breads, cereals and crackers with nuts or seeds; dried fruits; granola Nuts, pretzels, snack chips, potato chips; chewy candy (caramels, licorice). Review of Resident #52's active physician orders indicated the following: -Regular diet Mechanical soft with Ground meat texture, Thin Liquids consistency. Dated 2/29/24. - Diet Recommendations: 3 sippy cups with lids on her tray with meals. Dated 1/11/24. - pt (patient) issued lip plate with meals. Dated 10/3/23. Review of the medical record failed to indicate Resident #52 was assessed by speech therapy after Resident #52 had a swallowing incident as documented by the Nurse Practitioner on 8/16/24. On 10/8/24 at 8:20 A.M., the surveyor observed Resident #52 sitting in the dining room, in a wheelchair leaning forward with his/her head down on the table sleeping. There were no staff present. On 10/8/24 at 8:28 A.M., the surveyor observed Resident #52 sitting in the dining room eating whole French toast, oatmeal, and yogurt. Two sippy cups without lids were observed on the breakfast tray. The Resident was observed drinking from one sippy cup containing red liquid. The sippy cup did not have a lid. There were no staff members assisting or supervising the Resident during the meal. The Resident was observed placing a large piece of French toast into his/her mouth. The Resident began to choke and was leaning forward in his/her wheelchair. The Resident's facial color turned red, and the Resident could be heard making gargling and coughing sounds. Two staff members could hear the sounds from the nurses' station, and both came over to check on the Resident. The Resident continued to lean forward and was able to expectorate the French toast from his/her mouth. The Resident could be heard saying I choke a lot all the time to a staff member as the staff member assisted Resident #52 back to the table. The surveyor observed Nurse #1 checking the oxygenation saturation of the Resident and said to the Resident 98% you're good. On 10/8/24 at 12:12 P.M., the surveyor observed Resident #52 sitting in the dining room eating lunch. The Resident was observed eating a large square piece of corn bread. One large white Styrofoam cup was filled with dark soda. There was no lid on the cup. Resident #52 was observed drinking from the Styrofoam cup throughout the lunch meal. There were no sippy cups on the lunch tray. There was one staff member sitting at another table with their back to Resident #52. There were no staff proving supervision or cueing throughout the lunch meal. On 10/9/24 at 8:16 A.M., the surveyor observed Resident #52 sitting in the dining room eating breakfast. The Speech Language Pathologist (SLP) was present. The Resident had two whole slices of toast, eggs and soda on the breakfast tray. Throughout the observation Resident #52 did not eat his/her toast with the SLP present. On 10/9/24 at 12:14 P.M., the surveyor observed Resident #52 sitting in the dining room eating lunch. The lunch tray contained a large whole bread roll. There was one sippy cup on the lunch tray containing a red liquid. The sippy cup did not have a lid. There were two staff members providing feeding assistance to other Residents in the dining room. There were no staff providing supervision or cueing throughout the lunch meal. On 10/09/24 at 5:26 P.M., the surveyor observed Resident #52 sitting in the dining room eating dinner. The dinner tray contained one ground chicken sandwich cut in half and several whole orange cheese curls. The surveyor observed the Director of Nursing stop a staff member from placing covers on to two sippy cups. The DON said, she doesn't need a lid and the DON removed the lid off one of the sippy cups. The surveyor observed loose ice cubes inside the sippy cup. The surveyor observed Resident #52 drinking from the sippy cup and two ice cubes could be seen inside of the Residents mouth as he/she kept opening and closing his/her mouth moving the ice around. The DON was observed to be standing behind the Resident during this observation. There were no staff proving supervision or cueing throughout the lunch meal. During an interview on 10/09/24 at 12:24 P.M., Certified Nursing Assistant (CNA) #1 said Resident #52 needs sippy cups with handles because he/she shakes and said the Resident can have bread because it's soft. CNA # 1 said staff will check the Kardex to know how to care for the Resident and to check for eating issues or concerns. During an interview on 10/9/24 at 12:45 P.M., Nurse #2 said Resident #52 eats too fast and needs to slow down so he/she doesn't choke because he/she does this kind of thing often. Nurse #2 said Resident #52 is on a mechanical soft diet because he/she had swallowing issues in the past and said the Resident needs supervision with eating. Nurse #2 said the Resident has a care plan in place for diet needs and it is expected to be followed. During an interview on 10/09/24 at 5:38 P.M., The DON said Resident #52 needs a sippy cup with lids and handles and requires a mechanical soft diet. The DON said Residents who need supervision during meals need to be in the communal dining room and not eating alone. The DON said Resident #52 requires supervision and cueing throughout the meal to slow down his/her pace while eating. During an interview on 10/09/24 at 5:38 P.M., with the Administrator, Regional Clinical Director and the Director of Nursing (DON), The DON said Resident #52 requires supervision and cueing during meals and needs sippy cups with lids. The DON said Resident #52 should not have received bread products prior to the speech evaluation and said she removed the no bread products from the care plan after Resident #52 was evaluated by the speech therapist. The DON said the Resident should not have cheese curls without being evaluated by the speech therapist first. The DON said the Resident has no prior issues with swallowing or choking on food items and said the no bread products should have been removed from the care plan last year, but it was not. The Regional Clinical Director said, the no bread products are erroneous on the care plan and said the correct diet order is the physician order and said the Resident can have bread products. The Regional Clinical Director said she is not aware of any prior history of choking here at the facility, does not have swallowing issues and is not at risk for aspiration. The Regional Clinical Director said there is no reason Resident #52 can't have whole ice because ice melts into thin liquids and the Resident can drink thin liquids. The Administrator said he is not aware of any choking or swallowing issues related to Resident #52. During an interview on 10/10/24 at 7:18 A.M. the Speech Therapist (ST) said she evaluated Resident #52 yesterday morning after she was notified of the choking incident at breakfast. The ST said Resident #52 is on a mechanical soft diet that includes meat that is ground up, nothing sticky or difficult to chew and said she did not implement or alter any care plans at this time. The ST said mechanical soft diet does include soft breads and said she was not aware that the care plan indicated no bread products and was not aware of any history of choking or prior swallowing concerns. The ST said Resident #52 did not want to eat the toast yesterday morning and she did not see the Resident eat any bread products. The ST said Resident #52 should not be eating cheese curls without being assessed first and said Resident #52 requires supervision and cueing during meals and the use of sippy cups with handles to assist with holding the cup. The ST said Resident #52 needs reminders to slow down and to take small bites and said whole chunks of ice would not be a concern because the Resident has no history of aspirating or choking prior to yesterday. During a follow up interview on 10/10/24 at 7:41 A.M., the DON said the Resident was placed on a mechanical soft diet after she was admitted to the hospital for pneumonia and said a prior diet order for ground meat with no bread products was dated 8/11/23 due to an issue of choking at the hospital. The DON said the care plan should have been updated in January 2024, but it was not. The DON said she was not aware that the Resident had an issue while swallowing pasta in August and said Resident #52 should have been evaluated by speech therapy. During an interview on 10/10/24 at 9:32 A.M., the Dietician said Resident #52 requires supervision and cueing and must be supervised while eating due to his/her history of choking. The Dietician said she was notified by nursing staff of a choking incident in August while eating pasta and said she was also notified by the Occupational Therapist. The dietician said she would expect the Resident to be evaluated by speech therapy. During an interview on 10/10/24 at 10:23 A.M., the DOR said she is also an Occupational Therapist, is not familiar with the Resident and said Resident #52 was not evaluated after 2/2/24. The DOR said the resident is currently on a mechanical soft diet. The DOR said she does not recall an incident in August regarding an issue while eating pasta.

Based on observations, record review, and interviews, the facility failed to provide supervision with meals for two Residents, (#34 and #52) out of a total sample of 27 residents. Findings include: Review of the facility policy titled Activities of Daily Living (ADL) Supporting, dated as revised June 2022, indicated Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: D. dining (meals and snacks). 1. Resident #34 was admitted to the facility in August 2021 with diagnoses including dysphagia, gastro esophageal reflux disease, hyperlipidemia, and vitamin D deficiency. Review of the Minimum Data Set (MDS) assessment, dated 7/26/24, indicated Resident #34 had a Brief Interview for Mental Status (BIMS) exam score of 3 out of a possible 15, which indicated he/she had severely impaired cognition. The MDS further indicated Resident #34 requires assistance with ADL care. On 10/8/24 at 8:42 A.M., the surveyor observed Resident #34 in bed, with their privacy curtain pulled halfway across the bed with his/her breakfast attempting to eat the meal. The Resident had eggs on his/her clothing and on the floor. The Resident was not visible from the hallway, no staff were present in the room throughout the breakfast meal. On 10/9/24 at 12:08 P.M., the surveyor observed Resident #34 in bed, with their privacy curtain pulled halfway across the bed with his/her lunch attempting to eat the meal. The Resident had food items on his/her clothing and on the floor. The Resident was not visible from the hallway, no staff were present in the room throughout the lunch meal. On 10/9/24 at 5:32 P.M., the surveyor observed Resident #34 in bed, with his/her dinner attempting to eat the meal. The Resident had chips and pieces of bread on his/her clothing and blankets. The Resident was not visible from the hallway, no staff were present in the room throughout the dinner meal. Review of Resident #34's Dietary care plan, last revised on 7/29/24, indicated: -Eating: Set up. Devices: Lip plate. -Setup -Supervision/Touching Review of Resident #34's dysphagia care plan, last revised on 7/29/24, indicated: -Instruct resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly. -Monitor /report PRN (as needed) any s/sx (signs and symptoms) of difficulty swallowing; Pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing. Refusing to eat, appears concerned during meals. Review of Resident #34's nutritional assessment dated [DATE], indicated independent with setup, supervision, adaptive eating devices used lip plate and built-up utensils. Review of the Dietician progress note dated 8/22/24, indicated the following: The resident requires supervision for feeding. The resident uses an adaptive feeding device. Adaptive Feeding Device Type: lip plate and built-up utensils. Review of Resident #34's October 2024 Kardex (form indicating level of care needs) indicated the following: -Adaptive Equipment: Lip plate and built-up utensils. -Eating: Set up. -DEVICES: lip plate _X_ Setup _X_ Supervision/Touching -Instruct resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly. Review of the medical record indicated Resident #34 had an Occupational Therapy evaluation completed on 12/1/23, indicating: -due to unwitnessed fall and s/s of dysphagia requiring slp (Speech Language Pathology) eval (evaluation) and rec (recommendation) for modified diet and general aspiration precautions and indicated the following: S/u (setup) for self-feeing with lip plate and built-up utensils. During an interview on 10/9/24 at 12:24 P.M., Certified Nursing Assistant (CNA) #1 said Resident #34 is a setup for meals but needs supervision and cueing to make sure he/she is eating. CNA #1 said staff follow the information on the Kardex to know each resident's level of care. During an interview on 10/9/24 at 12:45 P.M., Nurse #2 said Resident #34 is a feeder and requires supervision with eating and cannot eat alone. Nurse #2 said Resident #34 will try to feed him/herself but needs help to make sure he/she eats. During an interview on 10/09/24 at 12:38 P.M., the Director of Nursing (DON) said she expects the Kardex and care plan to be followed, and said Residents who need assistance with setup and supervision/touching assistance during meals should not be left alone while eating. The DON said Resident #34 requires supervision with meals. During an interview on 10/10/24 at 9:48 A.M., the Dietician said Residents requiring setup/ supervision and touching assistance must be supervised while eating and not in their rooms unsupervised. The Dietician said Resident #34 requires supervision. During an interview on 10/10/24 at 10:23 A.M., the Director of Rehabilitation (DOR) said Residents' who require setup, supervision/touching assistance should not be eating alone in their rooms and require supervision while eating. 2. Resident #52 was admitted to the facility in October 2021 with diagnoses including major depressive disorder, diabetes, traumatic brain injury, and vitamin D deficiency. In June 2023, Resident #52 was diagnosed with dysphagia (difficulty chewing and swallowing). Review of the most recent Minimum Data Set (MDS) assessment, dated 9/24/24, indicated Resident #52 had a Brief Interview for Mental Status (BIMS) exam score of 3 out of a possible 15, which indicated he/she had severely impaired cognition. The MDS further indicated Resident #52 requires partial/moderate physical assistance with eating. On 10/8/24 at 8:28 A.M., the surveyor observed Resident #52 sitting in the dining room eating whole French toast, oatmeal, and yogurt. Two sippy cups without lids were observed on the breakfast tray. The Resident was observed drinking from one sippy cup containing red liquid. The sippy cup did not have a lid. There were no staff members assisting or supervising the Resident during the meal. The Resident was observed placing a large piece of French toast into his/her mouth. The Resident began to choke and was leaning forward in his/her wheelchair. The Resident's facial color turned red, and the Resident could be heard making gargling and coughing sounds. Two staff members could hear the sounds from the nurses' station, and both came over to check on the Resident. The Resident continued to lean forward and was able to expectorate the French toast from his/her mouth. The Resident could be heard saying I choke a lot all the time to a staff member as the staff member assisted Resident #52 back to the table. The surveyor observed Nurse #1 checking the oxygenation saturation of the Resident and said to the Resident 98% you're good. On 10/8/24 at 12:12 P.M., the surveyor observed Resident #52 sitting in the dining room eating lunch. The Resident was observed eating a large square piece of corn bread. One large white Styrofoam cup was filled with dark soda. There was no lid on the cup. Resident #52 was observed drinking from the Styrofoam cup throughout the lunch meal. There were no sippy cups on the lunch tray. There was one staff member sitting at another table with their back to Resident #52. There were no staff proving supervision or cueing throughout the lunch meal. On 10/9/24 at 12:14 P.M., the surveyor observed Resident #52 sitting in the dining room eating lunch. The lunch tray contained a large whole bread roll. There was one sippy cup on the lunch tray containing a red liquid. The sippy cup did not have a lid. There were two staff members proving feeding assistance to other Residents in the dining room. There were no staff proving supervision or cueing throughout the lunch meal. On 10/09/24 at 5:26 P.M., the surveyor observed Resident #52 sitting in the dining room eating dinner. The dinner tray contained one ground chicken sandwich cut in half and several whole orange cheese curls. The surveyor observed the Director of Nursing stop a staff member from placing covers on to two sippy cups. The DON said, she doesn't need a lid and the DON removed the lid off one of the sippy cups. The surveyor observed loose ice cubes inside the sippy cup. The surveyor observed Resident #52 drinking from the sippy cup and two ice cubes could be seen inside of the Residents mouth as he/she kept opening and closing his/her mouth moving the ice around. The DON was observed to be standing behind the Resident during this observation. There were no staff proving supervision or cueing throughout the lunch meal. Review of Resident #52's medical record indicated he/she choked while eating chicken in July 2022, requiring the Heimlich maneuver (a first aid procedure to treat airway obstructions by a foreign object) and, at that time, physician orders were obtained to downgrade the Resident's diet to a Mechanical Soft Diet (an altered textured diet for individuals with difficulty chewing and swallowing). Further review of the medial record indicated a second choking incident that occurred in July 2023, resulting in Resident #52 being transferred to the hospital, and a third swallowing incident that occurred in August 2024. Review of the Activities of Daily Living Care Plan dated 4/23/24 indicated the following: -Eating: Requires feeding assist at times, cueing. Lip Plate and sippy cups with meals. Cut up food to bite size, No bread products. Dated 4/23/23 -Supervision/touching. Dated 4/23/24. Review of the nutritional risk care plan dated 10/25/21 indicated the following interventions: - Increase initiation cues to help promote independence. Dated 10/27/23. -Resident to use lip plate and sippy cups to promote independence. Revised 2/16/24. -Supervised with meals. Dated 10/27/23. Review of Resident #52's nutritional assessment dated [DATE], indicated: Regular diet, mechanical soft, thin liquids. recent choking sensation eating pasta noted, NP aware. Eating skills: Independent with set up, Supervision, Limited Assist and eating devices - lipped plate, sippy cup. -New/recent indications or complaints: Constipation, Swallowing. Review of Resident #52's active physician orders indicated the following: -Regular diet Mechanical soft with Ground meat texture, Thin Liquids consistency. Dated 2/29/24. - Diet Recommendations: 3 sippy cups with lids on her tray with meals. Dated 1/11/24. - pt (patient) issued lip plate with meals. Dated 10/3/23. During an interview on 10/09/24 at 12:24 P.M., Certified Nursing Assistant (CNA) #1 said Resident #52 needs sippy cups with handles because he/she shakes and said the Resident can have bread because it's soft. CNA # 1 said staff will check the Kardex to know how to care for the Resident and to check for eating issues or concerns. During an interview on 10/9/24 at 12:45 P.M., Nurse #2 said Resident #52 eats too fast and needs to slow down so he/she doesn't choke because he/she does this kind of thing often. Nurse #2 said Resident #52 is on a mechanical soft diet because he/she had swallowing issues in the past and said the Resident needs supervision with eating. Nurse #2 said the Resident has a care plan in place for diet needs and it is expected to be followed. During an interview on 10/09/24 at 5:38 P.M., The DON said Resident #52 needs a sippy cup with lids and handles and requires a mechanical soft diet. The DON said Residents who need supervision during meals need to be in the communal dining room and not eating alone. The DON said Resident #52 requires supervision and cueing throughout the meal to slow down his/her pace while eating. During an interview on 10/10/24 at 7:18 A.M. the Speech Therapist (ST) said she evaluated Resident #52 yesterday morning after she was notified of the choking incident at breakfast. The ST said Resident #52 is on a mechanical soft diet that includes meat that is ground up, nothing sticky or difficult to chew and said she did not implement or alter any care plans at this time. The ST said Resident #52 needs reminders to slow down and to take small bites. During an interview on 10/10/24 at 9:32 A.M., the Dietician said Resident #52 requires supervision and cueing and must be supervised while eating due to his/her history of choking. The Dietician said she was notified by nursing staff of a choking incident in August while eating pasta and said she was also notified by the Occupational Therapist. The dietician said she would expect the Resident to be evaluated by speech therapy.

Based on observations, record review and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when one out of two nurses observed made two errors out of 25 opportunities, resulting in a medication error rate of 8%. Those errors impacted one Resident (#52), out of two residents observed. Specifically, for Resident #52, Nurse #2 failed to administer the correct doses of his/her medications. Findings Include: Review of facility policy titled Medication Administration, dated as revised 10/2022 indicated the following: -3. Medications must be administered in accordance with the orders, including any required time frame. -6. The medications nurse shall assure that the correct medication is administered by checking the physician's order and the medication label. Review of facility policy titled Physician Orders, dated as revised 10/2022 indicated the following: -Medication orders will include: -c. dosage Resident #52 was admitted to the facility in October 2021 with diagnoses that include metabolic encephalopathy and altered mental status. Review Resident #52's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 3 out of 15 indicating that the Resident has severe cognitive impairment. During the medication pass observation on 10/9/24 at 7:37 A.M., the surveyor observed Nurse #2 prepare and administer the following medications to Resident #52: -Simethicone 125 milligrams (mg) two tablets prepared and administered. -Cranberry Capsule 450 mg one capsule prepared and administered. Review of Resident #52's physician's orders indicated the following orders: -Cranberry tablet 300 mg give one tablet by mouth two times a day for prevention, dated 2/22/24. -Simethicone oral tablet 80 mg, give two tablets by mouth two times a day for complaints of increased ABD (abdominal) pain after eating, dated 5/31/24. On 10/9/2024 at 8:44 A.M., the surveyor and the Director of Nurses reviewed Resident #52's physician's orders and the over-the-counter medication bottles for simethicone and cranberry capsules present in the medication cart and the Director of Nurses said that the wrong doses were administered to Resident #52.

Based on record reviewed and interviews the facility failed to ensure nursing maintained an accurate medical record for one Resident (#49) out of a sample of 27 residents. Specifically, for Resident #49 nursing documented they obtained blood pressure from his/her left arm when they did not. Findings include: Review of the facility policy, titled Charting and Documentations, revised January 2023, indicated, but was not limited to, the following: - All observations, medications administered, services performed, etc., must be documented in the resident's clinical records. Resident #49 was admitted to the facility in February 2024 with a diagnosis of dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #49 scored a 0 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Review of Resident #49's active physician orders indicated the following order: - No IVs (intravenous)/ blood draws/BP (blood pressure readings) on left arm, initiated 2/23/24. Review of Resident #49's blood pressure readings indicated nursing obtained his/her blood pressure on his/her left arm on the following dates: 6/15/24, 6/16/24, 6/17/24, 6/18/24, 6/19/24, 6/20/24, 6/21/24, 6/23/24, 6/28/24, 6/29/24, 7/1/24, 7/2/24, 7/4/24, 7/9/24, 7/10/24, 7/11/24, 8/17/24, 8/18/24, 9/7/24, and 10/9/24. During an interview on 10/10/24 at 7:23 A.M., Nurse #3 said Resident #49's left arm should not be used to take blood pressure readings as the Resident had a mastectomy in the past. During a follow-up interview on 10/10/24 at 9:34 A.M., Nurse #3 said she had taken the blood pressure reading on 10/9/24, and that she had used Resident #49's right arm and had documented left arm in error. During an interview on 10/10/24 at 9:56 A.M., The Director of Nursing (DON) said her expectation was that nurses accurately document which arm the blood pressure was taken from.

Based on records reviewed and interviews for one of three sampled residents (Resident #3), who required extensive assistance of two staff members for transfers, the Facility failed to ensure staff implemented and followed his/her plan of care, when on 01/30/24, Certified Nurse Aide (CNA) #2 transferred Resident #3 by herself without another staff member present to assist and Resident #3 ended up on the floor. Findings Include: The Facility Policy titled, Care Plan-Comprehensive, dated as last revised 10/22/22, indicated that a comprehensive person-centered Care Plan that includes measurable objectives, and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The Policy indicated that the services provided or arranged by the Facility, as outlined by the comprehensive Care Plan shall be provided by qualified persons in accordance with each resident's written plan of care. Resident #3 was admitted to the Facility in January 2024, diagnoses included chronic obstructive pulmonary disease, pneumonia, weakness, lower back pain, and unsteadiness on feet. Review of Resident #3's Activity of Daily Living Care Plan, dated 01/24/24, indicated he/she required extensive assistance of two staff members for transfers. Review of the Facility Incident Report, dated 01/30/24, indicated that at approximately 8:20 A.M., a Certified Nurse Aide (CNA, later identified as CNA #2) called staff to Resident #3's room and he/she was observed on the floor in the bathroom. The Report indicated that after Resident #2 was toileted he/she went to sit down and slid down (onto the floor). Review of the Accident/Incident Statement Form, dated 01/30/24 and signed by CNA #2, indicated that she had transferred Resident #3 from his/her wheelchair onto the toilet and after she returned to the bathroom, she assisted him/her with toileting. The Statement indicated that (as she attempted to transfer Resident #3 back into his/her wheelchair) when Resident #3 went to sit down he/she was not seated back far enough in the wheelchair and that Resident #3 asked CNA #2 to help him/her sit back (further back into the wheelchair) but that Resident #3 slid from the wheelchair onto the floor. Review of Resident #3's Physical Therapy (PT) Evaluation & Plan of Treatment, dated 01/23/24, indicated that a short term goal for him/her was to improve ability to complete toilet/commode transfers with supervision or touching assistance with a target date of 02/12/24, and indicated that baseline for 01/23/24 was that he/she required substantial, maximum assistance. Review of Resident #3's PT Initial Assessment, dated for start of care 01/23/24, indicated that for functional mobility Resident #3 was assessed to require substantial, maximum assistance for chair/bed-to-chair transfers and for toilet transfers. The Assessment Summary indicated that due to weakness from recent medical complications, skilled PT services were required to address functional mobility, balance, and endurance impairments that are below baseline. During a telephone interview on 01/31/24 at 1:54 P.M., CNA #2 said when she assisted Resident #3 with toileting on 01/30/24, it was the first time she had ever provided care for him/her. CNA #2 said she assisted Resident #3 into the bathroom and transferred him/her onto the toilet from his/her wheelchair by herself. CNA #2 said after she assisted Resident #3 with toileting, she began to transfer him/her back into the wheelchair and said when she pivoted Resident #3 towards the wheelchair, he/she sat down at the edge of the wheelchair and was not seated back far enough. CNA #2 said Resident #3 asked her to pull him/her further back into the chair. CNA #2 said she got behind Resident #3's wheelchair and attempted to pull him/her back further into the wheelchair but Resident #3 slid off the edge of the wheelchair and fell to the floor. CNA #2 said that when she transferred Resident #3 before he/she fell that day, she had not been aware that he/she required two staff members for transfers but said that after Resident #3 fell , she discovered that he/she required the assistance of two staff members for transfers when she saw it documented in the computer. During a telephone interview on 01/31/24 at 2:28 P.M. and 02/07/24 at 3:16 P.M., the Director of Rehabilitation said Resident #3 required maximum assistance of two staff members for transfers as indicated in his/her care plan for nursing staff, as a precaution to ensure his/her safety. During a telephone interview on 02/06/24 at 11:51 A.M., the former Interim Director of Nursing (DON) said she had been acting DON from the end of December 2023 until 02/05/24. The former DON said that on 01/31/24, she became aware that Resident #3 had fallen on 01/30/24. The former DON said although she was unsure what Resident #3's transfer status was at the time of the fall, said if the Care Plan accurately indicated that he/she required two staff members for transfers, then he/she should have been transferred with two staff members.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who during the provision of personal care on the evening shift on 11/09/23 by a staff member (later identified as Certified Nurse Aide (CNA) #3) experienced a fall out of bed when his/her legs slid off the bed, causing his/her lower torso to slide off the bed and him/her landing on both knees on the floor, the facility failed to ensure he/she was provided with quality of care that met acceptable standards of practice, when CNA #3 picked Resident #1's lower torso/legs up off the floor and placed him/her back into bed, however CNA #3 had not notified his/her nurse or anyone one else in nursing about the fall. The following morning, Resident #1 was observed with extensive swelling to his/her right leg, complained of pain to his/her right leg, x-rays revealed he/she had a right femur (thigh bone) fracture, and he/she was transferred to the Hospital Emergency Department for further evaluation and treatment. Findings Include: The Facility Policy titled, Accidents and Incident, dated as revised 10/2022, indicated it was policy of the Facility to monitor and evaluate all occurrences of accidents or incidents occurring on the facility's premises which is not consistent with the routine operation of the facility or care of a particular resident. The Policy indicated the Nursing Supervisor/charge nurse, Unit Manager, and or the department Director or Supervisor shall promptly be notified and then responsible for assessing, reviewing, documenting, and reporting of the incident accident. The Policy indicated regardless of how minor an accident or incident may be, it must be reported to the Nurse Manager or Supervisor. The Facility Policy titled, Fall Prevention and Management, dated as revised 01/2023, indicated that a fall is the unintentional change in position coming to rest on the ground, floor or onto the next lower surface. The Policy indicated that an intercepted fall occurs when a resident would have fallen if he/she had not caught him/herself or had not been intercepted by another person, this is still considered a fall. The Policy indicated that in the event a has fallen and/or is found on the ground, a complete head to toe assessment must be performed. Resident #1 was admitted to the Facility in June 2022, diagnoses included chronic kidney disease, diabetes mellitus, vascular dementia, muscle weakness, abnormalities of gait, unsteadiness on feet, and essential tremor. Review of Resident #1's Minimum Data Set (MDS), dated [DATE], indicated he/she was severely cognitively impaired. Review of the Facility Incident Report, dated 11/10/23, indicated that a Certified Nurse Aide (CNA, later identified as CNA #1) reported that Resident #1 stated he/she fell out of bed last night (on 11/09/23 during the evening shift) and a man scooped him/her up. The Report indicated Resident #1 had a skin tear on his/her right arm and that he/she complained of pain at level 8 (on a 0-10 scale, zero being no pain and ten being the highest level of pain). Review of the Facility Accident/Incident Statement Form, dated 11/10/23, indicated that at 8:20 A.M., CNA #1 observed a skin tear on Resident #1's right elbow and blood on his/her sheets. The Statement Form indicated that when she asked Resident #1 what happened, he/she told her he/she had fallen out of bed and that a man dragged him/her back into bed. Review of Resident #1's Nurse Progress Note, dated 11/10/23, indicated he/she reported falling out of bed and that a CNA (later identified as CNA #3) scooped him/her up, put him/her back to bed and indicated that it was not clear if Resident #1 had actually fallen or not. The Note indicated the Nurse Practitioner (NP) was notified and that a STAT (immediate) x-ray was ordered for his/her right femur (thigh bone) and right knee. The Note indicated a skin tear was observed on Resident #1's right elbow and indicated that his/her appetite was poor. The Note further indicated that Resident #1's radiology report indicated he/she had a femur fracture, the Physician was notified, and an order was obtained to transfer Resident #1 to the Hospital Emergency Department. Review of Resident #1's Radiology results, dated 11/10/23, indicated he/she had a right femur fracture. Review of the Facility Staffing Schedule, dated 11/09/23, indicated CNA #3 was scheduled on both the 3:00 P.M. to 11:00 P.M. that day and following 11:00 P.M. to 7:00 A.M. shift (that ended on 11/10//23) on the Resident #1's unit. Review of Resident #1's Medical Record indicated there was no documentation to support that the incident of a fall was reported to nursing by CNA #3 on 11/09/23 during the 3:00 P.M to 11:00 P.M. shift or on the following 11:00 P.M. to 7:00 A.M. shift. During a telephone interview on 01/31/24 at 2:42 P.M., Certified Nurse Aide (CNA) #3 said that on 11/09/23 he worked the 3:00 P.M. to 11:00 P.M. and 11:00 P.M. to 7:00 A.M. shift (into 11/10/23). CNA #3 said that sometime between 9:00 P.M. and 10:00 P.M., Resident #1 was in bed and while he provided personal care for him/her, he rolled him/her over onto his/her side and his/her legs went off the bed. CNA #3 said both of Resident #1's knees hit the floor, but his/her upper body remained on the bed. CNA #3 said he lifted Resident #1's legs off the floor and put them back into bed. CNA #3 said Resident #1 moaned when his/her legs/knees hit the floor but said he did not report the incident to the nurse on the unit during the evening or night shifts. Although CNA #3 said Resident #1 moaned (indicator of pain) after he/she fell out of bed, CNA #3 decided not to inform nursing of the incident, but instead put Resident #1 back to bed, without having nursing assess Resident #1 for potential injury prior to moving him/her. Resident #1 was not assessed by nursing until the following day when day shift nursing staff discovered his/her injuries. During a telephone interview on 01/31/24 at 3:08 P.M., Nurse #1 said she worked the 3:00 P.M. to 11:00 P.M. and 11:00 P.M. to 7:00 A.M. shifts on 11/09/23. Nurse #1 said although Resident #1 was not on her assignment during the 3:00 P.M.-11:00 P.M. shift, said he/she was on her assignment during the 11:00 P.M. to 7:00 A.M. shift (into 11/10/23) that night. Nurse #1 said no incidents related to Resident #1 had been reported to her during either shift. During a telephone interview on 02/01/24 at 10:38 A.M., Nurse #2 said she worked the 3:00 P.M. to 11:00 P.M. shift on 11/09/23 on Resident #1's unit, but said she could not recall who Resident #1 was or if there were any incidents that occurred involving Resident #1 that night. During an interview on 01/31/24 at 12:31 P.M., CNA #1 said that on 11/10/23 sometime between 8:00 A.M. and 8:15 A.M., she went into Resident #1's room to bring him/her breakfast. CNA #1 said she observed blood on Resident #1's sheet just above where his/her right elbow rested on the bed and observed a skin tear on his/her elbow. CNA #1 said she asked Resident #1 what happened, and he/she told her that he/she fell out of bed and that a man dragged him/her back into bed. CNA #1 said she immediately reported it to one of the nurses but was unable to remember which nurse she told. During a telephone interview on 01/31/24 at 1:03 P.M., CNA #2 said that, on 11/10/23, she assisted CNA #1 with boosting Resident #1 up in bed for breakfast. CNA #2 said Resident #1 appeared to be in pain because when they boosted him/her up, he/she said ouch. CNA #2 said they had pulled Resident #1's blanket down in order to grab the draw sheet underneath him/her and said she observed that Resident #1's right knee and thigh were very swollen and appeared to be double the normal size. CNA #2 said she also observed a skin tear on Resident #1's right arm. During a telephone interview on 02/01/24 at 12:35 P.M., CNA #4 said she worked the 7:00 A.M. to 3:00 P.M. shift on 11/10/23. CNA #4 and said that when she started providing morning care for Resident #1, he/she told her that his/her leg hurt. CNA #4 said as she provided personal hygiene to Resident #1's upper body, she observed a skin tear on his/her right arm and blood on his/her sheet. CNA #4 said the NP came into the room to assess Resident #1 at that time and said when the NP touched his/her leg, Resident #1 yelled ouch. CNA #4 said when she observed Resident #1's leg, it was very swollen and said she asked Resident #1 what happened and although he/she did not say when, he/she told her she fell out of bed and a man picked him/her up. During a telephone interview on 02/01/24 at 4:49 P.M., Nurse #3 said on 11/10/23 when she got report on the residents on her assignment, she had not received any information about any incidents related to Resident #1 but said almost right away when she arrived on the unit, CNA #1 told her that Resident #1 said he/she had fallen out of bed (the night before). Nurse #3 said she immediately went to Resident #1's room and observed that his/her right leg was swollen. Nurse #3 said Resident #1's NP went to see him/her at approximately 9:00 A.M. and ordered a STAT leg x-ray. Nurse #3 said Resident #1's x-ray results revealing a right femur fracture were reported to the Facility at approximately 9:00 P.M. and Resident #1 was transferred to the Hospital Emergency Department. During a telephone interview on 02/06/24 at 11:51 A.M., the former Interim Director of Nursing said she had been acting DON from the end of December until 02/05/24 (DON at the time of the Survey). The former DON said a fall was defined as a change in plane from a higher to lower level. The former DON said a resident's whole body does not have to land on the floor in order for it to be considered a fall. The former DON said if a resident's knees fall onto the floor but his/her body is still on the bed, it is still considered a fall and should be reported to a nurse so that an incident report could be completed (which contains information about injuries assessed by the nurse) and the Physician notified.

Based on records reviewed and interviews for one of three sampled residents (Resident #3), who required extensive assistance of two staff members for transfers, the Facility failed to ensure Resident #1 was provided the necessary level of assistance to maintain his/her safety to prevent an incident or accident, when on 01/30/24 he/she was transferred by Certified Nurse Aide (CNA) #2 without the assistance of another staff member and without the use of a gait belt, per Facility Policy, and he/she sustained a fall. Findings Include: The Facility Policy titled, Fall Prevention and Management, dated as revised 01/2023, indicated that the interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. The Facility Policy titled, Gait Belts-Transfers, dated as revised 01/2023, indicated it was the policy of the Facility to utilize gait belts when applicable to promote safety in transfer, ambulation, and balance to minimize the risk of injury to the resident and caregiver. The Policy indicated that gait belts were to be used when a resident/patient required contact guard (when a caregiver places one or two hands on patient's body to help with balance but provides no other assistance to perform the functional mobility task) or greater assistance for ambulation and transfers. Resident #3 was admitted to the Facility in January 2024, diagnoses included chronic obstructive pulmonary disease, pneumonia, weakness, lower back pain, and unsteadiness on feet. Review of Resident #3's Activity of Daily Living Care Plan, dated 01/24/24, indicated he/she required extensive assistance of two staff members for transfers. Review of the Facility Incident Report, dated 01/30/24, indicated that at approximately 8:20 A.M., a CNA (later identified as CNA #2) called staff to Resident #3's room and he/she was observed on the floor in the bathroom. The Report indicated that after Resident #3 was toileted he/she went to sit down (in his/her wheelchair) and slid down (onto the floor). Review of the Accident/Incident Statement Form, dated 01/30/24 and signed by CNA #2, indicated that she (CNA #2) had transferred Resident #3 from his/her wheelchair onto the toilet and said after she finished assisting him/her with toileting, (while transferring him/her back into his/her wheelchair) Resident #3 went to sit back down (in the wheelchair) The Statement indicated that when Resident #3 sat down, he/she was not seated back far enough in the wheelchair so Resident #3 asked her (CNA #2) to help him/her sit back (further into the wheelchair) but that Resident #3 slid from the wheelchair onto the floor. Review of Resident #3's Physical Therapy (PT) Evaluation & Plan of Treatment, dated 01/23/24, indicated that a short term goal for him/her was to improve ability to complete toilet/commode transfers with supervision or touching assistance with a target date of 02/12/24 and indicated that baseline for 01/23/24 was that he/she required substantial, maximum assistance. Review of Resident #3's PT Initial Assessment, dated for start of care 01/23/24, indicated that for functional mobility Resident #3 was assessed to require substantial, maximum assistance for chair/bed-to-chair transfers and for toilet transfers. The Assessment Summary indicated that due to weakness from recent medical complications, skilled PT services were required to address functional mobility, balance, and endurance impairments that are below baseline. During a telephone interview on 01/31/24 at 1:54 P.M., CNA #2 said when she assisted Resident #3 with toileting on 01/30/24, it was the first time she had ever provided care for him/her. CNA #2 said she assisted Resident #3 into the bathroom and transferred him/her onto the toilet from his/her wheelchair. CNA #2 said after she assisted Resident #3 with toileting, she began to transfer him/her back into the wheelchair and said when she pivoted Resident #3 towards the wheelchair, he/she sat down at the edge of the wheelchair and was not seated back far enough. CNA #2 said Resident #3 asked her to pull him/her further back into the chair. CNA #2 said she got behind Resident #3's wheelchair and attempted to pull him/her back further into the wheelchair but Resident #3 slid off the edge of the wheelchair and fell to the floor. CNA #2 said because Resident #3 required assistance with transfers, she should have used a gait belt on Resident #3 during the transfer and said she did not use a gait belt because she did not see one in his/her room. CNA #3 said that when she transferred Resident #3 before he/she fell that day, she had not been aware he/she required two staff members for transfers but said that after Resident #3 fell , she discovered that he/she required the assistance of two staff members for transfers when she saw it documented in the computer. During a telephone interview on 01/31/24 at 2:28 P.M. and 02/07/24 at 3:16 P.M., the Director of Rehabilitation said that Resident #3 required maximum assistance of two staff members for transfers as indicated in his/her care plan, as a precaution to ensure his/her safety. During a telephone interview on 02/06/24 at 11:51 A.M., the former Interim Director of Nursing said she had been acting DON from the end of December until 02/05/24. The Former DON said she became aware of Resident #3's fall on 01/31/24 and that CNA did not use a gait belt during the transfer. The Former DON said gait belts were supposed to be used with transfers of residents who require more assistance than contact guard. The Former DON said she was unsure what level of assistance Resident #3 required for transfers but said if his/her Care Plan accurately indicated he/she required the assistance of two staff members for transfers, then he/she should have been transferred with the assistance of two staff members.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was observed with a right swollen leg, complained of pain, and reported to staff that he/she had fallen out of bed, the Facility failed to ensure the Nurse Practitioner's STAT x-ray order was sent to the Radiology Company in a timely manner. Findings Include: The Facility Policy titled Diagnostic Services, dated as revised 01/2023, indicated clinical laboratory and radiology services shall be available twenty-four hours a day, seven days per week, for all residents onsite. The Policy indicated all diagnostic testing procedures shall be performed as ordered by a Physician or licensed independent Practitioner. Resident #1 was admitted to the Facility in June 2022, diagnoses included chronic kidney disease, diabetes mellitus, vascular dementia, muscle weakness, abnormalities of gait, unsteadiness on feet, and essential tremor. Review of the Facility Incident Report, dated 11/10/23, indicated that a Certified Nurse Aide (CNA, later identified as CNA #2) reported Resident #1 stated he/she fell out of bed last night and a man scooped him/her up. The Report indicated Resident #1 had a skin tear on his/her right arm and that he/she complained of pain at level 8 (on a 0-10 scale,zero being no pain and ten being the highest level of pain). Review of Resident #1's Nurse Practitioner (NP) Orders, dated 11/10/23, indicated that a STAT order for a right femur and knee x-ray was ordered for him/her. During a telephone interview on 02/01/24 at 10:03 A.M. and 02/07/24 at 9:16 A.M., the Nurse Practitioner (NP) said that on 11/10/23, although she could not recall the exact time, said she went into Resident #1's room sometime between 8:00 A.M.-9:30 A.M. to assess him/her. The NP said the time of her visit that morning could not be determined by the time she documented her Progress Note because her documentation goes into the Medical Record later in the day and did not reflect the actual time she was in to see Resident #1. The NP said Resident #1 told her that he/she fell during the night and that his/her leg hurt. The NP said Resident #1's right leg was swollen and tender to touch. The NP said she ordered a STAT x-ray at that time due to Resident #1's leg pain, swelling, and complaint of a fall. The NP said she told Resident #1's assigned nurse that he/she complained of a fall and wanted an x-ray done STAT (immediately). The NP said that when she gave the order for the STAT x-ray for Resident #1, she expected nursing to put the order in to Mobile X-ray Company right away. During a telephone interview on 01/31/24 at 3:38 P.M. and 02/05/24 at 2:14 P.M., the Mobile X-Ray Company Customer Service Representative said Resident #1's STAT right leg x-rays were ordered by the Facility through the company's online portal on 11/10/23 at 12:30 P.M. (approximately three hours after NP gave STAT x-ray orders to nursing). The Representative said Resident #1's x-ray results were sent by fax to the Facility at 8:05 P.M. Review of Resident #1's Radiology results, dated 11/10/23, indicated he/she had a right femur fracture. During a telephone interview on 02/01/24 at 4:40 P.M., Nurse #3 said that on 11/10/23 she arrived onto Resident #1's unit at approximately 8:00 A.M. and said a CNA came to her right away and told her that Resident #1 said he/she had fallen out of bed. Nurse #3 said she went to his/her room right away and observed his/her leg was swollen. Nurse #3 said she thought Resident #1's NP went in to see him/her at approximately 9:00 A.M. and said she was aware the NP had ordered a STAT x-ray of Resident #1's leg right around that time. Nurse #3 said she was the one who put the NP's STAT x-ray order for Resident #1's right leg x-rays into the Mobile X-ray Company online website but said she may not have put the order in to the x-ray company right away because she had to catch up with giving some medications to other residents and said she also had to wait for someone to show her how to put the STAT order into the Mobile X-ray Company's website. Nurse #3 said she did not put the NP's orders for Resident #1's STAT x-rays in to the x-ray company right away because she did not think it was an emergency. Nurse #3 said once she put Resident #1's STAT x-ray order in, the company did not arrive to take the x-ray until approximately 5:00 P.M. Nurse #3 said Resident #1's x-ray results that indicated he/she had a fracture had been sent to the Facility by fax and said she saw the x-ray results at approximately 9:00 P.M. During a telephone interview on 02/06/24 at 11:51 P.M., the former Interim Director of Nursing said although she had not been the DON at the time of Resident #1's incident, said she had reviewed Resident #1's Medical Record and saw that his/her x-rays had been delayed. The former DON said that STAT x-rays usually take the Mobile X-ray Company 4-6 hours to complete per contract. The DON said STAT means immediately and said that nursing was expected to submit STAT x-ray orders to the Mobile X-Ray Company at the time the order is given by the Provider.

Based on observations, interviews and policy review the facility failed to provide adequate supervision and follow the plan of care to prevent accidents for 5 Residents (#62, #53, #50 #48 #31, and #63) out of a total sample of 34 residents. Specifically: 1a. For Resident #62, who has a known history of choking twice at the facility, requiring the Heimlich maneuver, the facility failed to provide supervision and cueing for safe swallowing strategies with meals and failed to provide with the appropriate diet consistency, as recommended by the Speech Language Pathologist (SLP), placing Resident #62 at high risk for a repeated choking incident, injury and/or death. During the second choking incident Resident #62 was found unsupervised with a meal and his/her face and lips were blue, cyanotic, requiring the Heimlich maneuver and transfer by 911 to the hospital. 1b. For Resident #53, who is at high risk for aspiration/choking, the facility failed to provide the appropriate level of assistance/supervision with meals; 1c. For Resident #50, who is at high risk for aspiration/choking, the facility failed to provide the appropriate level of assistance/supervision with meals; 2. For Resident #48, the facility failed to complete elopement assessments as well as incident reports after an elopement from the unit; 3a. For Resident #35, the facility failed to follow a falls care plan to prevent a fall; 3b and 3c. For Residents #48 and #31, the facility failed to complete incident reports investigating the cause of falls; and 4. For Resident #63, the facility failed to complete post fall assessments and implement interventions after a fall. Findings include: 1a. For Resident #62 who has a known history of choking twice at the facility, requiring the Heimlich maneuver, the facility failed to provide supervision and cueing for safe swallowing strategies with meals and failed to provide the appropriate diet consistency, as recommended by the Speech and Language Pathologist (SLP), placing the Resident at high risk for a repeated choking incident, injury and/or death. The facility policy titled Accidents and Incidents, revised 10/2022, indicated the following: -All incidents and accidents will be evaluated when applicable by the interdisciplinary team. -The team will review the investigation and continue if necessary, discuss and determine from the investigation the root causes, make recommendations for additional interventions, education and conclude the investigation. -The team will write an interdisciplinary team note discussing above. -Should the team feel an intervention is a Rehab evaluation please use the Rehabilitation Referral Form. The facility policy titled Safety and Supervision of Residents, dated as revised 1/2023, indicated the following: -Our facility strives to make the environment as free from accidents hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. -The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. -Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training, as necessary; d. Ensuring that interventions are implemented; and e. Documenting interventions. -Monitoring the effectiveness of interventions shall include the following: a. Ensuring that interventions are implemented correctly and consistently. Resident #62 was admitted to the facility in October 2021 with diagnoses including major depressive disorder. In June 2023, Resident #62 was diagnosed with dysphagia (difficulty chewing and swallowing). Review of the most recent Minimum Data Set (MDS) assessment, dated 9/14/23, indicated Resident #62 had a Brief Interview for Mental Status (BIMS) exam score of 5 out of a possible 15, which indicated he/she had severely impaired cognition. The MDS further indicated Resident #62 was independent with one-person physical assistance with eating. Review of Resident #62's medical record indicated he/she choked while eating chicken in July 2022, requiring the Heimlich maneuver (a first aid procedure to treat airway obstructions by a foreign object) and, at that time, physician orders were obtained to downgrade the Resident's diet to a Mechanical Soft Diet (an altered textured diet for individuals with difficulty chewing and swallowing). Review of Resident #62's Activities of Daily Living Care Plan indicated the following: *EATING: Independent after Set up assistance, last revised 10/25/21. - The care plan failed to indicate it was reviewed or updated following the choking incidents in July 2022, and July 2023 or following the recommendations made by the SLP (speech language pathologist) on 8/7/23. Review of the Licensed Nursing Summary, dated 6/30/23, indicated Resident #62 required physical assistance with eating. Review of the clinical progress note, dated 7/23/23 at 10:00 A.M., indicated Resident #62 had another choking episode. The medical record indicated: Nurse from opposite side of the hall requested assistance from this nurse r/t resident presenting with signs of choking. On assessment, 02 @ 62% (Oxygen Saturation (O2 sat) @ 62%; A normal oxygen saturation level is between 95-100%), not able to verbalize needs, face and lips blue, cyanotic. Instructed nurse to call 911. Visual examination of throat with blockage of large amount of cake donut blocking airway. Resident was bent forward in wheelchair while doing back blows then finger sweeps. Food removed piece by piece and opened airway. Resident able to take shallow breaths, 02 improved slowly to 90%. Emergency services arrived @ approx 0905 and care taken over, resident transferred to ER @ local Hospital. (sic) Review of the most recent Speech Therapy (SLP) Discharge Summary, dated 8/7/23, indicated Resident #62 was evaluated following the second choking incident. The SLP documented Patient remains a high risk for aspiration and choking given impulsive self-feeding behaviors, which have resulted in prior and recent choking incidents. He/she will continue to benefit from diet modification with soft/bite-sized foods and supervision at meals to provide verbal cues for safe swallowing strategies. Education provided with 3rd floor staff, who are aware. Written sign taped to wall in patient's room stating he/she must have supervision during meals. The SLP references that Resident #62's diet level at discharge from speech therapy to be IDDSI Soft and Bit Sized SB6 (level 6). Review of the current International Dysphagia Diet Standardization Initiative (IDDSD) indicated Level 6 Soft and Bite Sized includes: -Soft, tender and moist, but with no thin liquid leaking/dripping from the food; -Ability to bite off a piece of food is not required; -'Bite sized' pieces no bigger than 1.5 cm x 1.5 cm in size; -A knife is not required to cut this food. -Examples of food to avoid: Dry cake crumble foods. The Nutrition care plan, last revised 2/8/23, had the following interventions: -dated 2/8/23: Increase initiation cues to help promote independence -dated 10/25/21: Provide, serve diet as ordered. Monitor intake and record q (each) meal. Review of Resident #62's Activities of Daily Living Care Plan failed to indicate the facility updated the care plan after the Resident's second choking episode or to include the SLP recommendations from 8/7/23. The medical record failed to indicate Resident #62 had any behaviors of diet non-compliance or of refusing care. During an interview on 10/24/23 at 10:22 A.M., SLP #3 said that she was consulted after Resident #62's choking episode in July 2023 and evaluated Resident #62 at that time. SLP #3 said for Resident #62, the no bread products mean no donuts. She said that she believes, Resident #62's issues are related to impulsive eating, cognitive impairment and behaviors, as well as the strength of his/her swallow. SLP #3 said she instructed the nursing staff that Resident #62 must eat with supervision and responds well to cueing to take small bites and take small sips. SLP #3 said that she reiterated to nursing staff that she believes the choking issue is likely to occur again, and; therefore, Resident #62 needs to have the supervision and needs verbal cueing for the entirety of all meals. On 10/22/23 at 8:01 A.M., Resident #62 was observed in the unit dining room. There was a plate of food on the table directly in front of him/her. Resident #62's head was bobbing, as if he/she was falling asleep. A Certified Nursing Assistant (CNA) approached Resident #62, placed a towel across his/her chest and walked away. No one was present to assist or cue Resident #62 for safe swallow strategies with the meal. On 10/22/23 at 8:08 A.M., Resident #62 remained without assistance or cueing for safe swallow strategies with the meal. On 10/23/23 at 12:19 P.M., Resident #62 was observed alone in his/her room, in the dark, with his/her back to the door. There was a lunch tray directly in front of Resident #62 that included large slices of vegetable approximately 1.5 inches in size and dry rice. Review of the facility's therapeutic menu for that day indicated Resident #62 should have received steamed rice covered in gravy or sauce and chopped zucchini. A sign on the wall in Resident #62's room indicated the following: -Patient is high risk for aspiration and choking. -Needs supervision with meals. -Please bring to dining area for all meals. On 10/24/23 from 8:07 A.M. to 8:15 A.M., Resident #62 was observed in the unit dining room. A staff person delivered Resident #62 breakfast which included an uncut cheese omelet. Staff did not provide cues for safe swallow strategies. On 10/24/23 at 12:10 P.M., Resident #62 was observed putting food into his/her mouth and not swallowing prior to putting more food into his/her mouth. There was one nurse in the room who was at a different table and was not providing any cues for safe swallow strategies to Resident #62. During an observation on 10/25/23 at 8:20 A.M., Resident #62 and 5 other residents were observed in the unit dining room with no staff supervision, Resident #62's eye were closed, with his/her head facing downward as he/she chewed on eggs without swallowing. Staff walked in and out passing trays, however, no one provided cueing and safe swallow strategies to Resident #62. During an interview on 10/23/23 at 1:59 P.M., the Speech and Language Pathologist (SLP) #1 said that based upon the 8/7/23 SLP recommendations, she would expect Resident #62 to be provided with 1:1 supervision with meals if the meal was in his/her room and that Resident #62 should not be in his/her room for meals. She said Resident #62 should be receiving cues for safe swallow strategies throughout the meal. During an interview on 10/24/23 at 9:49 A.M., SLP #2 said that when a diet slip indicates No bread products that would include no donuts. During an interview on 10/24/23 at 12:15 P.M., with the Director of Nursing (DON) she said the following: -It is the expectation that residents that need supervision and cueing for safe swallowing strategies with meals should be receiving both throughout the entire meal. -That when therapy provides education to the nursing staff regarding new recommendations the education is provided verbally not written education with sign offs from the staff verifying that the education was provided. -That it is difficult to ensure plans of care are carried out because the facility is using 95% agency staff. -That she started working at the facility in August 2023 and was aware that all care plans at the facility had not been updated since 2021 and the staff could not refer to Resident #62's care plan to ensure she was being provided with the required care with meals. During an interview on 10/25/23 on 12:15 P.M., with Nurse (#3) she said that she worked on Resident #62's unit the day of the second choking incident. Nurse #3 said that Resident #62 was alone in his/her room and that a CNA dropped off the breakfast tray and left Resident #62 alone. Nurse #3 said that she entered Resident #62's room to give him/her medication and that his/her face was blueish/purplish. The Heimlich was provided, 911 called and the Resident sent to the hospital. Nurse #3 said that Resident #62 has weeks when he/she is very down and needs a lot of cueing with meals, that this week is one of those weeks. As well, she said Resident #62 at baseline feeds self to too fast and shovels food in, often overstuffing his/her mouth. During an interview on 10/25/23 at 1:41 P.M., with the Medical Director he said that he would expect that all resident's be provided with the diet that they are ordered to ensure safety. The Medical Director said that he defers to the recommendations that a Speech and Language Pathologist (SLP) make, regarding resident's care needs with meals, because a SLP has a very specific scope of knowledge that he does not have. He said that it is his expectation that staff follow the recommendations of the SLP, particularly for Resident #62 who has choked two times and that he/she should be provided with cues for safe swallow strategies and supervision for all meals. 41456 1b. Resident #53 was admitted to the facility in December 2021 with diagnoses including dysphagia, secondary Parkinsonism, and history of falling. Review of Resident #53's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident's cognitive ability was not assessed. The MDS also indicated Resident #53 required extensive assistance from staff for all mobility tasks. On 10/24/23 at 12:15 P.M., Resident #53 was observed eating lunch in the dining room. A Certified Nursing Assistant (CNA) was present in the room but not providing cues to the Resident. The Resident was not alternating between liquids and solids and was not clearing his/her mouth of food prior to taking another bite of food. On 10/25/23 at 8:29 A.M., Nurse #1 brought Resident #53 his/her breakfast in his/her room. The Resident was sitting up in his/her wheelchair when provided breakfast. Nurse #1 left the room after giving the Resident his/her meal and did not return to provide supervision. On 10/25/23 at approximately 12:20 P.M., Resident #53 was observed eating in his/her room with a family friend. The Resident was eating blueberries in yogurt and had a mouthful of blueberries while starting to take another bite. The family friend was not providing the Resident with any cues to slow down and, when asked, could not say if the Resident had any need for assistance with meals. On 10/26/23 at 8:28 A.M., Resident #53 was given his/her meal in his/her room. Resident #53 was left unsupervised while he/she ate the meal from 8:30 A.M. to 8:42 A.M. During his time, the Resident was observed to spill food onto him/herself and did not alternate liquids and solids. Resident #53 was also observed attempting to drink juice that still had a cellophane covering on it, with the cellophane entering the Resident's mouth. Review of Resident #53's activity of daily living care plan last revised 9/21/23, indicated the following: *Eating: 1:1 or supervised dining room. Position upright 90*, preferably sitting in w/c. Alternate liquids and solids, small bites, slow rate, chin tuck. Resident is impulsive and requires verbal and tactile cues to slow rate and implement strategies. Review of Resident #53's Kardex (a form indicating the level of assistance a resident requires) indicated the following: * Eating: 1:1 or supervised dining room. Position upright 90*, preferably sitting in w/c. Alternate liquids and solids, small bites, slow rate, chin tuck. Resident is impulsive and requires verbal and tactile cues to slow rate and implement strategies. Review of the speech language discharge summary dated 7/26/23, indicated the following recommendations post discharge: *Strategies: small bites/sips, slow case, swallow each bite/sips before taking more. *Functional Maintenance: Reviewed with nursing see strategies above. Ideally, patient would benefit from 1:1 supervision during meals though this has never been implemented despite previous recs. Therefore, RN encouraged to periodically check in during meals to ensure safe swallowing strategies are being implemented. During an interview on 10/26/23 at 11:16 A.M., Speech Therapist #4 said Resident #53 has a long-standing diagnosis of dysphagia and he/she requires supervision and cueing throughout meals. Speech Therapist #4 said Resident #53's family has been educated on the level of assistance Resident #53 requires and nursing should ensure the visitor is able to provide that during meals if nursing is not in the room. During an interview on 10/25/23 at 9:04 A.M., the Director of Nursing (DON) said she expects residents to receive the level of assistance care planned and recommended by the clinical staff. The DON said staff should refer to the Kardex or care plan to know what level of assistance each resident requires. 1c. Resident #50 was admitted to the facility in November 2022 with diagnoses including Barrett's esophagus and dysphagia. Review of Resident #50's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 which indicated he/she was cognitively intact. The MDS also indicated Resident #50 required partial/moderate assistance from staff for feeding tasks. The surveyor was provided with the facility's audit tool indicating the level of assistance residents in the facility require on 11/6/23 at 8:05 A.M. The audit tool identified Resident #50 as a resident who required assistance with meals. Review of the report titled, Physician Evaluation and Management Report, dated 10/26/23 indicated Resident #50 completed a Modified Barium Swallow (MBS) study to evaluate the Resident's level of dysphagia. The MBS indicated the following: *Patient presents with severe oropharyngeal dysphagia, affecting the safety and efficiency of the swallow. Nutrition/hydration as well as the respiratory status may be impacted by the patient's current pathophysiology and swallowing profile. *Based on today's consultation the overall risk of developing an aspiration pneumonia is considered to be high. This risk is based on the radiologic findings as well as risk factors assessed during the physician consultation. The patient is at risk for choking episode or airway obstruction; therefore, adherence to dietary recommendations is encouraged. *Patient completed the Penetration Aspiration Scale which has a rating of 1-8 with 8 being most severe and the Resident scored an 8. Review of Resident #50's activities of daily living care plan last revised 9/21/23, indicated the following intervention: *Eating: Extensive assistance with meals - tube feeding at night. On 11/6/23 at 8:13 A.M., Resident #50 was given a breakfast tray in his/her room. The Resident was lying almost flat in bed and the staff member did not reposition the Resident to be more upright. The staff member left the room at 8:14 A.M., leaving the Resident unsupervised with his/her meal. During an interview on 11/6/23 at 8:18 A.M., Nurse #12 said all staff have been educated on the importance of residents receiving the correct diet and amount of assistance with meals. Nurse #12 said an audit was created with all residents and their level of assistance needed with meals and the audit is available for all staff to review. On 11/6/23 at 12:16 P.M., Nurse #11 was reviewing the lunch trays in the meal cart. Nurse #11 ripped up Resident #50's tray ticket, indicating he/she would not be eating lunch. On 11/6/23 at 12:20 P.M., Nurse #11 said Resident #50 was NPO (nothing by mouth). When asked why the Resident had received a breakfast tray earlier in the day, Nurse #11 said the Resident was able to eat and then obtained his/her lunch tray and provided the Resident with lunch. The Resident was left alone in the room to eat independently. During an interview on 11/6/23 at 12:24 P.M., Resident #50 said (using a white board to write) that said he/she needs to have someone with him/her during meals. The Resident wrote I know it is not good a lot of it stays stuck in my mouth some of it falls out I have no muscle control. During an interview on 11/6/23 at 12:29 P.M., the Assistant Director of Nursing (ADON) said she was unable to remember the residents who required supervision or assistance with meals and would have to refer to the facility audit tool that indicated the level of assistance residents in the facility require for meals. The ADON showed the surveyor the audit tool which listed Resident #50 as requiring supervision for meals, which was different than the audit tool provided in the morning. The ADON said this audit tool was accurate and Resident #50 required supervision for all meals. The ADON observed that Resident #50 was in his/her room alone without supervision while eating and said the facility was not in compliance with the level of care Resident #50 required during meals. 2. For Resident #48, the facility failed to complete elopement assessments as well as incident reports after an elopement from the unit. Review of the facility policy titled; Elopement Preventions, dated 10/22, indicated the following: *The facility maintains a process to assess all residents for a risk of elopement, implement prevention strategies for those identified as an allotment risk, institute measures for resident identification at the time of admission, and conduct a missing resident procedure. *An elopement risk evaluation is completed by nursing staff on all residents on admission, readmission, quarterly, and upon change of condition. The initial resident assessment should be conducted on admission. Resident #48 was admitted to the facility in January 2023 with diagnoses including Parkinson's Disease, muscle weakness, history of falling and dementia. Review of Resident #48's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored 4 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #48 required extensive assistance from staff for functional daily tasks. Review of the nursing note dated 9/14/23 indicated the following: *This writer notes a wheelchair in front of one of the exits to the unit. This write went out to the stair well and noted this resident sitting on the step. The resident stated I need to go downstairs and get out of here. The patient is alert and confused at baseline. Vital signs - Temp 97.6, BP 104/68, HR 84, RR 18, O2 96%. The patient denies s/sx of SOB and pain at this time. Skin assessment has been performed with no new injuries noted. Patient refused to get onto the wheelchair and became combative. After a few attempts the patient was transferred to the third floor via wheelchair. Upon arrival to the third floor patient continued exit seeking. NP informed with no new orders. HCP and spouse have been informed. Review of Resident #48's medical record indicated an elopement evaluation was completed on 1/12/23 and 5/23/23 but failed to indicate an elopement assessment was completed after this incident. Review of Resident #48's elopement care plans last revised 9/21/23 indicated the following interventions: *Complete Elopement Risk Assessment upon admission, quarterly and with significant change in status assessment. *1:1 as needed. During an interview on 10/25/23 at 11:58 A.M., Nurse #3 said she was working on 9/14/23 and she was the nurse that found Resident #48 in the stairwell. Nurse #3 said she is familiar with Resident #48 and that he/she has reoccurring episodes of exit seeking. Nurse #3 said this was not the first time the Resident had made it through the door. Nurse #3 said the Resident had gone through the door a month prior and she is not sure why a note was note written about that incident or why an incident report was not made. During an interview on 10/26/23 at 9:27 A.M., the Assistant Director of Nursing (ADON) said elopement assessments should be completed upon admission, quarterly and if a resident has a change of status. The ADON said a change of status would include a resident having exit seeking behavior or leaving the unit. The ADON said Resident #48 should have had an elopement assessment completed on 9/14/23. The ADON said she was unaware of the Resident leaving the unit a month prior and would have expected a note and incident report to be completed. 3a. For Resident #35, the facility failed to follow the falls care to prevent a fall. Resident #35 was admitted to the facility in December 2021 with diagnoses including dysphagia, secondary Parkinsonism, and history of falling. Review of Resident #35's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident's cognitive ability was not assessed. The MDS also indicated Resident #35 required extensive assistance from staff for all mobility tasks. Review of the nursing note dated 6/13/23 indicated the following: *this writer was called to resident's room where the assigned CNA stated that she lowered resident to the ground after losing their footing during a transfer. stated that the resident did not hit (his/her) head. NO injuries noted at time of note. Skin intact. T:97.6 BP:117/71 P:70 O2:96% RR:18. Denied pain when asked (gestured thumbs down), shows no non-verbal signs of pain. No changes in mental status, no changes in ROM BE. Assisted off of the floor by two staff and pivoted into wheelchair. Plan is to ensure resident is wearing appropriate footwear and reinforce that resident is a two-person extensive assist with transfers. Notified HCP, provider and left message for DON and administrator. Review of the incident report dated 6/13/23 indicated the CNA was transferring the Resident with one staff only and the Resident was barefoot at the time of the transfer. Review of Resident #35's fall care plan last revised on 9/21/23, indicated that at the time of the fall on 6/23/23, the following care plan intervention was in place: *Use appropriate footwear (non-skid socks, non-slip soles on shoes/sneakers) when ambulating or mobilizing in wc. Initiates 12/30/21 and revised 2/8/23. During an interview on 10/26/23 at 9:27 A.M., the Assistant Director of Nursing (ADON) said she expects all care plan interventions to be followed to prevent falls as much as possible. The ADON did not know the circumstances of Resident #35's fall but said the Resident should not have been barefoot during the transfer. 3b. For Resident #48, the facility failed to complete fall incident reports after a fall. Review of the facility policy titled, Fall Prevention, dated 1/23. Indicated the following: *For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. * The interdisciplinary team and physician should continue to collect and evaluate information until causes for falls can be identified. Resident #48 was admitted to the facility in January 2023 with diagnoses including Parkinson's Disease, muscle weakness, history of falling and dementia. Review of Resident #48's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored 4 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #48 required extensive assistance from staff for functional daily tasks. Review of the nursing note dated 1/29/23 indicated the following: *At 0200, patient heard calling from (his/her) room. This nurse found patient lying on the floor in the bathroom entry. Patient was attempting to go to the bathroom unassisted. ROM WNL. Neuros WNL. Patient admitted to striking (his/her) head on floor. No wound or hematoma found. V/S 118/73 P 82 T 97.6 97% RA. On call ordered patient sent to local for CT of head and eval due to patient being on Eliquis. Family aware, daughter notified. DON notified. Message left for administrator. Intervention for patient is to move (him/her) to rm 100 due to patient having no safety awareness and getting up often without using call light. The facility was failed to provide and incident report investigating the cause of the fall. Review of the nursing note dated 2/13/23 indicated the following: *This nurse was assisting another pt when this pt started yelling out for someone to help (him/her). This nurse went to see what the pt needed and found (him/her) kneeling on the floor on the side of (his/her) bed with (his/her) upper half on the bed. When this nurse asked pt what had happened and where (he/she) was going pt stated (he/she) was trying to get back to bed.Pt assisted back into bed by CNA. The facility was failed to provide and incident report investigating the cause of the fall. Review of the nursing note dated 3/12/23 indicated the following: *I walked into room [ROOM NUMBER] and observed this resident sitting on the bathroom floor. (he/she) states (he/she) was attempting to go to the bathroom and slipped, (he/she) was wearing slipper socks. Assessed for injuries, no apparent injury occurred. The NP, resident's spouse, supervisor and Administrator were all notified. The facility was failed to provide and incident report investigating the cause of the fall. During an interview on 10/26/23 at 9:27 A.M., the Assistant Director of Nursing (ADON) said an incident report must be completed after a resident sustains a fall in order to investigate the cause of the fall to prevent further falls in the future. The ADON said she was unable to find an incident report for Resident #48's falls on 1/29/23. 2/13/23 and 3/12/23. 3c. For Resident #31, the facility failed to complete a fall incident report after a fall. Review of the facility policy titled, Fall Prevention, dated 1/23. Indicated the following: *For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. * The interdisciplinary team and physician should continue to collect and evaluate information until causes for falls can be identified. Resident #31 was admitted to the facility in March 2022 with diagnoses including hip fracture after a fall. Review of Resident #31's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 5 out of a possible 15, which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #31 requires extensive assistance for mobility tasks. Review of the nursing note dated 1/15/23 indicated the following: *Resident calling out from (his/her) room. The nurse checked on the resident and found resident laying on the floor net to the bed on door side of bed. Resident was alert and communicating appropriately. Resident was attempting to go to the bathroom. Resident was evaluated and found to have no apparent injury. When asked, the facility was unable to provide an incident report investigating the cause of the fall. During an interview on 10/26/23 at 9:27 A.M., the Assistant Director of Nursing (ADON) said an incident report must be completed after a resident sustains a fall in order to investigate the cause of the fall to prevent further falls in the future. The ADON said she was unable to find an incident report for Resident #31's fall in January 2023. 46339 4. For Resident #63, the facility failed to complete post fall assessments and implement interventions after a fall. Review of the facility policy titled, Fall Prevention, dated 1/23. Indicated the following: *

Based on document review and staff interviews, the facility failed to ensure that they implemented and maintained an effective training program for all new hires, consistent with their expected roles, and failed to determine the amount and type of training necessary based on the facility assessment. Specifically, 22 out of 22 new staff hired in 2023 to date, were not provided training, therefore, failing to ensure competent, safe, and effective resident care. Findings include: Review of the Facility Assessment indicated the following: -3.4 Every new hire must meet the minimum education and training requirements to hold and maintain their professional licensures and certifications. All new hires go through general orientation. At orientation, attendees are educated on the following: organizational structure, mission statement, philosophy of care, the characteristics of our resident population, federal and state regulations, OBRA, quality of care, quality of life, resident rights, resident bill of rights, facility practices, behavior policy, Joint Commission, QAPI process, OSHA, chemicals hazard, the Right to Know, all emergency codes; location of policies and procedures, disaster and evacuation policy and procedure including bomb threats. -We also tour the facility and meet the individual departments and explain their function. We discuss elevator use, explain the alarm system, show the emergency, and fire equipment location, and demonstrate the telephone and paging system, the call light system, safety practices including workplace violence, sexual harassment, and ergonomics. Infection control policy and procedure, CDC standard precautions, hand hygiene; disease specific isolation, exposure control plan, bloodborne pathogens including transmission; Hepatitis B vaccine; Persona Protective Equipment (PPE); Tuberculosis Policy and Procedure; Ombudsman program; privacy and confidentiality; HIPAA; Dignity; Resident Rights; Verbal and Physical Abuse, Neglect, Mistreatment, Psychological Harm and Misappropriation of property. Incident reporting policy and procedure, Resident incident reports, Safety and Accident Precautions, resident Safety, Employee Safety, Communication, Annual in-service Education requirements, Dementia Training, and Annual Performance Evaluation. The benefits, employee responsibilities regarding Time Schedule/request time off and time clock, paycheck distribution, parking, breakroom area, Personal Handbook and Job Description. -Competencies by department: All departments have annual competencies completed by the (Staff Development Coordinator) SDC and their respective Department Manager. Any employee who through their actions or by management oversight is determined to require additional training will be provided the education and new competencies completed. -All departments receive an initial 8 hours of dementia training and 4 hours annually. During an interview on 10/26/23 at 8:47 A.M., with the Business Office Manager (BOM), she provided the surveyors with an update regarding a Certified Nursing Assistant (CNA) #10 file that had been requested. The BOM said that CNA #10 started working at the facility the previous week, and although he had worked several shifts, the facility did not have staff available to provide orientation to CNA #10. Also, the BOM said that CNA #10 had told her that he had received 8 hours of dementia training at another nursing facility but that she did not yet have a copy of it on file. She said that there was no one to provide education to the staff since the facility was acquired by a new company in January 2023. The surveyors requested a list of new hires since the company was acquired by the new company in January 2023. During an interview on 10/26/23 at 9:18 A.M., with the Nursing Home Administrator (NHA) and Business Office Manager (BOM), the NHA said that the facility had not had a staff educator since previous ownership. The NHA said that traditionally the Assistant Director of Nursing (ADON) would do the education, but he does not know if that has started yet at the facility and does not know if any new hires have been oriented, educated, assessed for competency, or had dementia training since the current company acquired the facility in January 2023. The BOM said she does general building orientation such as teaching the new hires how to use the time clock, but that the clinical component of new orientation is completed by the Administrator and clinical staff. During an interview on 10/26/23 at 9:27 A.M., the ADON said she started working at the facility approximately 7 weeks ago and had not yet received an orientation from the facility administration or a designee. The ADON said in those 7 weeks she had not provided orientation to any staff that had been hired in 2023 and that she instructs staff to let her know if they need anything but that they otherwise learn as they go. The ADON said new hires are given an employee handbook and it is their responsibility to read through it and ask questions, but there is no way to ensure that they look at the handbook. The ADON also said there is no test to determine competency or ensure nursing staff are competent in the nursing skills required to provide competent, safe, and effective resident care. During a follow-up interview on 10/26/23 at 12:35 P.M., the NHA confirmed that the facility had no orientation packets for the 22 staff that were hired in 2023, as no orientation had been provided due to the lack of a staff educator or designee.

Based on observations, interviews and policy review the facility failed to follow the correct therapeutic menu (mechanical soft) for four Residents (#62, #53, #50 and #4) out of a total sample of 34 residents. Specifically, 1. Resident #62, who has a known history of choking twice at the facility, requiring the Heimlich maneuver and emergent transfer to the hosital, was observed to be served the incorrect diet, placing the Resident at serious risk of a repeated choking incident and/or death, 2. Resident #53 who has a long-standing history of dysphagia (difficulty chewing and swallowing), was served food not on his/her recommended diet, and 3. two Residents (#50 and #4) were provided a meal not in accordance with the physician's order. Findings include: 1. Resident #62 was admitted to the facility in October 2021 and in June 2023 Resident #62 was diagnosed with Dysphagia (difficulty chewing and swallowing). Review of the most recent Minimum Data Set assessment, dated 9/14/23, indicated Resident #62 had a Brief Interview for Mental Status exam score of 5 out of a possible 15, which indicated severely impaired cognition. The MDS further indicated Resident #62 was independent with 1 person physical assistance with eating . Review of the record indicated Resident #62 choked on chicken in July 2022, requiring the Heimlich maneuver and, at that time, Physician orders were obtained to downgrade the diet to a Mechanical Soft Diet. Review of the record indicated that in July 2023, Resident #62 was found in his/her room alone choking on a donut, requiring the Heimlich maneuver and emergent transfer to the hospital. Review of the most recent Speech Therapy (SLP) Discharge Summary, dated 8/7/23, indicated Resident #62 was evaluated following the second choking incident in July 2023. The SLP documented Patient remains a high risk for aspiration and choking given impulsive self-feeding behaviors, which have resulted in prior and recent choking incidents. He/she will continue to benefit from diet modification with soft/bite-sized foods and supervision at meals to provide verbal cues for safe swallowing strategies. Education provided with 3rd floor staff, who are aware. Written sign taped to wall in patient's room stating he/she must have supervision during meals. The SLP references that Resident #62's diet level at discharge from speech therapy to be IDDSI Soft and Bite Sized SB6 (level 6). Review of the facility's diet manual indicated Mechanical soft (Dental Soft) Diet: -Grains: soft, easily chewed breads. -Vegetables: Cooked, tender, chopped or shredded, vegetable juice. Review of the current International Dysphagia Diet Standardization Initiative (IDDSD) indicated Level 6 Soft and Bite Sized includes: -Soft, tender and moist, but with no thin liquid leaking/dripping from the food; -Ability to bite off a piece of food is not required; -'Bite sized' pieces no bigger than 1.5 cm x 1.5 cm in size; -A knife is not required to cut this food. Review of current Nutrition care plan, last revised 2/8/23, had an interventions: -dated 10/25/21: Provide, serve diet as ordered. Monitor intake and record q (each) meal. On 10/23/23 at 12:19 P.M., the surveyors observed Resident #62 alone in his/her room, in the dark, with his/her back to the door. The following was observed: -There was a lunch tray directly in front of Resident #62 that included large slices of vegetable approximately 1.5 inches in size and dry rice. Review of the facility's therapeutic menu for that day indicated Resident #62 should have received steamed rice covered in gravy or sauce and chopped zucchini. -The meal ticket indicated: cut up food bite size, mechanical soft. On 10/24/23 from 8:07 A.M. to 8:15 A.M., Resident #62 was observed in the unit dining room. A staff person delivered his/her breakfast including an uncut cheese omelet. On 10/24/23 at 12:10 P.M., Resident #62 was observed in the unit dining room with a plate of penne pasta and broccoli and a bowl of large pineapple chunks, approximately 1 cubic inch. The broccoli was cut in half but still larger than bite size pieces, approximately an inch in length. During an interview on 10/24/23 at 9:15 A.M., the Food Service Director (FSD) provided the surveyor with the detail report for Resident #62's diet. He said that the Resident should be served a meal consistent with the specific details on the report. The report includes the following: -Diet: Mechanical soft; -Alerts: Cut up food bite size, no bread products. During an interview on 10/24/23 at 10:22 A.M., with SLP #3, she said that she was consulted after Resident #62's choking episode in July 2023 and evaluated Resident #62 at that time. SLP #3 said that Resident #62 is on a mechanical soft diet, that should be bite sized. SLP #3 said that the facility does not have a chopped diet which would equate to bite sized. She said that she has brought this to the attention of the facility administration and the FSD and therefore she would expect the staff to read the meal ticket and cut up the food to bite-sized. During an interview on 10/24/23 at 12:15 P.M., with the Director of Nursing (DON) she said the following: -It is the expectation that residents receive the correct diet and diet consistency as ordered by the MD and recommended by the SLP. -That it is difficult to ensure plans of care, are carried out because the facility is 95% agency staff; During an interview on 10/24/23 at 1:56 P.M., with the DON, Nursing Home Administrator and Regional Nurse Consultant the surveyors shared the concerns during the survey process regarding Resident #62's meals and the accuracy of required diet being served to maintain safety. They said that they were not aware that there was any issues with meals. During an interview on 10/25/23 at 1:41 P.M., with the Medical Director he said that he would expect that all resident's be provided with the diet that they are ordered to ensure safety. As well, he said that he defers to the recommendations that a Speech and Language Pathologist (SLP) make regarding resident's care needs because an SLP has a very specific scope of knowledge that he does not have. He said that it is his expectation that staff follow the recommendations, particularly for Resident #62 who has choked two times and that he/she be served the accurate diet. During an interview on 10/26/23 at 10:31 A.M., the Food Service Director (FSD) said that there's been no education provided to the Dietary Staff since he started at the facility in September,2023 and that most of his staff has been at the facility less than 6 weeks. 41456 2. Resident #53 was admitted to the facility in December 2021 with diagnoses including dysphagia, secondary Parkinsonism, and history of falling. Review of Resident #53's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident's cognitive ability was not assessed. The MDS also indicated Resident #53 required extensive assistance from staff for all mobility tasks. On 10/24/23 at 12:15 P.M., Resident #53 was observed eating lunch in the dining room. The Resident's meal tray consisted of pasta not cut up, large broccoli pieces, and a full piece of garlic bread. On 10/25/23 at 12:24 P.M., Resident #53 was observed eating in his/her room with a family friend. The Resident was eating blueberries in yogurt and had a mouthful of blueberries while starting to take another bite. The family friend was not providing the Resident with any cues to slow down and, when asked, could not say if the Resident had any need for assistance with meals. On 10/25/23 at 12:25 P.M., Nurse #5 said he was unaware Resident #53's friend provided him/her with food and did not check the food to see if it followed the Resident's ordered diet. On 10/25/23 at 12:28 P.M., Nurse #1 said she was aware Resident #53's friend [NAME] him/her food and said she did not check the food to ensure it followed the Resident's ordered diet. On 10/26/23 at 8:28 A.M., Resident #53 was given his/her meal in his/her room. Resident #53 was left unsupervised while he/she ate the meal from 8:30 A.M. to 8:42 A.M. During his time, the Resident was observed attempting to drink juice that still had a cellophane covering on it, with the cellophane entering the Resident's mouth. Review of Resident #53's physician orders indicated the following order: *General diet diet (sic), chopped texture, nectar thick liquid consistency, initiated 8/10/23. *Cut up solids into bite sized pieces at the beginning of the meals, initiated 8/10/23. Review of Resident #53's diet slip provided by the Food Service Director indicated the following: *Alerts: cut up food bite size, no bread products. Review of the diet order located in Resident #53's medical record dated 7/26/23 indicated Please Chop Food. Review of the form titled Swallow and Dining Recommendations to Nursing, dated 1/26/22 indicated: *Cut up solids into bite sized pieces (about the size of a fingernail) During an interview on 10/26/23 at 11:16 A.M., Speech Therapist #4 said Resident #53 has a long-standing diagnosis of dysphagia and he/she requires his/her food cut up and should not be provided with any bread products and the pasta and broccoli should have been cut up and served as small pieces. Therapist #4 said she is unsure if Resident #53 is able to have blueberries because even though blueberries are soft and bite size, they have skin on them and that may be difficult to swallow. Speech Therapist #4 said Resident #53's family has been educated on the type of food modifications Resident #53 requires, however nursing should ensure the visitor is providing the correct diet prior to the Resident consuming the food. During an interview on 10/25/23 at 9:04 A.M., the Director of Nursing (DON) said she expects residents to receive the diet as ordered and recommended by the clinical staff. During an interview on 10/25/23 at 1:41 P.M., with the Medical Director he said that he would expect that all resident's be provided with the diet that they are ordered to ensure safety. As well, he said that he defers to the recommendations that a Speech and Language Pathologist (SLP) make regarding resident's care needs because an SLP has a very specific scope of knowledge that he does not have. He said that it is his expectation that staff follow the recommendations of the SLP. 3a. Resident #50 was admitted to the facility in November 2022 with diagnoses including Barrett's esophagus and dysphagia. Review of Resident #50's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 which indicated he/she was cognitively intact. The MDS also indicated Resident #50 required partial/moderate assistance from staff for feeding tasks. Review of the report titled, Physician Evaluation and Management Report, dated 10/26/23 indicate Resident #50 completed a Modified Barium Swallow (MBS) study to evaluate the Resident's level of dysphagia. The MBS indicated the following: *Patient presents with severe oropharyngeal dysphagia, affecting the safety and efficiency of the swallow. Nutrition/hydration as well as the respiratory status may be impacted by the patient's current pathophysiology and swallowing profile. *Based on today's consultation the overall risk of developing an aspiration pneumonia is considered to be high. This risk is based on the radiologic findings as well as risk factors assessed during the physician consultation. The patient is at risk for choking episode or airway obstruction; therefore, adherence to dietary recommendations is encouraged. *Patient completed the Penetration Aspiration Scale which has a rating of 1-8 with 8 being most severe and the Resident scored an 8. Review of Resident #50's physician order initiated on 11/3/23 indicated the following: *Pureed texture, thin liquids consistency related to gastrotomy status (z93.1). Please feeds only provide 2 puree items to tray, frozen ice cream, 5cc provale cup from kitchen with water only. On 11/6/23 at 12:24 P.M., Resident #50 was provided with his/her lunch tray. The tray included yogurt, ice cream, pureed mashed potatoes, pureed meat, pureed vegetables and pureed fruit. During an interview on 11/6/23 at 12:29 P.M., the Assistant Director of Nursing (ADON) said she was unaware of the Resident's physician orders for meals and reviewed the order on the computer. After review, the ADON said the Resident should only be receiving two pureed items on his/her meal trays. The ADON said both the kitchen staff and nurses on the unit should be checking the meal trays to ensure all residents are receiving the diets as ordered. During an interview on 11/6/23 at approximately 12: 50 P.M., the Food Service Director (FSD) said he was unaware Resident #50's lunch tray did not follow the diet as ordered by the physician. The FSD said he was unaware the Resident should only have 2 items on his/her meal tray and said he provided the Resident with a variety of food so he/she could try everything. 41019 3b. Resident #4 was admitted in 07/2011 with diagnoses including dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #4 was severely cognitively impaired. On 11/6/23 at 8:00 A.M., Resident #4 was in his/her room alone eating breakfast and Resident #4 had a whole banana with the peel on his/her tray. Review of the Resident's tray ticket indicated that he/she should receive 1/2 each fresh banana. On 11/6/23 at 10:40 A.M., the Food Service Director said that they give residents on mechanical soft diet petite bananas that we give them but we let the resident's peel them. The Food Service Director said that he doesn't know where that order for Resident #4 came from because it was a standing order before he got here. The Food Service Director said that he checks the trays, but did not know the Resident got a full banana. The surveyor pointed out the discrepancy between the mechanical soft therapeutic breakdowns and the tray ticket and the Food Service Director said he would follow up on it.

Based on observations and interviews the facility failed to ensure it was administered in a manner that enabled the facility to use its resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility administration failed to ensure orientation, education and training was provided to all staff to provide competent, safe, and effective resident care as well as ensuring the governance and leadership members sustain a sufficient Quality Assurance Performance Improvement (QAPI) program during transitions in leadership and staffing. Findings include: During the survey process it was identified that the Administration's failure to orient and educate staff on policies and procedures specifically related to resident's care and services resulted in residents who required therapeutic diets and supervision while eating to receive incorrect diets and insufficient supervision during meals which lead to at least one episode of choking for a resident with a history of choking. The Resident required the Heimlich Maneuver and transport to the hospital. During an interview on 10/24/23 at 12:15 P.M., the Director of Nursing (DON) said she did not receive orientation training when she was hired by the facility. The DON said that the Nursing Home Administrator (NHA) is not involved in the day to day running of the facility. The DON said the NHA is present at the facility morning meeting, however he doesn't pay attention and is very removed from clinical aspects of the building. The DON said the NHA doesn't really leave his office and has not held a QAPI (Quality Assurance Performance Improvement) meeting since she started working at the facility in August 2023. In addition, the DON said the NHA has not relayed any clinical concerns or facility issues that need to be worked on since she started. The DON said that the NHA being removed affects the building, but that staff are used to it and there should be a happy medium with an administrator. During an interview on 10/25/23 at 1:12 P.M., the facility's Medical Director said the facility Administration had not notified him that the facility's annual Recertification survey had been underway since 10/22/23. Also, he said that the facility Administration had not notified him that the facility Administrator was provided with the Immediate Jeopardy Templates for F689, F803 and F837 on 10/25/23 at 10:39 A.M. During an interview on 10/26/23 at 9:18 A.M., with the Nursing Home Administrator (NHA) and Business Office Manager (BOM), the NHA said that the facility had not had a staff educator since the previous ownership. The BOM and NHA provided the surveyor with a checklist of the expected orientation items for new hires. The BOM said she was responsible for the first part of orientation that educated on human resource policies and procedure. The NHA said he was responsible for the policies and procedures that related to resident care and safety. The NHA said he did not complete any education or orientation and the Assistant Director of Nursing (ADON) would traditionally do the staff education. The NHA said he did not know if any education had started at the facility yet and did not know if any new hires had been oriented, educated, assessed for competency, or had dementia training since the current company acquired the facility in January 2023. During an interview on 10/26/23 at 9:27 A.M., the ADON said she started working at the facility approximately 7 weeks ago and had not yet received an orientation from the facility administration or a designee. The ADON said in those 7 weeks she had not provided orientation to any staff that had been hired in 2023 and that she instructs staff to let her know if they need anything but that they otherwise learn as they go. The ADON said new hires are given an employee handbook and it is their responsibility to read through it and ask questions, but there is no way to ensure that they look at the handbook. The ADON also said there is no test to determine competency or ensure nursing staff are competent in the nursing skills required to provide competent, safe, and effective resident care. During an interview on 10/31/23 at 9:10 A.M., the Administrator said the Director of Nursing position had changed three times since his arrival to the building in March 2023 and said that he could provide no documentation of clinical concerns brought to the QAPI meetings including infection control measures, accidents and hazards, quality of care or quality of life that was comprehensive and measurable with goals. The Administrator said he needs to take a deeper dive into the QAPI program at the facility to identify issues and get systems into place but to date, had not done that. The Administrator further said the current Medical Director, who has been responsible for the building since the end of July has not been involved in the QAPI program. During an interview on 10/31/23 at 9:00 A.M., the Medical Director said that neither the Administrator or Governing Body has ever invited him to attend a QAPI meeting at the facility because the facility is not having QAPI meetings. The Medical Director added If I had to pick between making up policies that no one is going to follow, or taking care of my patients I will pick taking care of my patients. Despite the Nursing Home Administrator voicing knowledge that there had not been a Staff Educator in the building for all of 2023, and that all 22 new staff hires in that time frame were not provide with orientation, or assessed for competency, the facility's administrative team and governing body failed to develop a plan to ensure the facility could safely provide the services to meet the needs of the residents. Further, the facility Administration failed to make efforts to identify areas of concern, such as accidents and hazards, and make attempts to improve the quality-of-care delivery. See F689, F803, F837, F940

Based on interview and record review including the Facility Assessment and facility policies, the facility failed to ensure that the governing body provided oversight and accountability for: 1. ensuring education and competencies were completed per Facility Assessment on hire for 22 out of 22 employees hired since January 2023; 2. ensuring quality of care related to the safety and hazards in the facility was maintained for one Resident (#62) out of a total sample of 34; and 3. ensuring the governance and leadership members sustain a sufficient QAPI program during transitions in leadership and staffing. As a result of the governing body's failure, the facility failed to develop a plan to ensure the facility could safely provide the services to meet the needs of the residents as well as implement an effective QAPI program. Findings include: Review of the Facility Assessment, dated as reviewed with the QAPI committee, in October 2023, indicated that the Governing Body included, but was not limited to, the Administrator, Director of Nursing (DON), Assistant Director of Nursing, the Chief Operating Officer and the Medical Director. The Facility Assessment indicated the following: New Admissions: The admissions director reviews as needed with the Administrator, DON, Medical Director, Regional Nurse Consultant, and Staff Educator to ensure staff competencies and staffing needs can be met. - Every new hire must meet- the minimum education and training requirements to hold and maintain their professional licensures and certifications. All new hires go through general orientation. At orientation, attendees are educated on the following: organizational structure, mission statement, philosophy of care, the characteristics of our resident population, federal and state regulations, OBRA, quality of care, quality of life, resident rights, resident bill of rights, facility practices, behavior policy, Joint Commission, QAPI process, OSHA, chemical hazards, the Right to Know, all emergency codes; locations of policies and procedures, disaster and evacuation policy and procedures including bomb threats. - All Departments have annual competencies completed by the SDC and their respective Department Manager. Any employee who through their actions or by management oversight is determined to require additional training will be provided the education and new competencies completed. -3.5 The facility, together with the Medical Director work together to devise facility policies and procedures. Policies and procedures are devised based on regulatory guidelines, and standards of practice. Policies are reviewed at least annually by the facility and Medical Director. Review of the facility policy titled QAPI Plan, last reviewed 2/18/22 included, but was not limited to the following: - (The Company) shall ensure that the Governing Body, Administration, Medical Director, Director of Nursing, clinical and non-clinical staff demonstrate a consistent endeavor to deliver safe, effective, optimal resident care services in an environment of minimal risk. - This facility shall develop, implement, and maintain an effective, comprehensive, data-driven Performance Improvement Program that focuses on indicators of the outcomes of care and quality of life. - The organizational program, established by the Medical Director and Director of Nursing and interdisciplinary Performance Improvement Committee, with the support and approval from the Governing Body, shall have the responsibility for monitoring every aspect of resident care and services (including contracted services), from the time the resident enters the facility through diagnosis, treatment, recovery and discharge in order to identify and resolve any breakdowns that may result in sub-optimal resident care and safety, while striving to continuously improve and facilitate positive resident outcomes. 1. During an interview on 10/26/23 at 9:18 A.M., with the Nursing Home Administrator (NHA) and BOM (Business Office Manager), the NHA said that the facility had not had a staff educator since this company acquired the facility in January 2023. During an interview on 10/24/23 at 12:15 P.M., the Director of Nursing (DON) said that she did not receive orientation training when she was hired by the facility. The DON said that she was not educated or oriented to the buildings needs by her Regional Nurse Consultant, who oversees the building. She said that her Regional Nurse Consultant has been to the building once or twice since she started and that she has been left to figure things out by rounding the building and asking the staff, which is difficult as they are 95% agency staff. During an interview on 10/26/23 at 9:27 A.M., the Assistant Director of Nursing (ADON) said she started working at the facility approximately seven weeks ago and had not yet received an orientation from the facility administration or a designee. The ADON said in those seven weeks she had not provided orientation to any staff that had been hired in 2023 and that she instructs staff to let her know if they need anything but that they otherwise learn as they go. The ADON said new hires are given an employee handbook and it is their responsibility to read through it and ask questions, but there is no way to ensure that they look at the handbook. The ADON also said there is no test to determine competency or ensure nursing staff are competent in the nursing skills required to provide competent, safe, and effective resident care. During the recertification survey, newly hired employees and their education records were requested. A total of 22 new employees, including the Director of Nurses and Assistant Director of Nurses, had been identified as being hired since January of 2023. The facility was unable to provide education records for the 22 new employees hired since January of 2023. During a follow-up interview on 10/26/23 at 12:35 P.M., the NHA said the facility had no orientation packets for the 22 staff that were hired in 2023, as no orientation had been provided due to the lack of a staff educator or designee. 2. Resident #62 was admitted to the facility in October 2021 with diagnoses including major depressive disorder. In June 2023, Resident #62 was diagnosed with dysphagia (difficulty chewing and swallowing). Review of the facility policy titled Accidents and Incidents, revised 10/2022, indicated the following: -All incidents and accidents will be evaluated when applicable by the interdisciplinary team. -The team will review the investigation and continue if necessary, discuss and determine from the investigation the root causes, make recommendations for additional interventions, education and conclude the investigation. During an interview on 10/24/23 at 1:15 P.M., the Regional Nurse Consultant (RNC) said he provides clinical oversight to the facility. He said that includes reviewing reportable events such as a resident who had two choking incidents but that he does not track the events for trends. The RNC said that is a QA (Quality Assurance) expectation that falls on the facility. A record review during the survey indicated that one Resident (#62) had two choking events. When asked if the RNC assessed reoccurring events for possible system failures, the RNC said that at the time of the second choking incident he was on vacation and did not review it upon his return. The RNC said the incident was reviewed by another company nurse and that the events were far apart. He could provide no additional information regarding the two incidents. 3. During an interview on 10/31/23 at 9:10 A.M., with the Nursing Home Administrator (NHA), the QAPI program was reviewed. The NHA said he is responsible for overseeing the QAPI program within the building. He said he took the role as the Administrator in March of 2023 and since that time has held two meetings in April and July of 2023. He said a meeting should have been held in October of 2023 but you guys showed up. During an interview on 10/27/23 at 11:13 A.M., the Director of Nurses said she has been in the building for six weeks and has not attended a QAPI meeting since she started. She said she has not seen any QAPI projects specific to nursing or infection control. She said she gets some help from the Regional Nurse if she has questions but it's limited. During an interview on 10/31/23 at 9:10 A.M., the Administrator said the Director of Nursing position had changed three times since his arrival to the building in March and could provide no documentation of clinical concerns brought to the QAPI meetings including infection control measures, quality of care, quality of life or accidents and hazards (specifically for Resident #62 who choked for a second time at the facility and required the Heimlich maneuver both times) that was comprehensive and measurable with goals. During an interview on 10/24/23 at 1:15 P.M., the Regional Nurse Consultant said he provides clinical oversight to the facility and is in the building every three to four weeks. He said he reviews charts remotely as well as reportable incidents. He said he is not responsible for tracking incidents and that the QAPI expectation falls on the facility. During an interview on 10/31/23 at 9:00 A.M., the Medical Director said that neither the Administrator or Governing Body has ever invited him to attend a QAPI meeting at the facility because the facility is not having QAPI meetings. The Medical Director added If I had to pick between making up policies that no one is going to follow, or taking care of my patients I will pick taking care of my patients. The facility could provide no further documentation of concerns brought to the QAPI meetings, See F689, F803, F835, F940

Based on observation, record review and interview, the facility failed to 1. assist one Resident (#9) with oral care resulting in candidiasis and a mouth sore, 2. failed to ensure Residents ( #133, #35, and #40) were provided the level of assistance required for meals and 3. failed to ensure Residents (#23, #133 and #31), who are dependent for daily care, were provided morning care in care in accordance to their needs, out of a total sample of 34 residents. Findings include: Review of the facility policy titled, ADL Support, dated 10/22 indicated the following: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. -Care and services will be provided for residents who are unable to carry out their ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene, mobility, elimination, dining and communication. -If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care, approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate. -Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. 1. Resident #9 was admitted in 10/2020 with diagnoses including dementia and hypertension. Review of the Minimum Data Set (MDS) dated [DATE], indicated that Resident #9 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Review of the MDS indicated that Resident #9 requires limited assist for bed mobility, dressing, toilet use and personal hygiene. Resident #9 is independent with eating and requires supervision with walking and transfers. Review of the facility policy titled Dentures, dated 10/2022, indicated the following: - Direct care staff will assist residents with denture care, including removal, cleaning, and storage of dentures. Review of the care plan indicates the following: -Focus: the Resident has an ADL (activities of daily living) self-care performance deficit related to left scapula fracture, cognitive impairment -Intervention: PERSONAL HYGIENE/ORAL CARE: independent to limited assist of 1 (initiated 10/19/2020) During an interview on 10/23/23 at 10:22 A.M., Certified Nursing Aide (CNA) #1 said that the CNA's are responsible for washing dentures and if a resident refuses, then they are supposed to document and notify the nurse on duty. Review of the Dental note, dated 5/26/21, indicated the following recommendations: Remove and clean dentures at bedtime, soak overnight. Use denture adhesive as needed. Review of the Dental note, dated 11/10/22, indicated the following: -Existing dentures are covered in severe plaque and staining. Both also have worn teeth. Showed LPN and ADON. The lower denture does not fit. Inside denture base is convex. The denture was staying in because of the severe amount of debris was resting in the floor of the mouth. This is what caused the sore. Recommend patient not wear denture until denture sore has healed. Health care proxy contacted and obtained verbal permission to take lower denture from patient. Recommend patient not wear denture until denture sore has healed . Recommend Nystatin (an antifungal medication) swish and swallow for candidiasis (an overgrowth of oral bacteria due to a fungal infection) During an interview on 10/24/23 at 10:40 A.M., the Resident's health care proxy said that the Resident has upper and lower dentures and has always been [NAME] about his/her appearance, but will let someone clean them if staff direct him/her to do it. As long as the Resident is in control of the task, then he/she will clean them. During an interview on 10/26/23 at 8:07 A.M., CNA #1 said that the Resident often refuses, but will let you do it if you are with him/her and show him/her how to clean the dentures. CNA #1 said that nurses have to cue the Resident often in order to get him/her to clean her teeth. During an interview on 10/27/23 at 9:52 A.M., the Director of Nursing said that oral care should be done twice daily and dentures should be removed and placed in a resident's cup with his/her name on it. CNA's should document if the Resident refuses and nurses should be notified and the DON should also be notified about the issue. Resident #9's dentist declined to be interviewed. Review of the clinical record failed to indicate that Resident #9 refused oral care or that the dentist or nurse was notified of Resident #9 refusing oral care. 41456 2a. Resident #133 was admitted to the facility in October 2023 with diagnoses including dysphagia. On 10/26/23 at 8:31 A.M., Resident #133 was observed eating breakfast in the dining room. Certified Nursing Assistant (CNA) #8 was present in the room. She was standing next to Resident #133's table, however, was not observed to be providing him/her with close supervision or cueing as needed throughout the meal. Resident #133 was attempting to eat a muffin but was repeatedly spitting out his/her food. From 8:46 A.M. to 8:49 A.M., the Resident was left in the dining room without staff present. Review of Resident #133's activity of daily living care plan indicated the following: *Eating: limited assistance by 2 staff. Review of the speech therapy evaluation dated 10/16/23 indicated the following: *Compensatory strategies/positions: **1:1 supervision in room - close supervision if in dining room**To facilitate safety and efficiency, it is recommended the patient use the following strategies during oral intake: alteration of liquids/solids, bolus size modifications and rate modification, along with the following maneuver: upright posture during meals and upright posture for >30 mins after meals. During an interview on 10/26/23 at 8:38 A.M., CNA #8 said she was a new employee to the building, and this was her first time supervising the dining room. CNA #8 said she had not been told who required supervision or cueing during meals and thought she just needed to be in the dining room to provide general supervision to all residents in the room. CNA #8 said she was not told Resident #133 required cueing during meals. CNA #8 said the nurses are supposed to tell her this information, however, if they do not, she does not know where to gather this information. CNA #8 said she had not yet been fully oriented to the nursing unit. During an interview on 10/26/23 at 8:40 A.M., CNA #6 said Resident #133 was just transferred to this floor and she does not know the level of assistance Resident #133 requires for meals. During an interview on 10/26/23 at 8:45 A.M., Nurse #5 said he is an agency nurse and does not know the exact levels of assistance the residents on the floor require and does not know where to find this information. Nurse #5 said he would have been responsible for telling the CNA who required assistance during mealtime but did not. On 10/27/23 at approximately 8:38 A.M., Resident #133 was brought his/her breakfast tray by the Assistant Director of Nursing (ADON). At 8:40 A.M., the ADON left Resident #133 alone in his/her room and the surveyor entered the room and observed Resident #133 with his/her breakfast tray in front of him/her. The ADON came back into the room and then she briefly left the room to get syrup for the Resident's meal. The surveyor and the ADON observed the Resident with food residue in his/her mouth and the ADON said it was left over from when she gave him/her a bite of eggs but that the Resident would not be able to feed him/herself. The surveyor then observed egg on the Resident's lap and asked the ADON if she had dropped eggs on the Resident. The ADON said no, she did not drop any eggs and that the Resident must have attempted to eat part of his/her meal when she had left the room. The ADON said she should have moved the tray away from the Resident when she left the room or could have asked another staff member to get the syrup for her. The ADON said Resident #133 needs continuous supervision throughout mealtimes. During an interview on 10/26/23 at 11:16 A.M., Speech Therapist #4 said Resident #133 requires cueing and supervision throughout meals. Speech Therapist #4 said it is hard to get follow through on her recommendations because of inconsistent staffing. During an interview on 10/25/23 at 9:04 A.M., the Director of Nursing (DON) said she expects Residents to receive the level of assistance care planned and recommended by the clinical staff. The DON said staff should refer to the Kardex or care plan to know what level of assistance each resident requires. 2b. Resident #35 was admitted to the facility in July 2023 with diagnoses including chronic obstructive pulmonary disease and muscle weakness. Review of Resident #35's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status score of 13 out of a possible 15, which indicated he/she was cognitively intact. On 10/24/23 at 8:33 A.M., Resident #35 was observed lying in bed eating breakfast. The privacy curtain was drawn, and the Resident was not visible from the hallway. On 10/24/23 at 12:13 P.M., Resident #35 was observed lying in bed eating lunch. The privacy curtain was drawn, and the Resident was not visible from the hallway. On 10/25/23 at 12:23 P.M., Resident #35 was observed lying in bed eating lunch. The privacy curtain was drawn, and the Resident was not visible from the hallway. Review of Resident #35's activity of living care plan last revised on 9/22/23, indicated the following intervention: *Eating: Limited assistance by (specify NO#) staff. Review of Resident #35's Kardex (a form that indicates the level of assistance needed for functional tasks) indicated the following: *Eating: Limited assistance by (specify NO#) staff. During an interview on 10/27/23 at 9:48 A.M., the Director of Nursing said she was unaware of Resident #35's level of assistance required for meals, however, said all residents should be provided assistance as care planned. 2c. Resident #40 was admitted to the facility in June 2021 with diagnoses including dementia. Review of Resident #40's most recent Minimum Data Set (MDS) dated , 8/17/23, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15, which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #40 required supervision with meals. On 11/6/23 from 8:14 A.M. to 8:42 A.M., Resident #40 was observed sitting in his/her wheelchair eating breakfast alone in his/her room. Once the staff gave the Resident his/her meal at 8:13 A.M., there were no staff present during the meal and no staff that walked by the Resident's room to provide supervision during the meal. Review of Resident #40's activity of daily living care plan, last revised 10/31/23, indicated the following: * EATING: limited supervision after Set up, assistance by 1 staff as needed. Review of Resident #40's Kardex (a form indicating the level of assistance needed for tasks) indicated the following: * EATING: limited supervision after Set up, assistance by 1 staff as needed. The surveyor was provided with the facility's audit tool indicating the level of assistance residents in the facility require on 11/6/23 at 8:05 A.M. The audit tool identified Resident #40 as a resident who required supervision with meals. During an interview on 11/6/23 at 8:18 A.M., Nurse #12 said all staff have been educated on the importance of residents receiving the correct diet and amount of assistance with meals. Nurse #12 said an audit was created with all residents and their level of assistance needed with meals and the audit is available for all staff to review. During interviews on 11/6/23 at 10:52 A.M., and 12:29 P.M., the Assistant Director of Nursing reviewed the auditing tool with the surveyor and said it was accurate and that all Residents listed under the supervised category should be receiving supervision during meals. 36431 3 a. Resident #23 was admitted to the facility in October 2018 and has diagnoses that include but not limited to unspecified dementia, hypertension, adult failure to thrive and unspecified asthma. Review of the Minimum Data Set assessment dated [DATE], indicated Resident #23 had severe cognitive impairment with a score of 0 out of 15 on the Brief Interview for Mental Status exam, was always incontinent of bladder and bowel, at risk for developing a pressure ulcer, and dependent on staff for all aspects of daily care. -On 10/22/23 at 11:33 A.M., Resident #23 was resting in bed on his/her back. The oxygen concentrator was running at 2 liters and the nasal cannula was on the floor next to his/her bed. A strong fecal odor was emanating from the Resident. During an interview on 10/22/23 at 11:50 A.M., CNA #2 said Resident #23 has not been bathed, provided incontinence care, or repositioned yet this shift, which should be done every two hours because he/she can get red on his/her bottom. 3 b. Resident #133 was admitted to the facility in October 2023 with diagnoses including dysphagia. Review of Resident #133's Care Plan for Activities of Daily Care indicated Resident #133 required extensive assistance from staff for all functional daily tasks. -On 10/22/23 at 11:30 A.M., Resident #133 was observed resting in bed. The room had a foul odor. During an interview on 10/22/23 at 11:50 A.M., CNA #2 said Resident #133 has not been provided care including re-positioning, bathing, or incontinence care yet this shift. 3 c. Resident #31 was admitted in March 2022 with diagnoses including hypertension and depression. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #31 scored a 2 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Further, the MDS indicated that Resident #31 requires extensive assistance with bed mobility, is incontinent of bladder and bowel, is at risk of developing a pressure ulcer and has a skin and ulcer treatment for turning and repositioning. On 10/22/23 at 7:46 A.M., and 11:20 A.M., Resident #31 was observed to be frail and small in stature, resting in bed on his/her back. During an interview on 10/22/23 at 11:50 A.M., CNA #2 said Resident #31 has not been provided care including re-positioning, bathing, or incontinence care yet this shift. Residents #24, #133, and #31 were not provided care for over four and a half hours.

Based on record review and interview, the facility failed to protect the resident's right to be free from the deprivation of goods and services by staff for one Resident (#9), specifically failing to provide the plan of care for daily denture cleaning, resulting oral candidiasis and a mouth sore, out of a total of 34 residents: Findings include: Review of the facility policy titled Abuse, dated 10/23/22, indicated the following: - Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. - Neglect: failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness. Review of the facility policy titled Dentures, dated 10/2022, indicated the following: - Direct care staff will assist residents with denture care, including removal, cleaning, and storage of dentures. Resident #9 was admitted in 10/2020 with diagnoses including dementia and hypertension. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #9 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated he/she had severe cognitive impairment. The MDS also indicated that Resident #9 requires limited assist for personal hygiene. Review of the Dental note, dated 5/26/21, indicated the following recommendations: Remove and clean dentures at bedtime, soak overnight. Use denture adhesive as needed. Review of the Dental Annual Exam note, dated 11/10/22, indicated the following: -Existing dentures are covered in severe plaque and staining. Both also have worn teeth. Showed LPN (licensed practical nurse) and ADON (assistant director of nursing). The lower denture does not fit. Inside denture base is convex. The denture was staying in because of the severe amount of debris was resting in the floor of the mouth. This is what caused the sore. Recommend patient not wear denture until denture sore has healed. Health care proxy contacted and obtained verbal permission to take lower denture from patient. Recommend patient not wear denture until denture sore has healed . Recommend Nystatin (an antifungal medication) swish and swallow for candidiasis (an overgrowth of oral bacteria due to a fungal infection) Review of the care plan indicates the following: * Focus- the Resident has an ADL (activities of daily living) self-care performance deficit related to left scapula fracture, cognitive impairment * Intervention- PERSONAL HYGIENE/ORAL CARE: independent to limited assist of 1 (initiated 10/19/2020) During an interview on 10/24/23 at 10:40 A.M., the Resident's health care proxy said that the Resident has upper and lower dentures and has always been [NAME] about his/her appearance but will let someone clean them if staff direct him/her to do it. As long as the Resident is in control of the task, then he/she will clean them. During an interview on 10/23/23 at 10:22 A.M., Certified Nursing Aide (CNA) #1 said that the CNA's are responsible for washing dentures and if a resident refuses, then they are supposed to document and notify the nurse on duty. During an interview on 10/26/23 at 8:07 A.M., CNA #1 said that the Resident often refuses, but will let you do it if you are with him/her and show him/her how to clean the dentures. CNA #1 said that nurses have to cue the Resident often in order to get him/her to clean her teeth. During an interview on 10/27/23 at 9:52 A.M., the Director of Nursing (DON) said that oral care should be done twice daily, and dentures should be removed and placed in a resident's cup with his/her name on it. The DON said CNAs should document if the Resident refuses and nurses should be notified and the DON should also be notified about the issue. Resident #9's dentist declined to be interviewed. Review of the clinical record did not indicate that Resident #9 refused oral care or that the dentist or nurse was notified of Resident #9 refusing oral care.

Based on observation, record review and interview, the facility failed to develop and implement a comprehensive care plan related to depression for 1 Resident (#48) with a known history of suicidal ideation and psychiatric hospitalization s out of a sample of 21 Residents. Resident #48 experienced a worsening of depressive symptoms and attempted suicide while at the facility resulting in a hospitalization . Findings include: Review of the facility's Suicide Ideation Policy, dated ,d+[DATE] failed to include a means for monitoring ongoing behavior Resident #48 was admitted to the facility in [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of his/her most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she scored a 15 out of a possible 15 on the Brief Interview for Mental Status Exam, indicating he/she is cognitively intact, and requires assistance with bathing. The MDS also indicated that Resident #48 had reported feeling down, depressed or hopeless, had felt bad about himself/herself or that he/she was a failure or let his/herself or family down, and had trouble concentrating between ,d+[DATE] days in previous two weeks. During an interview with Resident #48 on [DATE] at 8:50 A.M., his/her affect appeared flat. Review of Resident #48's clinical record indicated he/she had been hospitalized for suicidal ideation in February, 2021 and was again hospitalized on [DATE] after attempting suicide at the facility. Review of Resident #48's depression care plan effective [DATE] - [DATE] indicated that Resident #48 had depression related to grief, loss, and [CONDITION(S)] disorder with interventions including: Discuss with the resident, family, caregivers any concerns, fears, issues regarding health or other subjects as concerns arise. Monitor for non-verbal signs of increased depression, e.g body position, crying, withdrawal, etc. The care plan failed to include information regarding Resident #48's history of suicidal ideation and previous psychiatric hospitalization s, or risks of self harm. The care plan failed to identify methods to intervene, respond, or redirect Resident #48's depression symptoms or grief, and failed to identify therapeutic or psychiatric resources for Resident #48. Review of Resident #48's clinical progress notes indicated: [DATE] Physician's Note: Asked to see patient today due to increased agitation and bouts of crying over the past two weeks. Tomorrow is patient's late significant other's birthday. Resident has history of psych admission while grieving over his/her partner in [DATE]. Over the past two weeks patient has not been dressing up or getting out of bed. Crying and paranoid. Followed by psych with recommendations to increase [MEDICATION(S)] to 125 daily. Will monitor behaviors and adjust dose appropriately. Discussed with social services who are attempting to have daughter connect with resident to help with depression/anxiety. [DATE] Social Worker #2: Visit with Resident #48. Resident reports feeling depressed, crying. He/she is missing seeing or hearing from his/her family despite calls he/she has placed to them. Tomorrow is the birthday of his/her decease significant other, another memory and loss for him/her. He/she has no present interest in getting dressed or attending activities. Feels safe in facility, wishes to remain in long term care, declined hospitalization at this time, likes his/her roommate and does not want to leave him/her. [DATE] Social Worker #2 Note: Visit with Resident #48 this morning, no issues or concerns. Affect appeared stable, no active sad expression or tearfulness. Social Service continues to be available for support. [DATE] Social Worker #2 Note: Room visit with Resident #48[he/she] is dressed. Reports his/her mood to be okay. [DATE] Nursing Note: Resident #48 reported that he/she has been feeling increasingly anxious and depressed. He/she stated that he/she has not heard from his/her family and he/she has called family members and left messages but no one has returned his/her calls. In the past this has led to self injurious behaviors. Will alert caregivers to monitor for mood changes and for self injurious behavior. Nursing supervisor was updated. (Behavioral Health services did not follow up with resident until 13 days later on [DATE]) [DATE] Social Worker #2 Quarterly Review: Depression assessment positive for moderate depression with a score of 11 [out of possible 27]. Resident endorsed feeling depressed, tired and occasional trouble concentrating, trouble falling asleep, fidgety, restless, little interest/pleasures. He/she had been attending activities of choice and walking in the hall, however reports that he/she hasn't been getting dressed, attending activities or eating in the dining room recently. He/she is sensitive to missing his/her family. Resident is seen by behavioral health services for medication management. Social Worker encouraged Resident #48 to contact social service or staff for any concerns/needs. Social Services available for support and advocacy. [DATE] Social Worker #1 Note: Resident interviewed by this writer after having been found by Certified Nurses Aide (CNA) with phone cord wrapped around his/her neck. He/she is sobbing and laying in fetal position in his/her bed continually stating he/she does not want to be here anymore. Resident #48 elaborated that means he/she wants to die. States he/she cannot take this anymore. He/she has no one in his/her life since significant other died . Anniversary date [of death] is approaching. Feels abandoned by family. Discussed some of his/her history and that hospitalization has helped in the past. Resident reports he/she wants to go to the hospital for evaluation. Transportation arranged. There were no updates made to Resident #48's care plans regarding Resident #48's documented worsening of depressive symptoms. On [DATE] at 11:56 A.M., the Surveyor interviewed Social Worker #1 and Social Worker #2. Social Worker #1 said that they were aware that Resident #48 was in need of seeing a therapist but due to staffing issues with the contracted behavioral health services, he/she had not been seen for 1:1 therapy between [DATE] through [DATE] Social Worker #2 said that they would check in with Resident #48 for support but were unable to articulate specifics regarding Resident #48's care plan regarding psychosocial needs or history of suicidal ideation with self injurious behavior hospitalization s previous to [DATE]. The facility failed to develop a comprehensive care plan regarding Resident #48's depression, suicidal ideation and psychosocial needs.

Based on observation, record review and interview, the facility failed to provide 1:1 behavioral health therapy services for 1 Resident #(48) with a known history of suicidal ideation and psychiatric hospitalization s out of a total of 21 sampled Residents. Resident #48's symptoms of depression increased resulting in a suicide attempt and hospitalization . Findings include: Resident #48 was admitted to the facility in [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of his/her most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she scored a 15 out of a possible 15 on the Brief Interview for Mental Status Exam, indicating he/she is cognitively intact, and requires assistance with bathing. The MDS also indicated that Resident #48 had reported feeling down, depressed or hopeless, had felt bad about himself/herself or that he/she was a failure or let his/herself or family down, and had trouble concentrating between ,d+[DATE] days in previous two weeks. During an interview with Resident #48 on [DATE] at 8:50 A.M., his/her affect appeared flat. Review of Resident #48's clinical record indicated he/she had been hospitalized for suicidal ideation in February 2021 and was again hospitalized on [DATE] after attempting suicide at the facility. Review of Resident #48's Depression Care plan effective [DATE] - [DATE] indicated that Resident #48 had depression related to grief, loss, and [CONDITION(S)] disorder with interventions including: Discuss with the resident, family, caregivers any concerns, fears, issues regarding health or other subjects as concerns arise. Monitor for non-verbal signs of increased depression, e.g body position, crying, withdrawal, etc. The care plan failed to include information regarding Resident #48's history of suicidal ideation and previous hospitalization s, risks of self harm or risks of self-injurious behaviors. The care plan failed to identity methods to intervene, respond, or redirect Resident #48's depression symptoms or grief, and failed to identify therapeutic or psychiatric resources for Resident #48. Review of Resident #48's behavioral health notes indicated the following: [DATE] Therapy Visit: Psychiatric History: 2 previous in patient admissions; hospitalized for depression, Section 12 Suicidal Ideation (SI) ,d+[DATE] Alert and oriented X 3, receptive to 1:1. He/she has been active, goes to many activities. Overall his/her mood is improving with some depressive episodes and anxiety. Plan Recommendations: 1:1 therapy in 2 weeks. [DATE] Med Management Visit: Resident presents sitting up in bed. Mood not good, always anxious and depressed .not sure why. Feels safe, denies SI/SIB/HI, Given report, would increase [MEDICATION(S)]. Recommendations: Continue 1:1 sessions per therapist. [DATE] Med Management Visit: Reports being depressed at night, unsure why once in awhile Would continue with current treatment plan at this time and follow up PRN (as needed). Recommendations: Continue 1:1 sessions per therapist. [DATE]: Med Management Visit: Staff report increased anxiety. Resident reports his/her anxiety and depression have worsened. It has been 8 weeks since last increase and he/she may benefit from an additional increase. Recommend [MEDICATION(S)] 125 mg daily. (Resident #48 had no behavioral health visits for [DATE].) [DATE]: Med Management Visit: Facility request resident be seen today for increased anxiety and depression. Resident states he/she had been increasingly depressed since losing his/her significant other last February after being together for [AGE] years. He/she is able to identify some positive coping mechanisms Recommend increasing [MEDICATION(S)] to 37.5 twice a day. [DATE]: Med Management Visit: Patient presents sitting in bed. Very weepy expressing his/her grief after losing his/her significant other this past year. Appears in no acute distress. Acknowledges anxiety and depression, Does not appear to be at risk for self harm or to others. Med recommendation with primary care physician, psychotherapy ,d+[DATE] X a month. The behavioral health notes fail to indicate that Resident #48 had received any 1:1 therapy services since [DATE] despite a documented increase in depression and anxiety symptoms. Review of Resident #48's clinical progress notes indicated: [DATE] Physician's Note: Asked to see patient today due to increased agitation and bouts of crying over the past two weeks. Tomorrow is patient's late significant other's birthday. Resident has history of psych admission while grieving over his/her partner in [DATE]. Over the past two weeks patient has not been dressing up or getting out of bed. Crying and paranoid. Followed by psych with recommendations to increase [MEDICATION(S)] to 125 daily. Will monitor behaviors and adjust dose appropriately. Discussed with social services who are attempting to have daughter connect with Resident to help with depression/anxiety. [DATE] Social Worker #2: Visit with Resident #48. Resident reports feeling depressed, crying. He/she is missing seeing or hearing from his/her family despite calls he/she has placed to them. Tomorrow is the birthday of his/her decease significant other, another memory and loss for him/her. He/she has no present interest in getting dressed or attending activities. Feels safe in facility, wishes to remain in long term care, declined hospitalization at this time, likes his/her roommate and does not want to leave him/her. [DATE] Social Worker #2 Note: Visit with Resident #48 this morning. no issues or concerns. Affect appeared stable, no active sad expression or tearfulness. Social Service continues to be available for support. [DATE] Social Worker #2 Note: Room visit with Resident #48[he/she] is dressed. Reports his/her mood to be okay. [DATE] Nursing Note: Resident #48 reported that he/she has been feeling increasingly anxious and depressed. He/she stated that he/she has not heard from his/her family and he/she has called family members and left messages but no one has returned his/her calls. In the past this has led to self injurious behaviors. Will alert caregivers to monitor for mood changes and for self injurious behavior. Nursing supervisor was updated. (Behavioral Health services did not follow up with Resident until 13 days later on [DATE]) [DATE] Social Worker #2 Quarterly Review: Depression assessment positive for moderate depression with a score of 11. Resident endorsed feeling depressed, tired and occasional trouble concentrating, trouble falling asleep, fidgety, restless, little interest/pleasures. He/she had been attending activities of choice and walking in the hall, however reports that he/she hasn't been getting dressed, attending activities or eating in the dining room recently. He/she is sensitive to missing his/her family. Resident is seen by behavioral health services for medication management. Social Worker encouraged Resident #48 to contact social service or staff for any concerns/needs. Social Services available for support and advocacy. [DATE] Social Worker #1 Note: Resident interviewed by this writer after having been found by Certified Nurses Aide (CNA) with phone cord wrapped around his/her neck. He/she is sobbing and laying in fetal position in his/her bed continually stating he/she does not want to be here anymore. Resident #48 elaborated that means he/she wants to die. States he/she cannot take this anymore. He/she has no one in his/her life since significant other died . Anniversary date [of death] is approaching. Feels abandoned by family. Discussed some of his/her history and that hospitalization has helped in the past. Resident reports he/she wants to go to the hospital for evaluation. Transportation arranged. On [DATE] at 11:56 A.M., the Surveyor interviewed Social Worker #1 and Social Worker #2. Social Worker #1 said that they were aware that Resident #48 was in need of seeing a therapist but due to staffing issues with the contracted behavioral health services, Resident #48 was not seeing one regularly. Social Worker #1 said that her license allowed her to provide therapy, and Social Worker #2 said that she was not licensed to provide therapy. Social Worker #1 and Social Worker #2 said that they would check in with Resident #48 for support but were unable to articulate specifics regarding Resident #48's care plan regarding psychosocial needs or history of suicidal ideation with self injurious behavior hospitalization s previous to [DATE]. Social Worker #1 said that they had placed Resident #48 on a wait list for outside therapy services but that he/she was in the 100's on a wait list. Social Worker #1 was unable to say when Resident #48 was put on the wait list and said that they had not attempted other therapy providers. Social Worker #1 said that after Resident #48 was hospitalized , he/she began tele-health therapy visits with an outside provider and now Resident #48 is working with a new therapist through behavioral health services. During an interview with the Behavioral Health Services Coordinator #1 (BHSC) on [DATE] at 8:25 A.M., she said that the provider had been struggling with staffing over the past year and was familiar with the concerns regarding a break in therapy services for Resident #48. The BHSC #1 said that the nurse practitioners who had been documenting for Resident #48 to be seen by therapy services should have been indicating that Resident #48 would benefit from services and not dictating the frequency of therapy visits. She said that it was the company's policy to offer facilities who are in need of therapy services for Residents' tele-health with other therapists and she did not know if the facility made a request for tele-health therapy visits for Resident #48. The BHSC #1 said that if a Resident in a facility had elected to see an outside provider for therapy, behavioral health services could still provide medication management services with their psychiatric nurse practitioners. During an interview with the BHSC #2 on [DATE] at 11:57 A.M., she said that could not find documentation or recall if she had alerted the facility that they could provide tele-health therapy services to Residents. During an interview with Resident #48 on [DATE] 9:02 A.M., he/she said that before he/she was hospitalized in [DATE], he/she was only seeing a psychiatric nurse practitioner for support. Resident #48 said that she would randomly see Social Worker #1 and Social Worker #2 would check in and bring him/her a Diet Coke. Resident #48 said that he/she has therapy services now, but that it's not enough. I need more. I can talk to the staff here, but they're busy. I don't want to bother them. I need to talk to someone about how I'm feeling. Resident #48 said he/she was willing to do tele-health visits. During an interview with the Director of Nursing on [DATE] 9:10 A.M., the surveyor shared Resident #48's desire to have more therapeutic interventions. The Director of Nursing said that Resident #48 receives weekly therapy sessions. During an interview with Unit Manager #1 on [DATE], she said that Resident #48 does not receive weekly therapy sessions. Review of Resident #48's most recent therapy visit dated [DATE] indicated a plan for Resident #48 to receive therapy ,d+[DATE] X per month. The facility failed to provide ongoing therapy services to Resident #48 despite a worsening of depressive symptoms.