Every finding on record at Alpine Meadow Rehabilitation and Nursing

Based on interview and record review, the facility did not ensure that the irregularities reported by the pharmacist to the attending physician and Medical Director (MD) were acted upon. In addition, the facility did not ensure the attending physician documented in the resident's medical record that the identified irregularity had been reviewed and what, if any, action had been taken to address it. Specifically, for 5 out of 20 sampled residents, pharmacy recommendations were not acted upon by the MD and the MD did not document the identified irregularity and what action was taken in the resident's medical record. Resident identifiers: 10, 18, 19, 24, and 34.Findings included:1. Resident 18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, dementia, and paranoid schizophrenia. The facility Pharmacy Consult for March 2026 was reviewed. The recommendation for the physician documented, [Name redacted], [resident 18] uses Lantus and sliding scale Humalog. She only uses her evening and bedtime Humalog. Recommend changing her sliding scale to dinner and bedtime to decrease the number of times she's tested each day. The recommendation was not documented on a separate report and sent to the attending physician or facility MD for review. The MD did not document in resident 18's medical record that the identified irregularity had been reviewed and what, if any, action had been taken to address it. It should be noted that if no medication change was ordered, the MD should document their rationale in the medical record. 2. Resident 24 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, chronic venous hypertension with ulcer of left lower extremity, schizoaffective disorder, and generalized anxiety disorder. The facility Pharmacy Consult for November 2025 was reviewed. The recommendation for the physician documented, [Name redacted], [resident 24's] GFR [glomerular filtration rate] was 47 when checked last month. She has an order for milk of magnesia that is contraindicated in renal impairment. Consider discontinuing this medication to prevent toxicity. The facility Pharmacy Consult for January 2026 was reviewed. The recommendation for the physician documented, [Name redacted], [resident 24's] blood pressure has been elevated (SBP [systolic blood pressure] 130-156). She currently takes lisinopril 5mg [milligrams] daily. Recommend increasing her dose to 10mg once daily. There was a handwritten note on the January 2026 Pharmacy Consult, MAR [Medication Administration Record] updated. The facility Pharmacy Consult for February 2026 was reviewed. The recommendation for the physician documented, [Name redacted], [resident 24] hasn't used her PRN [as needed] Voltaren or Tums in over a month. Recommend discontinuing these medications if they're no longer needed. The recommendations were not documented on a separate report and sent to the attending physician or facility MD for review. The MD did not document in resident 24's medical record that the identified irregularities had been reviewed and what, if any, action had been taken to address it. It should be noted that if no medication change was ordered, the MD should document their rationale in the medical record. 3. Resident 10 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, major depressive disorder, post traumatic stress disorder, personality disorder, and generalized anxiety disorder. The facility Pharmacy Consult for January 2026 was reviewed. The recommendation for the physician documented, [Name redacted], [resident 10] hasn't used his PRN lidocaine patches or albuterol in over a month. Recommend discontinuing these medications if they're no longer needed. There was a hand written note on the Pharmacy Consult, 0 DC [discontinue] per MD The recommendation was not documented on a separate report and sent to the attending physician or facility MD for review. The MD did not document in resident 10's medical record that the identified irregularity had been reviewed and what, if any, action had been taken to address it. It should be noted that if no medication change was ordered, the MD should document their rationale in the medical record. 4. Resident 19 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, neurocognitive disorder with Lewy bodies, type 2 diabetes mellitus, dementia, major depressive disorder, generalized anxiety disorder, conversion disorder with seizures or convulsions, and cognitive communication deficit. The facility Pharmacy Consult for December 2025 was reviewed. The recommendation for the physician documented, [Name redacted], [resident 19] hasn't used his PRN Flonase, diclofenac, loperamide, Mucinex, or ondanstron [sic] in over a month. Recommend discontinuing these medications if they're no longer needed. The recommendation was not documented on a separate report and sent to the attending physician or facility MD for review. The MD did not document in resident 19's medical record that the identified irregularity had been reviewed and what, if any, action had been taken to address it. It should be noted that if no medication change was ordered, the MD should document their rationale in the medical record. 5. Resident 34 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, active primary progressive Multiple Sclerosis, major depressive disorder, and generalized anxiety disorder. The facility Pharmacy Consult for January 2026 was reviewed. The recommendation for the physician documented, [Name redacted], [resident 34] hasn't used his PRN guaifenesin since November. Recommend discontinuing this medication if it's no longer needed. The facility Pharmacy Consult for March 2026 was reviewed. The recommendation for the physician documented, [Name redacted], [resident 34] has an order for triamcinolone cream to be used as needed. Please add a schedule to this medication so the nurses know how many times they can give it. The recommendations were not documented on a separate report and sent to the attending physician or facility MD for review. The MD did not document in resident 34's medical record that the identified irregularities had been reviewed and what, if any, action had been taken to address it. It should be noted that if no medication change was ordered, the MD should document their rationale in the medical record. On 4/22/26 at 9:46 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the pharmacist would review the residents' medications monthly and would send her the Pharmacy Consult reports. The DON stated that the MD reviewed the recommendations on the Pharmacy Consult reports and would sign off on them. The DON stated that the recommendations would be implemented if approved and uploaded into the resident's medical record. The DON stated that the pharmacist was doing separate forms for recommendations. [It should be noted that no separate recommendation forms were provided by the DON.]

Based on interview and record review, the facility did not ensure residents were offered the Coronavirus disease 2019 (COVID-19) vaccines. Specifically, for 1 out of 5 sampled residents, no documentation was located to demonstrate how the resident accepted or refused the COVID-19 vaccination. Resident identifiers: 19. Findings included:Resident 19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include, but were not limited to, neurocognitive disorder with Lewy bodies.A review of resident 19's immunization in the medical record revealed no documentation for the current 2025/2026 COVID-19 season.On 4/22/26 at 11:09 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated they did not have the requested documentation for resident 19. The RNC stated they had a spreadsheet that resident 19 refused but no declination form was completed. The RNC stated on admission the immunization consent forms were in the admission paperwork. The RNC stated that every September and October they would offer the Covid, influenza, and pneumococcal vaccines to the residents. The RNC stated they would audit those residents who were ready and would do an immunization clinic.

Based on interview and record review, the facility did not ensure that residents were offered the influenza vaccine and that the medical record included documentation that the resident either received the vaccine or did not due to medical contraindications or refusal. Specifically, for 1 out of 5 sampled residents, there was no documentation of declination of the influenza vaccine. Resident identifier: 19.Findings included: Resident 19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include, but were not limited to, neurocognitive disorder with Lewy bodies.A review of resident 19's immunizations in the medical record documented the last influenza vaccine was completed on 10/25/24. There was no documentation for the current 2025/2026 influenza season.On 4/22/26 at 11:09 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated they did not have the requested documentation for resident 19. The RNC stated they had a spreadsheet that resident 19 refused but no declination form was completed. The RNC stated on admission the immunization consent forms were in the admission paperwork. The RNC stated that every September and October they would offer the Covid, influenza, and pneumococcal vaccines to the residents. The RNC stated they would audit those residents who were ready and would do an immunization clinic.

Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 1 out of 20 sampled residents, staff did not wear personal protective equipment (PPE) during wound care for a resident that should have been on Enhanced Barrier Precautions (EBP). Resident identifier: 34.Findings included:Resident 34 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, unspecified open wound of lower back and pelvis without penetration into retroperitoneum.A physician's order dated 4/8/26, documented SKIN TX [treatment] to chronic pilonidal ulcer: cleanse, pack with collagen sheet, cover with bordered dressing. every day shift.Resident 34 was observed to not have EBP signage outside his door or PPE available for use.On 4/20/26 at 10:30 AM, an observation and interview were conducted with Registered Nurse (RN) 1. RN 1 was observed to perform hand hygiene prior to entering resident 34's room and then donned gloves. Resident 34 stated the old bandage was removed because he had a bowel movement. RN 1 confirmed that the area was open a little bit. RN 1 cleaned the area with wound cleaner, doffed gloves, and performed hand hygiene. RN 1 donned gloves and packed the wound with a collagen sheet and applied a border dressing. RN 1 doffed gloves and performed hand hygiene. After wound care was completed, RN 1 stated that EBP precautions would be used for any open wound and anything that was leaking. RN 1 stated she would take precautions to prevent infection. RN 1 stated the facility was good with EBP and she did not think resident 34 needed EBP because of the stage of his wound and they were healing. RN 1 stated she had used EBP with another resident earlier because of the duration of contact with that resident. On 4/22/26 at 9:49 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that EBP should be implemented for any resident with a catheter, feeding tube, peripherally inserted central catheter (PICC) line, open wounds, and a history of multidrug-resistant organisms (MDRO). The DON stated if a resident was on EBP staff should have worn PPE, including a gown and gloves, for any high contact activity, such as a brief change and wound care. The DON stated that resident 34 had EBP in place for a very long time and last week she was told that not all wounds required EBP, only certain wounds. The DON stated that she was told all wounds with a dressing required EBP. The facility policy Enhanced Barrier Precautions implemented on 4/11/25, was reviewed. Policy:It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.2. Initiation of Enhanced Barrier Precautions:a. The facility will have the discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an MDRO that is not currently targeted by CDC [Centers for Disease Control and Prevention] but may be considered epidemiologically important.b. An order for enhanced barrier precautions will be obtained for residents with any of the following:i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO. (Peripheral IVs, continuous glucose monitors, insulin pumps, or ostomies without an associated indwelling medical device are not an indication for EBP.)ii. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply.3. Implementation of Enhanced Barrier Precautions:a. Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care).b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room.c. Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room).d. Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room.e. The Infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education.f. Provide education to residents and visitors.g. Do not restrict room placement or out-of-room activities due to enhanced barrier precautions.h. See Table 1 for implementing contact versus enhanced barrier precautions for more information.4. High-contact resident care activities include:a. Dressingb. Bathingc. Transferringd. Providing hygienee. Changing linensf. Changing briefs or assisting with toiletingg. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline cathetersh. Wound care: any skin opening requiring a dressing .10. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.

Based on interview and record review, the facility did not ensure residents were free of any significant medication errors. Specifically, for 1 out of 20 sampled residents, a resident taking two types of diuretics had those diuretics administered at the same time when they should have been 30 minutes apart. Resident identifier: 10.Findings included:Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, heart failure, systolic congestive heart failure, essential hypertension. A physician's order dated 4/1/26, documented metOLazone Oral Tablet 5 MG [milligrams] (Metolazone) Give 5 mg by mouth every 48 hours related to HEART FAILURE, UNSPECIFIED . *GIVE 30 MINUTES PRIOR TO BUMEX [bumetanide].A physician's order dated 4/1/26, documented Bumetanide Oral Tablet 2 MG (Bumetanide) Give 3 mg by mouth every 48 hours related to HEART FAILURE, UNSPECIFIED.The April 2026 Medication Administration Record was reviewed. The metolazone and bumetanide were administered at the same time every 48 hours.On 4/21/26 at 1:45 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that the medical record showed that the medications were given at the same time when they should have been administered 30 minutes apart per the physician's order. On 4/21/26 at 1:48 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the medications should be given 30 minutes apart. The DON stated the instructions to give the medication 30 minutes apart was in the additional directions but when staff clicked on the medication it was not populating. The DON stated she could add the instruction as a supplement to the documentation so it would prompt the nurses better.

Based on observation, interview, and record review, the facility did not ensure that the resident right to self-administer medications was clinically appropriate and safe. Specifically, for 1 out of 20 sampled residents, a resident was observed to have medication in their room and was not evaluated to determine if they were safe to self-administer that medication. Resident identifier: 1.Findings included:Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, personal history of pneumonia (recurrent), and pneumonitis due to inhalation of food and vomit.On 4/19/26 at 8:23 AM, an observation and interview were conducted with resident 1. A nebulizer machine and three vials of medication were observed on resident 1's night stand. Resident 1 stated the vials contained his nebulizer medication, which he administered throughout the day. Resident 1 stated that he would administer a vial after breakfast, before lunch, and before dinner. The April 2026 Medication Administration Record (MAR) was reviewed. The following medications were administered via the nebulizer machine.a. Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG [milligrams]/3ML [milliliters]) 0.083% (Albuterol Sulfate) 2.5 mg inhale orally every 4 hours as needed for SOB [shortness of breath] -Order Date12/30/2025. It should be noted that there were no administrations for April 2026.b. Budesonide Inhalation Suspension 0.5 MG/2ML (Budesonide (Inhalation) 0.25 mg inhale orally two times a day for SOB -Order Date12/30/2025. On 4/21/26 at 12:26 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that she did not have any residents that self administered medications and no residents had asked her if they could self administer their medications. On 4/21/26 at 12:44 PM, an interview was conducted with the Director of Nursing (DON). The DON stated they did not have any residents in the facility that self administered medications. The DON stated if a resident requested to self administer their medications there was an assessment that would be completed on admission and quarterly. The DON stated that they would provide the residents with a lock box for the medications. On 4/21/26 at 1:02 PM, an interview was conducted with resident 1. Resident 1 stated that the two vials of medicine next to his nebulizer machine were albuterol. Resident 1 stated that he also took budesonide but he took that medication immediately when the nurse brought it into his room. Resident 1 stated that they did not allow him to have the albuterol inhaler in his room but he preferred the albuterol nebulizer. Two vials of albuterol were observed next to the nebulizer machine.The facility policy Resident Self-Administration of Medication implemented on 4/11/25, was reviewed. Policy:It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely.Policy Explanation and Compliance Guidelines:1. Each resident is offered the opportunity to self-administer medications during the routine assessment by the facility's interdisciplinary team.2. Resident's preference will be documented on the appropriate form and placed in the medical record.3. When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following:a. The medications appropriate and safe for self-administration;b. The resident's physical capacity to: swallow without difficulty, open medication bottles, administer injections;c. The resident's cognitive status, including their ability to correctly name their medications and know what conditions they are taken for;d. The resident's capability to follow directions and tell time to know when medications need to be taken;e. The resident's comprehension of instructions for the medications they are taking, including the dose, timing, and signs of side effects, and when to report to facility staff.f. The resident's ability to understand what refusal of medication is, and appropriate steps taken by staff to educate when this occurs.g. The resident's ability to ensure that medication is stored safely and securely.4. The results of the interdisciplinary team assessment are recorded on the MEDICATION SELF-ADMINISTRATION SAFETY SCREEN, which is an evaluation in the resident's medical record.5. Once evaluated for ability to self-administer medication orders are obtained from the medical provider to self-administer and the individual orders are updated to indicate self-administration.a. The nurse does not document on the MAR for medications that are self-administered unless the resident requires supervised self-administration.6. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms or to confused roommates of the resident who self-administers medication. The following conditions are met for bedside storage to occur:a. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if locked storage is ineffective.b. The medications provided to the resident for bedside storage are kept in the containers dispensed by the provider pharmacy.7. All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. Unauthorized medications are given to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of policy and procedures regarding resident self-administration when necessary.8. Medications stored at the bedside are reordered in the same manner as other medications.9. The nursing staff is responsible for proper rotation of bedside stock and removal of expired medications.10. When the interdisciplinary team determines that bedside or in-room storage of medications would be a safety risk to other residents, the medications of residents permitted to self-administer are stored in the medication cart or medication room.11. Diabetic residents with attached insulin pumps for glucose control will follow the physician's orders for basal rates and/or bolus doses, blood glucose checks, and changing of infusion sets/tubing, cartridges, reservoirs, or syringes for the insulin and will notify staff of any changes in glucose readings, skin changes at the site insertion or pain at the delivery site.12. Resident may apply and self-monitor continuous glucose monitor (CGM) with physician approval if evaluated and deemed competent to do so. (See Continuous Glucose Monitors Policy)13. The care plan must reflect resident self-administration and storage arrangements for such medications and CGM devices.14. Medication errors occurring with residents who self-administer will not be counted in the facility's medication error rate.15. A re-assessment for safety at a minimum should be considered by the interdisciplinary team for the following:a. Significant change in resident's status.b. Medication errors occur.

Based on observation, interview, and record review, the facility did not establish an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, hand hygiene was not performed when delivering lunch trays between multiple resident rooms. Findings include: On 3/31/25 at 12:40 PM through 12:47 PM, an observation of the East Wing during lunch service was completed. An observation was made of Certified Nursing Assistant (CNA) 1 who served room [ROOM NUMBER] a food tray and placed the tray on the bedside table. CNA 1 was observed to have moved the table closer to the resident then exited room. CNA 1 then went to the meal cart without performing hand hygiene and grabbed a food tray for room [ROOM NUMBER]. CNA 1 delivered the tray, set up the meal for the resident, exited the room and hand hygiene was not completed. Certified Nursing Assistant Coordinator (CNAC) was observed to deliver a food tray to room [ROOM NUMBER] and exited the room, no hand hygiene was performed. CNAC proceeded to obtain another food tray and delivered it to room [ROOM NUMBER]. The CNAC was observed to set up the meal which included uncovering a drink and no hand hygiene was observed to have been performed. CNAC was then observed going into room [ROOM NUMBER] delivered a meal tray, exited the room and grabbed another food tray which was delivered to room [ROOM NUMBER], no hand hygiene was performed. On 3/31/25 at 12:30 PM, an observation was made of the lunch service for the 100 hallway. CNA 1 was observed to get a tray from the meal cart, no hand hygiene was observed before or after the tray was taken to room [ROOM NUMBER]. CNA 1 was then observed to take a meal tray into room [ROOM NUMBER], remove the cover and arrange items on the residents bed side table. No hand hygiene was performed on exiting of the room. CNA 1 was then observed to take a meal try into room [ROOM NUMBER], CNA 1 was observed to move the room curtain for the resident after setting up the meal tray. No hand hygiene was observed on exiting the room. CNA 1 was then observed to walk the dining room and get some covered cups filled with coffee. CNA 1 took a coffee cup to room [ROOM NUMBER] and removed the lid from the cup, no hand hygiene was observed. CNA 1 was then observed to take a tray into room [ROOM NUMBER], set up the tray, no hand hygiene was observed before entering or on exiting the room. On 4/2/25 at 12:19 PM, an observation was made of the CNAC passing meal trays in the 100 hallway, the CNAC was observed to have a cloth support wrap on her left hand that covered her palm and went up to her wrist. The CNAC was observed to take a meal tray to rooms [ROOM NUMBER] and assist with setting up the meal tray, no hand hygiene was observed before or after the interactions. On 4/3/25 at 8:30 AM, an interview was conducted with the CNAC who stated the staff should check each food tray for accuracy by lifting the lid of the meal and checking it against the food ticket. The CNAC stated each staff should use hand sanitizer each time they go in and out of a resident room, touch the meal tray or touch the residents items when setting up the meal tray. The CNAC stated that they needed to make sure they used hand sanitizer to keep the residents safe. On 4/3/25 at 9:15 AM, an interview was conducted with the Director of Nursing (DON) who stated the staff should use hand hygiene before and after entering a resident's room. The DON stated when the staff pass meal trays they should use hand hygiene to keep everything clean.

Based on interview and record review it was determined, for 1 of 19 sampled residents, the facility must obtain laboratory services only when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist. In addition, the facility must promptly notify the ordering physician of laboratory results that fall outside of clinical reference ranges. Specifically, resident's urinalysis (UA) results were not obtained from the lab and reported to the ordering physician. Resident identifier: 6. Findings include: Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with generalized muscle weakness, type II diabetes, need for assistance with personal cares, and chronic kidney disease stage 3. The medical record of resident 6 was reviewed 3/31/25 through 4/3/25. A progress note dated 1/16/25 documented, .pt [patient] co [complained of] retaining urine [sic] retention, straight Cath [catheter] performed on patient and there was 255 mls [milliliters] postvoid. PT also co dysuria, urine appeared dark and had strong odor. Notified [provider] NEW orders: send sample to Lab and do UA C&S [culture and sensitivity]. A physician's order dated 1/20/25 revealed resident 6 was to be straight cathed to obtain a urine sample. The Laboratory Analysis results collected on 1/16/25, and completed on 1/20/25, were reviewed. The lab results revealed resident 6's urine was positive for protein, glucose, white blood cells and had Lactobacillus present. Progress note dated 1/29/25 revealed, Lab results for culture sent to [provider]. unable to obtain results due to presence of unknown interference substances. PT still experiencing symptoms and requested to be put on an antibiotic. Notified MD [medical doctor]. MD ordered Amoxicillin 875 mg po [by mouth] bid [twice daily] x [times] 7 days for UTI [urinary tract infection] symptoms. There were 9 days in between when the lab results were obtained and the provider was made aware of the results. Resident 6's Medication Administration Record (MAR) documented that Amoxicillin Oral Tablet 875 MG (milligrams). Give 875 mg by mouth two times a day for UTI for 7 Days was ordered on 1/29/25 and administered on 1/30/25. On 4/01/25 at 1:22 PM, an interview was conducted with Registered Nurse (RN) 1 who stated if a resident needed urine collected then the staff would obtain an order from the provider. RN 1 stated they would call or text the lab to come collect the sample. RN 1 stated the lab would come pick up the sample on the same day. RN 1 stated the lab would fax the results or they would call them if it is a stat order. If the results were faxed over the nurse on duty would then pass the information along in report to the other nurses. RN 1 stated the facility has an emergency kit (ekit) for antibiotics that would be used if the pharmacy could not bring the antibiotic. RN 1 stated if the antibiotic was available from the ekit the nursing staff would get it from there for the resident. RN 1 showed this surveyor the ekit and Amoxicillin 250 mg was observed to be in the ekit. On 4/02/25 at 1:58 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the nursing staff are expected to follow the provider orders, obtain the urine sample, and then notify the lab company to come collect the sample. The DON stated the lab would usually collect the sample the same day and would then send over the results when they were ready via fax. The DON stated that she had online access to the lab company and would watch for the results. The DON stated that if the on duty nurse got the results, they were expected to send those results to the provider. The DON stated she was unsure why it had taken so long for the resident to start antibiotics after an infection was found and would look into it. On 04/03/25 at 10:36 AM, a follow up interview was conducted with the DON. The DON stated the lab did not send the final result as they had in the past. The DON stated she did not look into it until the provider called and asked about the results. The DON stated she had missed it and with the process they had in place she should have checked with the lab before the provider had to call, but she had worked some night shifts that week and it it fell through the cracks. The DON stated the resident did not get started on abx until after the doctor had requested the result. The DON stated it should have and usually did happen sooner.

Based on interview and record review, the facility did not ensure that 3 of 12 sampled residents were free of significant medication errors. Specifically, three residents were not administered insulin at the correct time per the physician orders. Resident identifiers: 2, 4, and 10. Findings include: The facility's posted insulin administration times are: 7:00 AM, 11:30 AM, and 4:30 PM. Resident Council Notes dated 5/14/24 revealed the following. Not getting meds in a timely manner . Resident Council Notes dated 6/12/24 revealed the following. Meds still not on time Resident Council Notes dated 7/9/24 revealed the following. Meds being passed too late at [sic.] night Resident Council Notes dated 8/27/24 revealed the following. Meds not given when asked. 1. Resident 2 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses which included Type 1 diabetes mellitus, acute kidney failure, sepsis, encephalopathy, type 2 diabetes mellitus with foot ulcer, and depression. Review of Resident 2's records was completed 10/28/24 through 10/29/24. A quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 2 had a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. A physician's order for Resident 2 revealed the following: Insulin Glargine Subcutaneous Solution 100 UNIT/milliliter (ML), subcutaneously one time a day related to type 2 diabetes mellitus at AM pass. A physician's order for Resident 2 revealed the following: Humalog Injection Solution 100 UNIT/ML injected subcutaneously before meals and at bedtime for DM (diabetes mellitus). A review of Resident 2's Medication Administration Record (MAR) for May 2024 revealed the following: On 5/6/24 Insulin Glargine Subcutaneous Solution was administered at 8:37AM, which was 37 minutes overdue. On 5/6/24 Humalog Injection Solution was administered at 8:36 AM, which was 36 minutes overdue. On 5/7/24 Insulin Glargine Subcutaneous Solution was administered at 8:50 AM, which was 50 minutes overdue. On 5/15/24 Insulin Humalog Injection Solution was administered at 10:36 AM, which was 1 hour and 36 minutes overdue. On 5/15/24 Insulin Humalog Injection Solution was administered at 9:30 PM, which was 1 hour and 30 minutes overdue. On 5/16/24 Insulin Humalog Injection Solution was administered at 9:23 PM, which was 1 hour and 23 minutes overdue. On 5/19/24 Insulin Glargine Subcutaneous Solution was administered at 11:26 AM, which was 2 hours and 26 minutes overdue. On 5/20/24 Insulin Humalog Injection Solution was administered at 1:18 PM, which was 1 hour and 18 minutes overdue. On 5/20/24 Insulin Humalog Injection Solution was administered at 12:23 AM, which was 1 hour and 23 minutes overdue. On 5/24/24 Insulin Glargine Subcutaneous Solution was administered at 10:41AM, which was 1 hour and 41 minutes overdue. On 5/26/24 Insulin Humalog Injection Solution was administered at 10:53 PM, which was 1 hour and 53 minutes overdue. 2. Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE] then discharged on [DATE] with diagnoses which included type 2 diabetes mellitus with diabetic neuropathy, Crohn's disease, post-traumatic stress disorder, schizoaffective disorder, and major depressive disorder. Review of Resident 4's records was completed 10/28/24 through 10/29/24. A quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 4 had a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. A physician's order for Resident 4 revealed the following: Humalog Injection Solution 100 UNIT/ML injected subcutaneously before meals related to type 2 diabetes mellitus with diabetic neuropathy. Specific times being, 7:00 AM, 11:30 AM, and 4:30 PM. A physician's order for Resident 4 revealed the following: Lantus Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 10 unit subcutaneously at bedtime with time ranges of 7:00 PM through 9:00 PM. A review of Resident 4's Medication Administration Record (MAR) for May 2024 revealed the following: On 5/3/24 Insulin Humalog Injection Solution was administered at 9:01 PM, which was 1 hour and 1 minute overdue. On 5/6/24 Lantus Subcutaneous Solution was administered at 10:10 PM, which was 1 hour and 10 minutes overdue. On 5/8/24 Insulin Humalog Injection Solution was administered at 9:36 AM, which was 1 hour and 36 minutes overdue. On 5/8/24 Lantus Subcutaneous Solution was administered at 8:51 PM, which was 51 minutes overdue. On 5/9/24 Insulin Humalog Injection Solution was administered at 10:41 PM, which was 1 hour and 41 minutes overdue. On 5/26/24 Insulin Humalog Injection Solution was administered at 8:44 AM, which was 44 minutes overdue. 3. Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included acute osteomyelitis, left ankle and foot; type 2 diabetes mellitus with foot ulcer; infection of amputation stump; depression; and anxiety. Review of Resident 10's records was completed 10/28/24 through 10/29/24. A quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 10 had a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. A physician's order for Resident 10 revealed the following: Humalog Injection Solution 100 UNIT/ML injected subcutaneously before meals and at bedtime related to type 2 diabetes mellitus with diabetic neuropathy. Specific times being, 7:00 AM, 11:30 AM, 4:30 PM, and 8:00 PM. A physician's order for Resident 10 revealed the following: Lantus Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 25 units subcutaneously at bedtime with time ranges of 7:00 PM through 9:00 PM. On 10/3/24 Lantus Subcutaneous Solution was administered at 11:18 PM, which was 3 hours and 18 minutes overdue. On 10/3/24 Insulin Humalog Injection Solution was administered at 11:18 AM, which was 3 hours and 18 minutes overdue. On 10/4/24 Lantus Subcutaneous Solution was administered at 10:00 PM, which was 2 hours and 1 minute overdue. On 10/4/24 Insulin Humalog Injection Solution was administered at 9:58 PM, which was 1 hour and 58 minutes overdue. On 10/5/24 Lantus Subcutaneous Solution was administered at 10:41 PM, which was 2 hours and 41 minutes overdue. On 10/5/24 Insulin Humalog Injection Solution was administered at 10:45 PM, which was 2 hours and 45 minutes overdue. On 10/6/24 Lantus Subcutaneous Solution was administered at 11:14 PM, which was 3 hours and 14 minutes overdue. On 10/6/24 Insulin Humalog Injection Solution was administered at 11:27 PM, which was 3 hours and 27 minutes overdue. On 10/10/24 Lantus Subcutaneous Solution was administered at 11:48 PM, which was 3 hours and 48 minutes overdue. On 10/10/24 Insulin Humalog Injection Solution was administered at 11:48 PM, which was 3 hours and 48 minutes overdue. On 10/11/24 Lantus Subcutaneous Solution was administered at 10:51 PM, which was 2 hours and 51 minutes overdue. On 10/11/24 Insulin Humalog Injection Solution was administered at 11:04 PM, which was 3 hours and 4 minutes overdue. On 10/12/24 Lantus Subcutaneous Solution was administered at 11:08 PM, which was 3 hours and 8 minutes overdue. On 10/13/24 Insulin Humalog Injection Solution was administered at 9:21 PM, which was 1 hour and 21 minutes overdue. On 10/13/24 Lantus Subcutaneous Solution was administered at 9:24 PM, which was 1 hour and 24 minutes overdue. On 10/18/24 Insulin Humalog Injection Solution was administered at 10:00 PM, which was 1 hour overdue. On 10/17/24 Lantus Subcutaneous Solution was administered at 11:32 PM, which was 3 hours and 32 minutes overdue. On 10/20/24 Lantus Subcutaneous Solution was administered at 11:02 PM, which was 3 hours and 2 minutes overdue. On 10/20/24 Insulin Humalog Injection Solution was administered at 11:49 PM, which was 49 minutes overdue. On 10/24/24 Lantus Subcutaneous Solution was administered at 11:34 AM, which was 3 hours and 34 minutes overdue. On 10/25/24 Lantus Subcutaneous Solution was administered at 12:07 AM, which was 4 hours and 7 minutes overdue. On 10/25/24 Insulin Humalog Injection Solution was administered at 12:07, which was 4 hours and 7 minutes overdue. On 10/26/24 Insulin Humalog Injection Solution was administered at 9:54 PM, which was 54 minutes overdue. On 10/27/24 Insulin Humalog Injection Solution was administered at 11:43 PM, which was 2 hours and 43 minutes overdue. On 10/29/24 at 8:30 AM, an interview was conducted with the Assistant Director of Nursing (ADON). ADON stated the medication administration times were: 6:00 AM-9:00 AM, 11:00 AM-1:00 PM, 3:00 PM-5:00 PM, and 7:00 AM-9:00 AM. ADON stated that the insulin scheduled times for the morning was at 7:00 AM, with an administration time window of 6:00 AM-8:00 AM. Mid-day insulin scheduled time was 11:30 AM, with an administration time window of 10:30 AM-12:30 PM. Evening insulin scheduled time was 4:30 PM, with an administration time window of 3:30 PM-5:30 PM. ADON stated that there could be implications, depending on the medication. ADON stated that she makes sure that she does everything in her power to not be late. ADON stated that she likes to administer insulin as close to mealtimes as possible and that she would postpone other medication to get all scheduled insulin orders administered on time. ADON stated that the risk of not giving insulin at the ordered time could cause blood sugars to spike or drop too low, which created additional concerns. Per the National Library of Medicine regarding Nursing Rights of Medication Administration indicated the following: 'Right time' - administering medications at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level. A guiding principle of this 'right' is that medications should be prescribed as closely to the time as possible, and nurses should not deviate from this time by more than half an hour to avoid consequences such as altering bioavailability or other chemical mechanisms . https://www.ncbi.nlm.nih.gov/books/NBK560654/

Based on interview and record review, it was determined for 1 of 12 sampled residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily injury to the State Survey Agency (SSA). Specifically, a sexual abuse allegation was reported to the SSA. Resident identifier: 11. Findings included: An untitled and undated document was provided as part of a facility abuse allegation investigation, it indicated, Resident/room #/staff member [resident 11] -105 B - What interaction have you had in the past with this staff member? - when changing me, his hand brushed across my breast. Possibly intentionally. -didn't think it was intentional so I didn't tell any [illegible hand writing] - patted on backside and stomach briefly when being changed - just weird. A few weeks ago. On 10/29/24 at 9:50 AM, the ADM provided a document that included his interpretation of his hand writing of the interview with resident 11, it indicated, Resident [Resident 11] Statement: When CNA [CNA 3] was changing me, his hand brushed across my breast. I didn't think it was intentional so I didn't tell anyone. I was patted on the backside and stomach briefly when being changed. It just seemed weird. It should be noted that the untitled and undated document was attached to Form 359 regarding another resident's allegation of abuse. The form was dated 9/20/24 at 4:45 PM. On 10/29/24 at 8:49 AM, an interview was conducted with the Administrator (ADM). The ADM stated that this incident was reported by resident 11 during another abuse investigation, so it was all done as one investigation and that it was not reported as a separate abuse investigation. The ADM stated that when an abuse allegation was reported that the facility would get as much information as possible from residents, staff, and witnesses and then that would be followed by a five-day, thorough investigation. The ADM stated abuse allegations needed to be reported to authorities, like the local police department and ombudsman so they were aware of the situation. The ADM stated that any allegation of abuse needed to be reported within 24 hours. The ADM confirmed this allegation was not reported.

Based on interview and record review, it was determined for 1 of 12 sampled residents, that in response to allegations of abuse, neglect, exploitation, or mistreatment the facility failed to have evidence that all alleged violations were thoroughly investigated. Specifically, there was an allegation of abuse that was not thoroughly investigated. Resident identifier: 11. Findings included: An untitled and undated document was provided as part of a facility abuse allegation investigation, it indicated, Resident/room #/staff member [resident 11] -105 B - What interaction have you had in the past with this staff member? - when changing me, his hand brushed across my breast. Possibly intentionally. -didn't think it was intentional so I didn't tell any [illegible hand writing] - patted on backside and stomach briefly when being changed - just weird. A few weeks ago. On 10/29/24 at 9:50 AM, the Administrator (ADM) provided a document that included his interpretation of his hand writing of the interview with resident 11, it indicated, Resident [Resident 11] Statement: When CNA [Certified Nurse Assistant] [CNA 3] was changing me, his hand brushed across my breast. I didn't think it was intentional so I didn't tell anyone. I was patted on the backside and stomach briefly when being changed. It just seemed weird. It should be noted that the untitled and undated document was attached to Form 359 regarding another resident's allegation of abuse. The form was dated 9/20/24 at 4:45 PM. On 10/29/24 at 8:49 AM, an interview was conducted with the Administrator (ADM). The ADM stated that this incident was reported to staff by resident 11 during another abuse investigation, so it was all done as one investigation and that it was not reported or investigated as a separate abuse investigation. The ADM stated that when an abuse allegation was reported that the facility would get as much information as possible from residents, staff, and witnesses and then that would be followed by a five-day, thorough investigation. The ADM stated abuse allegations needed to be reported to authorities, like the local police department and ombudsman so they are aware of the situation. On 10/29/24 at 10:45 AM, a follow-up interview was conducted with the ADM. The ADM stated that a date was never discovered for when resident 11 was tapped on the buttocks by CNA 3.

Based on interview and record review, it was determined for 2 of 12 sampled residents that the facility did not ensure that the residents were free from abuse. Specifically, two residents reported that a Certified Nurse Assistant (CNA) inappropriately touched them on their genitals. Resident identifiers: 1 and 11. Findings included: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses which included left knee osteoarthritis, type 2 diabetes mellitus, morbid obesity, chronic pain syndrome, and venous peripheral insufficiency. The facility investigation was reviewed 10/28/24 through 10/29/24. Form 358 was submitted to the State Survey Agency on 9/16/24 at 7:55 PM. The form indicated an incident of sexual abuse was reported by the Administrator (ADM). It indicated, [CNA 2]- CNA during her shift was helping another CNA on shift help change resident [resident 1]. [Resident 1] had been engaging in small talk with [CNA 2] and then told her that a man (CNA [CNA 3]) on night shift got 'touchy' with her and that he was trying to put his fingers inside of her vagina. [Resident 1] yelled at him to 'get the hell out of my room' before he was able to do so and he then left. Form 359, dated 9/20/24 at 4:45 PM, indicated, CNA [CNA 3] stated that he visited patient [resident 1] around 4:30 am on Thursday (9-12) to change her brief. 'She replied that she categorically refuses to change her brief, since she thought she was dry. I didn't conflict with her and left her room. I informed the CNA Coordinator -[name redacted]- that patient [resident 1] refused a brief change. [CNA Coordinator] stated that I should try again. So I asked her again and she quietly agreed. I changed her brief calmly, carefully, and quickly. She repeatedly said thank you, thank you. I then went and told [name redacted] CNA Coordinator that the change took place without any problems.' He stated: 'Perhaps I could have inadvertently touched her vagina while wiping her crotch from copious amounts of urine, but I am categorically rejecting the the [sic] allegation that I was trying to insert my fingers into her vagina.' It further indicated, Not verified-due to interviews with residents and staff, it's determined that this allegation is not verified due to Resident [resident 1] easily getting confused. On 10/28/24 at 12:17 PM, an interview was conducted with resident 1. Resident 1 stated an older man came into her room and told her he had to check her vagina to see if it is okay. Resident 1 stated he tried to get under my blanket, but that he did not get under her blanket because she told him that she thinks he better leave. Resident 1 stated the older man turned around and left. Resident 1 stated that when that happens, you just feel dazed. Resident 1 stated she felt panicked. Resident 1 stated the older man never touched her breasts or vagina because she told him no and told him to leave and he left. Resident 1 stated she never saw him again. Resident 1's medical record was reviewed 10/28/24 through 10/29/24. A Minimum Data Set (MDS) 3.0 Section C Cognitive Patterns, dated 8/16/24, indicated resident 1 had a BIMS (Brief Interview for Mental Status) Score of 8 which indicated a moderate cognitive impairment. A review of the Time Card Report for CNA 3, indicated CNA 3 clocked in on 9/12/24 at 5:42 PM, clocked out at 8:12 PM, clocked in at 8:42 PM, and clocked out on 9/13/24 at 6:03 AM. An Abuse Packet was signed as reviewed by CNA 3 on 8/21/24. A facility Abuse Neglect training, dated 9/10/24, indicated CNA 3's signature. The OIG (Office of Inspector General) LEIE (List of Excluded Individuals and Entities) database for CNA 3, dated 8/20/24 at 5:19 PM, indicated no results found. A Utah Nursing Assistant Registry for CNA 3 indicated a current license, dated 3/23/23, and indicated an expiration date of 5/31/25. On 10/28/24 at 10:35 AM, an interview was conducted with the Administrator (ADM). The ADM stated that resident 1 expressed some concern about CNA 3, about inappropriate touching. The ADM stated that CNA 3 was immediately suspended on 9/16/24. The ADM stated he was unable to find any concrete evidence because resident 1 was very confused about the timeline and anything specific but for safety reasons, he decided to part ways with CNA 3. The ADM stated the last day CNA 3 worked at the facility was 9/12/24 and that they had no prior complaints about CNA 3. On 10/28/24 at 10:40 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated resident 1 had a BIMS that fluctuated between an 8 to a 5 and that it depended on the day, but that she was more on the confused side. The ADON stated resident 1 had no behavioral changes after the abuse allegation. On 10/28/24 at 1:03 PM, a telephone interview was conducted with CNA 2. CNA 2 stated she was working with CNA 3 and was going to help him bathe resident 1 on the day of the incident, 9/12/24. CNA 2 stated when she went into resident 1's room, she was in bed, CNA 3 was there, and resident 1 looked at her with wide eyes and resident 1 stated that she was glad that CNA 2 was there. CNA 2 stated she did not think anything of that interaction at that time. CNA 2 stated that the following week, resident 1 told her that CNA 3 had stuck his fingers in her vagina. CNA 2 stated that resident 1 told her that when CNA 2 entered the room on the day of the incident, CNA 3 had hopped off of her. CNA 2 stated she did not see CNA 3 on the resident. CNA 2 stated resident 1 was very lucid and was not confused at all and that when she would ask resident 1 questions over and over again about the incident, she would not mix it up at all. CNA 2 stated resident 1 reported the abuse a week after it happened. CNA 2 stated resident 1 told her that the Russian guy was in her room and he stuck his fingers in her and she called him a sick [expletive removed] and he stuck his fingers in her, all the way. CNA 2 stated resident 1 said in her cookie, which she referred to her vagina as her cookie. CNA 2 stated resident 1 was more confused at this current time because she might have a urinary tract infection. CNA 2 stated resident 1 told her that nobody had ever done that to her in her whole life and that she felt taken advantage of. On 10/29/24 at 10:43 AM, an interview was conducted with the CNA Coordinator. The CNA Coordinator stated that resident 1 reported that she was sleeping and CNA 3 came into her room and woke her up by touching her. The CNA Coordinator stated that resident 1 reported that she felt CNA 3's hand in her brief and that he said he was just checking if she needed to be changed. The CNA Coordinator stated that resident 1 reported that she told CNA 3 that he did not have to put his hand in her vagina and that resident 1 felt CNA 3's fingers in her vagina. The CNA Coordinator stated she observed one instance when resident 1 displayed a change in behavior after the abuse allegation. The CNA Coordinator stated the day after she interviewed resident 1 about the abuse allegation, she asked resident 1 if she could check if her brief was wet, and she observed resident 1 cover her pubic region with her hands and then stated, you are not going to put your hands in my vagina. The CNA Coordinator stated that when you check a resident's brief, you just move the brief to the side or open it, but that you were never supposed to put your hand in the brief. On 10/29/24 at 2:15 PM, a telephone interview was conducted with Registered Nurse (RN) 2. RN 2 stated she was notified of the abuse allegation by CNA 2 the Monday morning following the incident that occurred the previous Wednesday night. RN 2 stated resident 1 did not notify any staff until that Monday morning. RN 2 stated that she and CNA 2 went into resident 1's room to try and get more information, but that CNA 2 had already reported everything to the CNA Coordinator. RN 2 stated that resident 1 can be confused at times but was not confused at that time and had been completely lucid and clear that day and night that she reported the abuse allegation. RN 2 stated resident 1 reported CNA 3 tried to put his finger in her cookie. RN 2 stated she asked resident 1 specifically if CNA 3 put his finger inside her and resident 1 responded that CNA 3 put it right close to it, on the side of it. RN 2 stated that resident 1 reported that she threw CNA 3 out of her room and that she never wanted that man in her room again. On 10/29/24 at 3:25 PM, a follow-up interview was conducted with the ADM. The ADM stated this incident was reported to the police but they did not come in or follow up with them about it. The ADM stated that resident 1 told him that CNA 3 had attempted to put his fingers in her vagina and that nobody told him that CNA 3 actually put his finger in her vagina. 2. Resident 11 was admitted to the facility on [DATE] with diagnoses which included pulmonary embolism, weakness, difficulty in walking, and encephalopathy. On 10/29/24 at 9:31 AM, an interview was conducted with resident 11. Resident 11 stated CNA 3 touched her inappropriately and that she did not remember the exact date but that it was shortly before he was suspended. Resident 11 stated CNA 3 was changing her brief and needed to replace the sheet and CNA 3 told her he had to go get a clean sheet and that he left her laying on her side with her buttocks exposed and patted her on the buttocks before he walked away. Resident 11 stated CNA 3 left her bare and patted her on her bare bottom like a baby. Resident 11 stated it made her feel violated and that it did not feel right and that it made her feel like she did not want to be touched. Resident 11 stated she did not report that incident to staff at that time. An undated document was provided as part of the facility abuse allegation investigation, it indicated, Resident/room #/staff member [resident 11] -105 B - What interaction have you had in the past with this staff member? - when changing me, his hand brushed across my breast. Possibly intentionally. -didn't think it was intentional so I didn't tell any [illegible hand writing] - patted on backside and stomach briefly when being changed - just weird. A few weeks ago. On 10/29/24 at 9:50 AM, the ADM provided a document that included his interpretation of his hand writing of the interview with resident 11, it indicated, Resident [Resident 11] Statement: When CNA [CNA 3] was changing me, his hand brushed across my breast. I didn't think it was intentional so I didn't tell anyone. I was patted on the backside and stomach briefly when being changed. It just seemed weird. Resident 11's medical record was reviewed 10/28/24 through 10/29/24. A MDS 3.0 Section C Cognitive Patterns, dated 9/28/24, indicated resident 11 had a BIMS score of 15 which indicated an intact cognition. On 10/28/24 at 1:03 PM, a telephone interview was conducted with CNA 2. CNA 2 stated that she was aware that resident 11 reported that she was spanked on her buttocks by CNA 3. On 10/29/24 at 8:49 AM, an interview was conducted with the ADM. The ADM stated there was never an okay time to tap anyone on the buttocks. The ADM stated that this incident was reported to staff by resident 11 during the abuse investigation from resident 1. The ADM stated resident 11's abuse allegation was not reported to the State Survey Agency. The ADM stated that when an abuse allegation was reported that the facility would get as much information as possible from residents, staff, and witnesses and then that would be followed by a five-day, thorough investigation. The ADM stated abuse allegations needed to be reported to authorities, like the local police department and ombudsman so they are aware of the situation. The ADM stated that any allegation of abuse needed to be reported within 24 hours. On 10/29/24 at 10:43 AM, an interview was conducted with the CNA Coordinator. The CNA Coordinator stated that she was aware of the incident where resident 11 reported being hit on the buttocks by CNA 3. The CNA Coordinator stated that there was never a time that it would be okay to hit or tap a resident on the buttocks. On 10/29/24 at 10:45 AM, a follow-up interview was conducted with the ADM. The ADM stated that a date was never discovered for when resident 11 was smacked on the buttocks.

Based on observation, interview, and record review, the facility did not 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, including Coronavirus Disease 2019 (COVID-19). Specifically, during a COVID-19 outbreak the facility staff did not dispose of their used Personal Protective Equipment (PPE) correctly, staff did not wear eye protection when entering COVID positive resident rooms, meal trays were not bagged and identified when taken from COVID positive resident rooms and a symptomatic resident was not tested promptly for COVID-19 after staff were made aware. Resident identifier: 4 & 35. Findings included: 1. On 12/20/23 at 10:21 AM, an observation was made of the Certified Nursing Assistant Coordinator (CNAC) and Certified Nursing Assistant (CNA) 3. CNAC and CNA 3 were observed to remove the garbage which held the soiled gowns and gloves from the following COVID isolation rooms. a. 124 b. 125 c. 126 d. 127 e. 118 CNAC and CNA 3 were observed to have N95 masks in place, no other Personal Protective Equipment (PPE) was worn. CNAC was observed to step into room [ROOM NUMBER] and remove the garbage bag, bring it out into the hallway, place it onto a rolling garbage bin and press it down. CNAC's scrubs, hands and lower arms were observed to touch the gowns and garbage as it was pressed into the bin. Hand Hygiene (HH) was not observed to be performed after the garbage was placed in the bin or between rooms. On 12/20/23 at 10:35 AM, CNA 3 was observed to take the garbage bin outside to the receptacle. CNA 3 was observed to lift the bag of garbage out of the bin. CNA 3 did not have a gown or gloves on, the bag of garbage was observed to press against the clothing of CNA 3 as she lifted it into the garbage receptacle. No HH was used when CNA 3 re-entered the building. On 12/20/23 at 10:36 AM, an interview was conducted with CNAC and CNA 3. CNAC stated that when the garbage is taken from the COVID positive rooms they do not double bag the garbage. The CNAC stated the red bags are only used for bodily fluids and stuff. The CNAC stated they did not wear gowns or gloves to bag out the rooms. The CNAC stated they were supposed to use HH after each room and that they cleaned the garbage can after they were done bagging out. The CNAC stated usually the housekeeper does it but she was busy so they were helping her. On 12/20/23 at 10:39 AM, an observation was made of the CNAC and CNA 3 enter rooms 106, 105, 113, 112, 102, 103, and 110 on the non-COVID hallway. The CNAC was observed to interact with the residents in each room. An immediate interview was conducted with the CNAC. The CNAC stated that she and CNA 3 worked the entire facility and that they helped both on the COVID side and the non-COVID side. On 12/20/23 at 11:01 AM, an observation was made of the Housekeeper (HSK). The HSK was observed to wear an N95 mask and shield, don a gown and gloves then enter room [ROOM NUMBER]. A mop and wash cloth were taken into the room, the HSK brought the mop out into the hallway and the entrance to room [ROOM NUMBER] was mopped. The HSK was then observed to doff the gown and gloves in the hallway and placed them in garbage of the housekeeping cart. HH was used and the HSK cleaned her faceshield. On 12/20/23 at 11:07 AM, an observation was made of the HSK. The HSK was observed to stand in the hallway and doff her gown and gloves, placed them in the housekeeping cart garbage can after cleaning room [ROOM NUMBER], a COVID positive room. On 12/20/23 at 11:14 AM, an interview was conducted with the HSK through a translator. The HSK stated she left the COVID positive rooms to be cleaned until the end. The HSK stated she wore gloves, a gown, a shield and mask when she went in the isolation rooms. The HSK stated after the room was disinfected she came out of the room into the hallway and removed her gown and gloves and placed them in the garbage can on her cart. The HSK stated most of the time the CNAs removed the soiled linens and gowns from the rooms. The HSK stated they used regular bags to discard the soiled linens and gowns. 2. On 12/19/23 at 10:30 AM, an observation was made of the CNAC. The CNAC donned all PPE except a face shield and entered resident 4's room, who was on COVID precautions. On 12/20/23 at 11:05 AM, an observation was made of the CNAC. The CNAC entered room [ROOM NUMBER], a COVID isolation room, no eye protection was worn. On 12/20/23 at 11:11 AM, an observation was made of the CNAC and CNA 3. CNAC an CNA 3 entered room [ROOM NUMBER], a COVID isolation room, no eye protection was worn by either employee. On 12/20/23, each COVID positive resident room was observed to have signage with instructions to don and doff PPE. The donning instructions revealed the following: STEPS TO PUT ON PPE . 4. Put on face shield or goggles. Please note: glasses are not an appropriate substitute for a face shield or goggles . STEPS TO TAKE OFF PPE . STEPS 1-5 are completed in the patient's room: Remove gown, being careful to fold the gown inward into a ball. Gloves should remain on at this time. Place gown into waste container . Steps 6-9 are completed outside the patient's room: 6. Exit the patient care area. The only PPE you should still have on is your N95 mask. 3. On 12/20/23 at 12:30 PM, an observation was made of trays being passed in the east hallway. A non-disposable tray was observed to be taken into room [ROOM NUMBER]. On 12/20/23 at 12:35 PM, an observation was made of a the CNAC. The CNAC took a plate, small bowl and spoon were taken into room [ROOM NUMBER], no disposable items were used. The CNAC was observed to wear an N95 mask, don a gown, gloves, no eye protection was observed to be worn. Staff was observed to yell into room telling the resident the meal was on the bedside table while he used the bathroom. The meal was observed to not be covered as it had been removed prior to being taken into the room. On 12/20/23 at 12:52 PM, an interview was conducted with the CNAC. The CNAC stated the staff use regular plates and trays for passing meals, no disposable items are used. The CNAC stated there was no way for the kitchen staff to know what trays came from the COVID rooms and which ones did not come from the COVID rooms. The CNAC stated she usually placed the trays on the bottom of the cart but there is no way for the kitchen staff to know so she would usually try to tell them. On 12/20/23 at 12:55 PM, an interview was conducted with CNA 1. CNA 1 stated the staff should not be taking the mugs from COVID rooms and refilling them by the nurses station but it does happen. CNA 1 stated the facility does not use disposable mugs, trays or utinsels when passing food or water to the COVID positive residents. On 12/19/23 at 9:57 AM, an interview was conducted with the Director of Nursing (DON). The DON stated PPE was used to prevent the spread of infection. The DON stated given the poplulation and how fast COVID was spreading, they needed to use the PPE as indicated on the resident doors. The DON stated everyone needed to use a face shield when going into COVID rooms and they needed to be cleaning the face shields in between rooms. On 12/20/23 at 1:42 PM, a follow up interview was conducted with the DON. The DON stated the expectation was the staff should don PPE when they were bagging out the COVID positive rooms. The DON stated the staff should wear a gown, gloves, and N95 mask while they took the garbage out of the rooms. The DON stated cross contamination was possible when the staff did not wear the appropriate PPE when they took care of COVID positive patients. The DON stated she did not know that the food trays needed to be bagged when removed from COVID positive rooms to prevent cross contamination until today. The DON stated they did not use disposable dinner ware because they felt it was a dignity issue. The DON stated the staff should be bagging the trays that come from the COVID positive residents rooms and that they had educated their staff. The DON stated they had also educated the kitchen staff to wear a mask and gloves when handling the trays. The DON stated prior to today the kitchen staff would not have any way of knowing which trays came from a COVID positive residents room and that this increased the chance of cross contamination. 43212 On 12/21/23 at 8:53 AM, an observation was made of the Dietary Aide (DA) putting dishes through the dish machine. The DA was wearing an apron, mask and gloves. After finishing the dishes at the dish machine, the DA was observed to go to the food preparation area with the same apron on and begin cleaning up the area from the breakfast meal without taking off her apron. On 12/21/23 at 9:04 AM, an interview was conducted with the DA. The DA stated trays from COVID positive rooms were put into bags before being sent back to the kitchen. The DA stated once in the kitchen, the trays were removed from the bags, scraped, sprayed with sanitizer and run through the dish machine 2 times. The DA also stated that she removed her gloves and apron before completing other tasks in the kitchen. On 12/21/23 at 9:04 AM, an interview was conducted with the Dietary Manager (DM), who stated COVID positive residents should be served in disposable containers but the facility was unprepared for the number of cases they had. 45490 4. On 12/20/23 at 8:00 AM, an observation of resident 35 was conducted. Resident 35 was in his room laying on his bed, he told registered nurse (RN) 1 that he had body aches and had been coughing and needed ibuprofen and cough syrup. On 12/20/23 at 8:35 AM, an observation of resident 35 and RN 1 was conducted. Resident 35 was sitting on the edge of the bed and was observed to have a productive cough. RN 1 was administering medications and asked the resident how long he had the body aches and productive coughing. Resident 35 stated that he had been feeling sick two days. An interview with RN 1. RN 1 stated that the resident had been tested for COVID-19 about three days ago and that it was negative, but had not been tested since complaining of feeling sick. [It should be noted that resident 35's room was located in the hallway of the facility where all of the COVID-19 positive residents were located.] On 12/20/23 at 1:00 PM, an observation of resident Resident 35 was conducted. Resident 35 was observed to be sitting in his wheelchair in the hall outside of his room. The resident was observed to have a mask on and was coughing. Resident 35 stated he could not taste his lunch this afternoon. The Certified nursing assistant coordinator (CNAC) was observed to take a COVID-19 test to resident 35's room. The CNAC was observed to be wearing an N95 mask and entered resident 35's room. The CNAC did not put on eye protection, or a gown when testing resident 35. The CNAC was observed to leave resident 35's room and closed the residents door. The CNAC told RN 1 that she must now gown up on resident 35's room because he tested positive for COVID-19. On 12/20/23 at 2:06 PM, an interview was conducted with the DON. The DON stated that when staff test a resident that is suspected of having COVID-19 the expectation is the staff will wear the correct PPE including: gloves, gown, N95 face mask and the eye protective face shields, because the resident could be positive if testing a resident suspected of having COVID-19. The DON stated that the nurses are the ones that test for COVID-19, she stated that the CNA's do not test resident for COVID-19 because she can not ensure that it is being done properly. When she was informed a CNA administered the COVID-19 test, the DON stated that she will re-educated staff. The facility policy titled, Coronavirus 2019, Prevention and Control revised 2/1/2021 documented, 2. The best way to prevent COVID-19 is to avoid being exposed to the virus. Strategies to reduce the risk for exposure include: a. All residents, staff and visitors should avoid close contact with people who are sick . Symptoms: 5. Residents will be actively screened for fever and respiratory symptoms .

Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the refrigerators and freezers were open to air. Findings include: 1. On 12/19/23 at 9:07 AM, an initial inspection was completed. In the freezer labeled Freezer 2, a box of pork sausage patties was open to air. In the refrigerator labeled Fridge 1, a container of curry paste with an expiration date of 9/11/2020 was present. Also in Fridge 1, a container of egg product had a use by date of 12/4/23. The container had been opened on 12/19/23 and an expiration date of 12/25/23 was written on the container. 2. On 12/21/23 at 8:53 AM, a second walk-through of the kitchen was conducted. The freezer labeled Freezer 2 contained a box of pork sausage patties that were open to air. The freezer labeled Freezer 1 contained a box of white dinner rolls that was open to air. The refrigerator labeled Fridge 1 the container of curry paste with an expiration date of 9/11/2020 was still present. Also in Fridge 1, a large container of mayonnaise with no dates as to when it was opened or when it would expire. On 12/21/23 at 9:04 AM, an interview was conducted with the Dietary Manager (DM). The DM stated she was the person who received food deliveries, dated the items and put them away. The DM stated when food items were removed from the refrigerator or freezer, the remainder of the food in that container should be sealed before putting it back. The DM stated all food items should be labeled and dated. The DM also stated that mayonnaise should only be kept for 7 days. The DM stated the consultant dietitian conducted kitchen audits 1-2 times per week and at least monthly. The DM stated the consultant dietitian would send the results of the kitchen audit to the administrator for his review, and then she would receive it and correct anything that needed to be fixed. The DM stated that she had purchased the curry paste quite some time ago, and since she did not use it often, it was usually kept in the freezer. The DM stated she planned on using the curry paste for an upcoming meal, which was why it was in the refrigerator. The DM stated she did not know what the shelf life was for curry paste, but thought it would be ok since it had been in the freezer.

Based on interview and record review it was determined for 4 of 20 sampled residents that the facility did not ensure that the residents were free from any significant medication errors. Specifically, a resident was given the incorrect dose of medication, a resident's insulin medication was not administered per the physician's ordered time, one residents pain medication was not administered per the physician's ordered time, and on residents anxiety medication was not administered timely causing the resident distress. Resident identifiers: 1, 20, 35, and 4. Findings included: 1. Resident 20 was admitted to the facility on [DATE] with diagnoses which included depression, chronic systolic heart failure and hypertension. On 12/20/23 at 7:52 AM, an observation was made of Registered Nurse (RN) 1 during morning medication administration. RN 1 was observed to prepare and administer medications to resident 20. RN 1 administered Divalproex delayed release 500 MG (milligram). Resident 20's Medication Administration Record (MAR) was reviewed for December 2023 and revealed the following order: a. Divalproex delayed release 250 MG. Give 250 mg by mouth one time a day. [Note RN 1 administered divalproex 500 MG tablet] On 12/20/23 at 7:58 AM, an interview was conducted with RN 1. RN 1 stated that the order for resident 20 stated divalproex 250 MG, she stated that the 500 MG tablet was in with his medications. When RN 1 was asked if the 250 MG tablet was available RN 1 was able to find the correct medication in the medication cart under resident 20's medications. RN 1 stated that the divalproex 500 MG dose was resident 20's bedtime dose. RN 1 stated that she was unsure why there was a divalproex 500 mg medication card in with his morning medications and one medication card in with his evening medications and why the divalproex 250 mg medication card was turned backward in resident 20's medication area. On 12/20/23 at 8:10 AM, an interview was conducted with the Director of Nursing (DON). DON stated that resident 20 had an order change and should be receiving divalproex 500 MG. When the DON was asked if the order or divalproex 500 MG in the morning was located in the chart the DON stated it was not in the chart. The DON stated that the nurses should be following the orders in the computer. When the DON was asked if it is considered a medication error for resident 20 to receive an incorrect dose then what is listed in his order the DON stated that it was a medication error and would be filing an incident report. 2. Resident 35 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus and osteomylitis. On 12/20/23 at 8:37 AM, an observation was made of RN 1 during morning medication administration. RN 1 was observed to prepare and administer medications to resident 35. RN 1 stated that resident 35 had a blood sugar of 251 which needed a correction dose, RN 1 administered Lispro insulin 4 units and Insulin glargine 16 units. Resident 35's MAR was reviewed for December 2023 and revealed the following: a. Humalog (insulin Lispro) inject as per sliding scale: if . 251-300= 4 . subcutaneously before meals related to type 2 diabetes . The scheduled time was 12/20/23 at 7:00 AM. The documented administration was 8:35 AM. b. Insulin Glargine Inject 16 unites subcutaneously one time a day. The scheduled time was 12/20/23 at 7:00 AM. The documented administration time was 8:33 AM. [Note: Both medications were administered over an hour and a half later than the scheduled time.] 3. Resident 1 was admitted to the facility on [DATE] with diagnoses which included chronic pain, polyneuropathy, anxiety disorder, and major depressive disorder. On 12/20/23 at 9:00 AM, an observation was made of Registered Nurse (RN) 1 during morning medication administration. RN 1 was observed to prepare and administer medications to resident 1. RN 1 administered Hydromorphone 2 MG (milligram), Tylenol extra strength 500 MG, Gabapentin 300 MG, and Baclofen 10 MG to resident 1. Resident 1's MAR was reviewed for December 2023 and revealed the following: a. Hydromorphone 2 MG. Give by mouth every 4 hours related to chronic pain. The scheduled time for resident 1 to receive hydromorphone was 12/20/23 at 8:00 AM. The documented administration time was 9:08 AM. The observed administration time was at 9:22 AM. b. Tylenol extra strength 500 MG. Give 1000 MG by mouth three times a day related to chronic pain. The scheduled time was 12/20/23 at 8:00 AM. The documented administration time was 9:08 AM. The observed administration time was at 9:22 AM. c. Gabapentin 300 MG. Give 1 capsule by mouth two times a day for neuropathy. The scheduled time was 12/20/23 at 7:00 AM. The documented administration time was 9:10 AM. The observed administration time was at 9:22 AM. d. Baclofen 10 MG. Give 10 mg by mouth two times a day for pain. The scheduled time was 12/20/23 at 7:00 AM. The documented administration time was 9:10 AM. The observed administration time was at 9:22 AM. On 12/21/23 at 10:57 AM, an interview was conducted with the DON. The DON stated that it is the expectation that insulin for residents are given with in the one hour before or one hour after time frame of the medication order. The DON stated that if a blood sugar is out of range it is expected that the RN would give the resident the correct units on the sliding scale to correct the residents blood sugar within a timely manner. The DON stated that the expectation for residents to get there scheduled pain medications is with in the one hour time frame of when the medication is ordered and scheduled to be given, to maintain pain control and avoid discomfort or jeopardize the residents health. 46232 4. Resident 4 was admitted to 6/8/23 with the following diagnosis that included metabolic encephalopathy, acute respiratory failure, muscle weakness, insomnia, and schizoaffective disorder. On 12/19/23 at 10:23 AM, an interview was conducted with resident 4. Resident 4 stated their medications were 2 hours late this morning. Resident 4 stated they have not freaked out this bad since they were hospitalized at the age of 19. Resident 4 stated they really needed their medication on time since they were bipolar. Resident 4's medical record was reviewed on 12/21/23. A care plan focus area initiated on 6/28/23 documented resident 4 used psychotropic medications including olanzapine, Depakote and buspirone due to schizoaffective disorder. An identified intervention stated to administer psychotropic medication as ordered by the physician. Resident 4's physician orders were reviewed and documented the following medication orders: a. An order with a start date of 6/8/23, read as follows, Depakote Oral Tablet Delayed Release 250 MG (milligrams). Give 250 mg by mouth two times a day related to SCHIZOAFFECTIVE DISORDER, DEPRESSIVE TYPE b. An order with a start date of 6/8/23, read as follows, Buspirone HCl Oral Tablet 10 MG. Give 20 mg by mouth two times a day for ANXIETY. c. An order with a start date of 6/9/23, read as follows, Fluoxetine HCl Oral Capsule 40 MG. Give 40 mg by mouth one time a day related to SCHIZOAFFECTIVE DISORDER, DEPRESSIVE TYPE. d. An order with a start date of 12/13/23, read as follows, Risperdal Oral Tablet 1MG. Give 1 mg by mouth one time a day related to SCHIZOAFFECTIVE DISORDER, DEPRESSIVE TYPE. Resident 4's Medication Administration Record (MAR) was reviewed and revealed that resident 4's morning medication were scheduled for 7 AM. It documented that on 12/17, 12/18, 12/19, and 12/20; resident 4 had received their morning medication between 10 AM - 11 AM. On 12/21/23 at 10:43 AM, an interview was conducted with the DON. The DON stated resident 4 had a history of behaviors and was on several psychotropic medications due to a diagnosis of schizophrenia and depression. The DON stated resident 4 was seen by valley behavioral health. The DON stated it was important for resident 4 to get their medications but would not expect to see any side effects if their medication were administered late. The DON stated they had just talked to the doctors about resident 4's increased anxiety, and it was determined it related to resident 4 being on isolation due to covid-19. The DON stated resident mental health has been affected since being isolated to their room since they are no longer able to walk around the building. The DON stated resident 4 use to just find them and let them know they were ready for their morning medications.

Based on observation, interview, and record review, the facility did not ensure that medication error rates were not 5 percent or greater. Observations of 28 medication opportunities on 12/20/23, revealed seven medication errors which resulted in a 25% medication error rate. Specifically, for 3 out of 20 sampled residents, a resident was given an incorrect dose of an anticonvulsant, a resident received long acting insulin and corrective insulin for an elevated blood sugar late, and a resident with scheduled pain medication received them late. Resident identifier: 1, 20, 35. Findings included: 1. Resident 20 was admitted to the facility on [DATE] with diagnoses which included depression, chronic systolic heart failure and hypertension. On 12/20/23 at 7:52 AM, an observation was made of Registered Nurse (RN) 1 during morning medication administration. RN 1 was observed to prepare and administer medications to resident 20. RN 1 administered Divalproex delayed release 500 MG (milligram). Resident 20's Medication Administration Record (MAR) was reviewed for December 2023 and revealed the following order: a. Divalproex delayed release 250 MG. Give 250 mg by mouth one time a day. [Note RN 1 administered divalproex 500 MG tablet] On 12/20/23 at 7:58 AM, an interview was conducted with RN 1. RN 1 stated that the order for resident 20 stated divalproex 250 MG, she stated that the 500 MG tablet was in with his medications. When RN 1 was asked if the 250 MG tablet was available RN 1 was able to find the correct medication in the medication cart under resident 20's medications. RN 1 stated that the divalproex 500 MG dose was resident 20's bedtime dose. RN 1 stated that she was unsure why there was a divalproex 500 mg medication card in with his morning medications and one medication card in with his evening medications and why the divalproex 250 mg medication card was turned backward in resident 20's medication area. On 12/20/23 at 8:10 AM, an interview was conducted with the Director of Nursing (DON). DON stated that resident 20 had an order change and should be receiving divalproex 500 MG. When the DON was asked if the order or divalproex 500 MG in the morning was located in the chart the DON stated it was not in the chart. The DON stated that the nurses should be following the orders in the computer. When the DON was asked if it is considered a medication error for resident 20 to receive an incorrect dose then what is listed in his order the DON stated that it was a medication error and would be filing an incident report. 2. Resident 35 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus and osteomylitis. On 12/20/23 at 8:37 AM, an observation was made of RN 1 during morning medication administration. RN 1 was observed to prepare and administer medications to resident 35. RN 1 stated that resident 35 had a blood sugar of 251 which needed a correction dose, RN 1 administered Lispro insulin 4 units and Insulin glargine 16 units. Resident 35's MAR was reviewed for December 2023 and revealed the following: a. Humalog (insulin Lispro) inject as per sliding scale: if . 251-300= 4 . subcutaneously before meals related to type 2 diabetes . The scheduled time was 12/20/23 at 7:00 AM. The documented administration was 8:35 AM. b. Insulin Glargine Inject 16 unites subcutaneously one time a day. The scheduled time was 12/20/23 at 7:00 AM. The documented administration time was 8:33 AM. [Note: Both medications were administered over an hour and a half later than the scheduled time.] 3. Resident 1 was admitted to the facility on [DATE] with diagnoses which included chronic pain, polyneuropathy, anxiety disorder, and major depressive disorder. On 12/20/23 at 9:00 AM, an observation was made of Registered Nurse (RN) 1 during morning medication administration. RN 1 was observed to prepare and administer medications to resident 1. RN 1 administered Hydromorphone 2 MG (milligram), Tylenol extra strength 500 MG, Gabapentin 300 MG, and Baclofen 10 MG to resident 1. Resident 1's MAR was reviewed for December 2023 and revealed the following: a. Hydromorphone 2 MG. Give by mouth every 4 hours related to chronic pain. The scheduled time for resident 1 to receive hydromorphone was 12/20/23 at 8:00 AM. The documented administration time was 9:08 AM. The observed administration time was at 9:22 AM. b. Tylenol extra strength 500 MG. Give 1000 MG by mouth three times a day related to chronic pain. The scheduled time was 12/20/23 at 8:00 AM. The documented administration time was 9:08 AM. The observed administration time was at 9:22 AM. c. Gabapentin 300 MG. Give 1 capsule by mouth two times a day for neuropathy. The scheduled time was 12/20/23 at 7:00 AM. The documented administration time was 9:10 AM. The observed administration time was at 9:22 AM. d. Baclofen 10 MG. Give 10 mg by mouth two times a day for pain. The scheduled time was 12/20/23 at 7:00 AM. The documented administration time was 9:10 AM. The observed administration time was at 9:22 AM. [Note: The hydromorphone and the tylenol were administered over an hour later, and the gabapentine and baclofen were administered over two hours later than the scheduled time.] On 12/21/23 at 10:57 AM, an interview was conducted with the DON. The DON stated that it is the expectation that insulin for residents are given with in the one hour before or one hour after time frame of the medication order. The DON stated that if a blood sugar is out of range it is expected that the RN would give the resident the correct units on the sliding scale to correct the residents blood sugar within a timely manner. The DON stated that the expectation for residents to get there scheduled pain medications is with in the one hour time frame of when the medication is ordered and scheduled to be given, to maintain pain control and avoid discomfort or jeopardize the residents health.

Based on observation, interview, and record review it was determined, for 2 of 20 sample residents, that the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice. Specifically, facility staff were not changing the oxygen tubing. Resident identifier: 1, 18. Findings included: 1. Resident 1 was admitted to the facility on [DATE] with diagnosis which included chronic obstructive pulmonary disease, unspecified dementia, and muscle weakness. On 12/19/23 at 10:10 AM, an interview was conducted with resident 1. Resident 1 stated that she could not remember when her oxygen tubing was last changed, but that it was suppose to be changed frequently. Resident 1's oxygen tubing was observed with a date of 12/3/23 written on tape which was wrapped around the oxygen tubing. On 12/20/23 resident 1's medical record was reviewed. A physicians order documented an oxygen maintenance order: Change oxygen tubing and storage bag weekly. Label with new date. If being used, clean humidifier bottle with soapy water, rinse and dry and fill humidifier bottle with distilled water. Remove concentrator filter and cleanse with warm soapy water, dry and replace. Clean outside of concentrator with bleach wipe. The order directions documented for oxygen maintenance to occur every Sunday. On 12/20/23 at 9:55 AM, a follow up observation was conduced of resident 1. Resident 1's oxygen tubing was still dated 12/3/23, and the water was empty in the humidifier bottle. On 12/20/23 at 9:57 AM, an interview was conducted with registered nurse (RN) 1. RN 1 stated that oxygen tubing is changed weekly on Sunday. She stated that a task will show up on a residents record and will remind the nurses to change a residents tubing then the nurses will chart when the tubing has been changed. She stated that she changed a few on Sunday 12/17/23 but could not remember which residents they were. 45470 46232 2. Resident 18 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnosis of chronic respiratory failure, obesity, heart failure, and nicotine dependence. On 12/19/23 at 9:52 AM, an observation was made of resident 18's oxygen cord with the date of 12/10/23. Resident 18's electronic medical record was reviewed on 12/21/23. An oxygen maintenance order with a start date of 2/12/23 documented as follows, Change oxygen tubing and storage bag weekly. Label with new date . Resident 18's Treatment Administration Record (TAR) was reviewed, and it documented that resident 18's oxygen tubing had been labeled and changed on 12/3, 12/10, and 12/17. On 12/20/23 at 1:28 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. The CNA 1 stated the CNA's were supposed to be changing them and labeling them on Sundays. The CNA 1 stated the oxygen tubing was labeled with the date so staff were aware when it was last changed. On 12/21/23 at 10:43 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the CNAs changed the tubing on Sundays and the nurses went back and verified the oxygen tubing had been changed and labeled with the new date. The DON stated the nurse was the one responsible for documenting it in the TAR once they had verified it had been done.

Based on record review and interview it was determined, for 1 of 20 sampled residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency (SSA). Specifically, a resident had an unwitnessed fall which resulted in a fracture and the SSA was not notified. Resident Identifier: 28. Findings Included: Resident 28 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses of chronic respiratory failure, muscle weakness, acute pulmonary edema, heart failure, acute kidney failure, and cellulitis. Resident 28's medical record was reviewed on 12/20/23. On 8/25/23, a Quarterly Minimum Data Set (MDS) documented Resident 28 had a Brief Interview for Mental Status (BIMS) score of 2 which indicated resident 28 was severely cognitively impaired. Resident 28's functional status was documented as a two-person physical assist. On 10/12/23 at 5:58 PM, a health status note stated, At approximately 15:30 Actives [sic] Director notified floor nurse that resident was on the ground. Floor nurse, ADON [assistant director of nursing], and DON [director of nursing] immediately went to assess resident condition. Resident was found laying on the floor parallel to his bed but facing opposite direction. Noted on visual inspection that his R [right] foot was turned outward and patient was CO [complaining] of severe pain to RLE [right lower extremity]. Head toe assessment completed, resident denies any other pain besides to his RLE. Unable to give 0-10 rating but would yell out and cry with light palpation to his R ankle. Due patient condition and current anticoagulant therapy, advised not to move resident from current position and to seek emergency medical treatment. 911 notified and resident was transferred to [name of local hospital] for further evaluation . On 10/12/23 at 10 PM, a late entry Health status note stated, .resident has fractured R medial fibula, has short leg posterior splint/brace , is NWB [non weight bearing], he has had morphine IV [intravenous] at ER [emergency room ] and will be sent back to facility with Oxycodone and Tylenol for pain as needed. On 10/15/23 at 9:39 PM, an event template note stated, Event Description: At approximately 15:30 Actives [sic] Director notified floor nurse that resident was on the ground. Floor nurse, ADON, and DON immediately went to assess resident condition. Resident was found laying on the floor parallel to his bed but facing opposite direction. Noted on visual inspection that his R foot was turned outward and patient was CO of severe pain to RLE. Risk Factors and Root Cause Identification: IDT [interdisciplinary team] conducted investigation to identify root cause and identified that resident has increased confusion related to hypoxia and bed was not in the lowest position at time of fall. Preventative Measures: Head toe assessment completed, resident denies any other pain besides to his RLE. Unable to give 0-10 rating but would yell out and cry with light palpation to his R ankle. Due patient condition and current anticoagulant therapy, advised not to move resident from current position and to seek emergency medical treatment. 911 notified and resident was transferred to [name of local hospital] for further evaluation. MD [medical doctor], IDT, and POA [power of attorney] notified. New Interventions: Resident was transfered [sic] to [name of local hospital] ER for evaluation and returned with diagnosis of a fracture that required follow up with ortho and to hold PTINR [prothrombin time and international normalized ratio]. It should be noted that no documentation was located to indicate the SSA was notified of resident 28's fall with fracture on 10/12/23. On 12/20/23 at 2:29 PM, an interview was conducted simultaneously with the DON, Regional Nurse Consultant (RNC) and the Administrator (Admin). The DON stated the administrator was the one that conducted all investigations and reported them to the SSA. The DON stated the resident was unable to state how and why they fell . The RNC stated an exhibit 358 was started if there was any suspicion of neglect or abuse. The RNC stated they had not done an exhibit from 358 on resident 28's unwitnessed fall with fracture because they knew no neglect or abuse had occurred, since the CNA had just been in resident 28's room [ROOM NUMBER] minutes prior to the fall providing cares. The Admin stated they were not the administrator when this had occurred but agreed they did not need to report or investigate resident 28's fall since they knew it was not caused by neglect or abuse.

Based on interview and record review it was determined, for 1 of 20 sampled residents, that in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility failed to have evidence that all alleged violations were thoroughly investigated. Specifically, the facility did not thoroughly investigate an unwitnessed fall that resulted in a fracture. Resident Identifier: 28. Findings Included: Resident 28 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses of chronic respiratory failure, muscle weakness, acute pulmonary edema, heart failure, acute kidney failure, and cellulitis. Resident 28's medical record was reviewed on 12/20/23. On 8/25/23, a Quarterly Minimum Data Set (MDS) documented Resident 28 had a Brief Interview for Mental Status (BIMS) score of 2 which indicated resident 28 was severely cognitively impaired. Resident 28's functional status was documented as a two-person physical assist. On 10/12/23 at 5:58 PM, a health status note stated, At approximately 15:30 Actives [sic] Director notified floor nurse that resident was on the ground. Floor nurse, ADON [assistant director of nursing], and DON [director of nursing] immediately went to assess resident condition. Resident was found laying on the floor parallel to his bed but facing opposite direction. Noted on visual inspection that his R [right] foot was turned outward and patient was CO [complaining] of severe pain to RLE [right lower extremity]. Head toe assessment completed, resident denies any other pain besides to his RLE. Unable to give 0-10 rating but would yell out and cry with light palpation to his R ankle. Due patient condition and current anticoagulant therapy, advised not to move resident from current position and to seek emergency medical treatment. 911 notified and resident was transferred to [name of local hospital] for further evaluation . On 10/12/23 at 10 PM, a late entry Health status note stated, .resident has fractured R medial fibula, has short leg posterior splint/brace , is NWB [non weight bearing], he has had morphine IV [intravenous] at ER [emergency room ] and will be sent back to facility with Oxycodone and Tylenol for pain as needed. On 10/15/23 at 9:39 PM, an event template note stated, Event Description: At approximately 15:30 Actives [sic] Director notified floor nurse that resident was on the ground. Floor nurse, ADON, and DON immediately went to assess resident condition. Resident was found laying on the floor parallel to his bed but facing opposite direction. Noted on visual inspection that his R foot was turned outward and patient was CO of severe pain to RLE. Risk Factors and Root Cause Identification: IDT [interdisciplinary team] conducted investigation to identify root cause and identified that resident has increased confusion related to hypoxia and bed was not in the lowest position at time of fall. Preventative Measures: Head toe assessment completed, resident denies any other pain besides to his RLE. Unable to give 0-10 rating but would yell out and cry with light palpation to his R ankle. Due patient condition and current anticoagulant therapy, advised not to move resident from current position and to seek emergency medical treatment. 911 notified and resident was transferred to [name of local hospital] for further evaluation. MD [medical doctor], IDT, and POA [power of attorney] notified. New Interventions: Resident was transfered [sic] to [name of local hospital] ER for evaluation and returned with diagnosis of a fracture that required follow up with ortho and to hold PTINR [prothrombin time and international normalized ratio]. On 10/12/23 at 3:30 pm, an incident report documented no further information about resident 28's fall. The incident report documented there were no injuries observed at the time of the incident and documented that post incident resident 28 had a right fractured ankle. The nurse and CNA at the time of fall were interviewed. The CNA stated they had just left resident 28's room after changing them. The CNA stated resident 28's oxygen tubing was in place when they left the room and when they returned to check on the resident, they had found resident 28 on the floor with the oxygen off. The Nurse stated there was an obvious deformity to resident 28's leg when they entered the room and noticed resident 28 had their oxygen off. There were no exhibit's 358 and exhibit's 359 submitted to State Survey Agency. On 12/20/23 at 2:29 PM, an interview was conducted simultaneously with the DON, Regional Nurse Consultant (RNC) and the Administrator (Admin). The DON stated the administrator was the one that conducted all investigations and reported them to the SSA. The DON stated resident 28 had always been an extensive assist. The DON stated after resident 28's fall they changed his bed to add a bolster for positional awareness. The DON stated when the fall happened, resident 28 had their oxygen off. The DON stated there were two factors that may have caused his fall, first was the oxygen being off and the second was the mattress may have caved and pushed resident 28 off the bed. The DON stated the resident was unable to state how and why they fell . The DON stated resident 28 was only focused on the pain. The RNC stated an exhibit 358 was started if there was any suspicion of neglect or abuse. The RNC stated they had not done an exhibit from 358 on resident 28's unwitnessed fall with fracture because they knew no neglect or abuse had occurred, since the CNA had just been in resident 28's room [ROOM NUMBER] minutes prior to the fall providing cares. The Admin stated they were not the administrator when this had occurred but agreed they did not need to report or investigate resident 28's fall since they knew it was not caused by neglect or abuse. On 12/21/23 at 10:27 AM, an interview was conducted with certified nursing assistant (CNA 2). The CNA 2 stated when a resident fell , first off they make sure the resident is okay and get vitals and then they notified the nurse. The CNA 2 stated then the nurse came in and took over. The CNA 2 stated the nurse notified them if a resident was a high fall risk. The CNA 2 stated resident 28 was unable to get up on his own and was a two person assist. The CNA 2 stated resident 28 had fall interventions in place that included frequent checks and a special mattress. The CNA 2 stated resident 28 was capable of using their call light if they needed anything. The CNA 2 stated resident 28 had fallen before. The CNA 2 stated he had fallen one day after they had changed him, and they had walked out of the room. The CNA 2 stated they were unsure how resident 28 had fallen. The CNA 2 stated they were notified of resident 28's fall that day when they saw a whole bunch of people running into resident 28's room. The CNA 2 stated they were not the first person to find him on the ground after his fall. The CNA 2 stated they were unsure if resident 28 had gotten injured after the fall. The CNA 2 stated to their understanding, resident 28 had not been hurt. The CNA 2 stated they were interviewed about resident 28's fall by the administrator. On 12/21/23 at 10:50 AM, a follow up interview was conducted with the DON. The DON stated when a resident fell , first they checked on the resident to make sure they are okay and then they notified the charge nurse. The DON stated the charge nurse then evaluated the resident by doing a head-to-toe assessment. The DON stated the first set of vitals were obtained on the floor and then once the patient was moved they continued vitals and the neuro checks. The DON stated the entire team which consisted of the doctor, DON, and administrator were notified when a resident fell . The DON stated if an injury was involved after a fall, and they felt like it was not safe to move the resident then they called emergency medical services [ems] to take them to the hospital. The DON stated with resident 28's fall, they did notice a visible deformity to their lower extremity and that was why they called ems. The DON stated resident 28 was very fixated on their pain at the time and was unable to tell them what had occurred due to that. The DON stated resident 28 might have been confused at the time due to their oxygen being off. The DON stated they had done an investigation into resident 28's fall and determined there was no neglect or abuse involved. The DON stated at the time of the fall, the CNA had just been in resident 28's room about 15-20 minutes ago. The DON stated they knew resident 28 had been in a safe position and had their oxygen on when the CNA had left the room. The DON stated the same CNA had gone into the room and found them on the floor 15 minutes later. The DON stated they were unsure how resident 28 had fallen. The DON stated the previous administrator at the time had been notified of resident 28's fall.

Based on observation, interview and record review, it was determined for 4 out of 13 sampled residents, that the facility failed to ensure that the residents received food prepared in a form designed to meet their individual needs. Specifically, a resident received and partially consumed a meal that had not been mechanically altered per the physician orders which resulted in the resident choking on the food and requiring emergency medical attention. Additionally, 3 other residents received and/or consumed meals that were not mechanically altered per the physician orders. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. Resident identifier: 1, 5, 6, and 14. NOTICE On [DATE] at 4:30 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to observe meals and food preparation to assure the food was prepared and appropriate to meet the resident's needs according to their assessment and care plan. Specifically, the facility failed to ensure that residents who were evaluated for and prescribed a mechanically altered diet had those diet modifications implemented; and were monitored and supervised to ensure the appropriate food preparation and delivery of the prescribed modified diet texture. Notice of IJ was given verbally to the facility Administrator (ADM), Director of Nursing (DON), the Corporate Resource Nurse (CRN) 2, and the Regional Administrator. On [DATE] at 10:01 PM, the facility provided the following written abatement plan for the removal of the Immediate Jeopardy effective on [DATE] at 2:00 PM. IJ Abatement Plan For F805 and F689 at Alpine Meadow Rehabilitation and Nursing [DATE] Immediate Actions Taken to Correct Deficient Practices Administrator has hired a Certified Dietary Manager who is competently trained and educated on therapeutic/mechanically altered diets and the menu system who will take on the role of dietary manager effective [DATE] at 0600 [6:00 AM]. On [DATE], a Diet and Tray Card audit was completed by the regional nurse consultant to ensure that correct physician prescribed diet orders in PointClickCare match the meal tickets in Nutrition Management. Beginning on [DATE] at lunch meal, regional nurse consultant implemented a Therapeutic Diet audit to be completed for all residents with mechanically altered diet textures at all meals by the regional nurse consultant or appropriately trained and competent designee to ensure correct physician prescribed diet orders are followed to prevent further harm to any residents. Measures to Ensure the Deficient Practice Does Not Recur Regional nurse consultant will complete an inservice on [DATE] by 2 PM with all nursing, dietary, activity and social service staff on requirements for their respective departments regarding resident diet orders and meal tray delivery to residents, including the different types of diets offered at the facility and how to recognize and verify each type of diet before serving the diet to each resident. Administrator will print and laminate visual aids with information on all diet types offered at the facility that will be placed at each nursing station, aide station, on each meal cart and in the kitchen for ease of reference by nursing, dietary, activity and social service staff. To be completed [DATE] by 2 PM. Speech language pathologist (SLP) will complete a screen and/or evaluation as indicated with all residents on mechanically altered diets to verify that each resident has the correct physician prescribed diet type in place. Any recommendations for diet type changes will be referred to the Medical Director for approval before the diet order is changed. To be completed [DATE] by 2 PM. Beginning [DATE], regional nurse consultant or appropriately trained and competent designee will complete a Therapeutic Diet audit for all residents with mechanically altered diet textures at all meals daily x [times] 2 weeks then at one meal daily Monday through Friday x 2 weeks to ensure correct physician prescribed diet orders are followed to prevent further harm to any residents. Beginning [DATE], Human Resources Director (HR) will complete a New Hire audit for all newly hired employees daily Monday through Friday x 4 weeks in the nursing, dietary, social service and activity department and verify that the appropriate competency checklist is completed before the end of the on-boarding process. Measures to Monitor and Ensure Corrective Action is Achieved and Sustained QAA [Quality Assurance Assessment] committee under the direction of the administrator will review the findings from the Therapeutic Diet audit and New Hire audit monthly until a lesser frequency is determined to be appropriate. Any ongoing problems with residents of the facility receiving the correct physician prescribed diet order or the facility's training process for new staff regarding resident diet orders and meal tray delivery to residents will be addressed with modifications to the plan of correction implemented at the direction of the QAA committee. Findings included: IMMEDIATE JEOPARDY 1. Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of paranoid schizophrenia, dysphagia, anorexia, adult failure to thrive, and pneumonitis. On [DATE], the Annual Minimum Data Set (MDS) assessment of resident 1 documented a Brief Interview for Mental Status (BIMS) score of ,d+[DATE], which would indicate a severe cognitive impairment. Facility staff assessed resident 1 as having hallucinations. Facility staff assessed that resident 1 required supervision with set up help only for eating. The assessment documented that resident 1 had a swallowing disorder with loss of liquids from the mouth when eating or drinking, holding food in mouth or cheek or residual food in mouth after meals, and coughing or choking during meals or when swallowing medication. Review of resident 1's physician orders revealed a diet order for a pureed texture diet that was initiated on [DATE]. On [DATE], resident 1's diet order was changed to a pureed texture diet with honey thick liquids. Review of resident 1's progress notes revealed the following: a. On [DATE] at 11:00 AM, the progress note documented, SLP completed initial observation/evaluation of resident yesterday. SLP reports resident drank thin water and ate a cup of pudding without any overt s/s [signs and symptoms] difficulty swallowing. Resident was impulsive during the eval and did not follow prompts or cues to take single sips of water when given. He reported, 'I am,' demonstrating a lack of insight or cognitive ability to process the instructions. He also reported to SLP that he couldn't eat pudding after finishing the cup of pudding and did not demonstrate understanding or insight when SLP drew his attention to the fact that he had just eaten a cup of pudding. It remains unclear if resident's inability to eat is related to lack of dentition and unwillingness to eat a downgraded diet texture or if there is an element of dysphagia as well. An MBS [modified barium swallow] has been scheduled for Friday for further evaluation. SLP plans to observe resident eat lunch today and will keep facility staff apprised of any recommended changes to resident's plan of care. b. On [DATE] at 3:35 PM, the MD progress note documented, [Resident 1] is a [AGE] year old male with paranoid schizophrenia who was admitted to the [name of hospital omitted] ,d+[DATE] due to failure to thrive. He had been losing weight due to poor oral intake. Teeth had been removed but he had healed and no swallowing issues were identified. He had a fixed delusion that he could not swallow because of his missing teeth. At the [hospital] he was started on a pureed diet. They reported he at [sic] this well. c. On [DATE] at 6:32 PM, the progress note documented, CNA [Certified Nurse Assistant] asked if RN would come into the room and assist her. RN went to assess what had happened. RN walked in and saw drops of blood on the floor, RN saw resident on his knees on the floor and with his head on head on the bed. Resident lifted his head up and RN saw a string of clotted blood. RN went to get supplies to clean wound. Resident took off his glasses, RN asked resident what had happened. Resident sat himself up and sat himself on his bed. RN asked CNA to obtain another CNA for assistance. Other CNA came in; RN noticed resident started to cough. RN noticed food in his mouth; resident pulled out pork from dinner out of his mouth, resident started coughing more. RN asked resident if he was able to breathe; resident kept coughing and unable to answer RN. RN started the Heimlich, CNA took over and RN called 911. Resident was going in and out of consciousness; CNA assessed pulse and CNA informed RN that pulse was not present, CNA started CPR, CNA did break ribs. Resident came out of consciousness, RN an CNA's [sic] were back blowing, RN during this time is getting instructions from 911 operator. At one point 911 operator was instructing RN to apply AED [automated external defibrillator] pads, RN informed 911 operator that resident was in and out of consciousness and didn't want to apply it; RN assessed residents pulse, resident had a pulse, resident was breathing, residents eyes were open. Paramedics arrived and take over. Paramedics took resident to ER; RN gave face sheet and med list. RN called and informed MD. d. On [DATE] at 9:57 PM, the progress note documented, At approximately 9:50 pm I called [local hospital] to get an update on patient. RN reported patient is currently stable, they did a food extraction just above his epiglottis with mild sedation. Patient is stable and will be admitted for pneumonia. On [DATE], the SLP evaluation documented that resident 1 had a recent onset of difficulty with chewing due to recent loss of some teeth. Resident 1 attributed all swallowing difficulty to decreased ability to chew and that resident 1 endorsed he could not chew complex texture foods and had been declining in overall oral intake. The oral peripheral exam documented impairments to the mandibular range of motion (ROM), mandibular strength/tone and mandibular coordination. The exam documented an impairment to the lingual sensation/function. The exam documented that the laryngeal/pharyngeal performance was impaired with the reflexive cough strangled and wet and the volitional throat clearance as strangled. The clinical bedside assessment of swallowing documented, Pt [patient] p/w [presented with] clinical s/s of aspiration during thin liquid PO [by mouth] trials via sequential straw sip. Pt noted to be impulsive, continue to drink thin liquid while simultaneously coughing. Pt with persistent cough following PO intake of thins, with pt endorsing choking on thin liquids. The assessment further documented, Pt p/w delayed cough following sequential PO intake of puree (pudding) consistencies. Pt with strong hyolarygeal elevation w/ [with] PO intake, however, pt with wet vocal quality and delayed cough. The assessment summary documented, Patient presents with moderate oropharyngeal dysphagia characterized by decreased mandibular ROM/strength, decreased lingual ROM/strength, decreased safety awareness w/PO intake, decreased overall PO intake which necessitates skilled SLP services for dysphagia to analyze pharyngeal function, analyze oral function, assess/evaluate for safest level of oral intake, develop and instruct in compensatory strategies, maximize nutrition/hydration with oral motor facilitation and minimize risk of weight loss with swallow analysis in order to improve ability to decrease risk of malnutrition/weight loss, safely consume highest level of oral intake and safely swallow without signs/symptoms of aspiration. On [DATE], resident 1's SLP Discharge summary documented that resident 1 was discharged to the hospital and they were unable to complete the modified barium swallow study on site. On [DATE], the menu documented country style pork ribs, potato salad, mixed vegetables, peach jello, and a salad were scheduled. On [DATE], the hospital discharge summary documented that resident 1 was given the wrong plate of food at dinner in the facility. He was given a regular consistency instead of a pureed diet. The summary documented resident 1 ' s diagnosis as aspiration pneumonia secondary to foreign body aspiration of his dinner. The History of Present Illness documented that the facility DON reported that resident 1 had an order for a pureed diet but was served the wrong plate of food at dinner this evening. The resident aspirated the food, lost consciousness and a staff member performed the Heimlich maneuver that was unsuccessful. They also performed CPR and when EMS [emergency medical services] arrived the patient was found to be hypoxic but with a pulse. In the ER [emergency room ] patient was given ketamine and the food was retrieved from his trachea. ER physician reports he had stridorous respirations off and on and there was a high suspicion that there is still material in the lower trachea. The director of nursing reported the patient had multiple teeth extracted earlier this year and ever since then has had dysphagia and was treated for aspiration pneumonia on [DATE]th. It was determined in May of this year that he needed a feeding tube but he refused .Also noted that patient has excessive secretions the oropharynx and is likely chronically aspirating his secretions. The discharge summary documented that on [DATE] resident 1 underwent a barium swallow and failed the test. He was explained that he needs a feeding tube to prevent further aspiration events. Patient does not believe he has aspirated, does not believe he has pneumonia He says he absolutely refuses to have a feeding tube placed. He wants to eat and go home. Representative from his facility came to see patient. They discussed hospice and he decided he wants to go home on hospice. He wants abx [antibiotics] and o2 [oxygen] discontinued and asked code status to be changed to DNR [Do Not Resuscitate]. On [DATE], resident 1 had a care plan for at risk for nutritional status initiated. Interventions identified included to monitor/document/report any signs and symptoms of dysphagia such as Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing; to provide and serve the diet as ordered; Registered Dietician to evaluate and make diet change recommendations; and staff to provide supervision and encouragement with meals as needed. 2. Resident 6 was admitted to the facility on [DATE] with diagnoses which consisted of, but were not limited to, type 2 diabetes mellitus, pain, dementia, pulmonary hypertension, nonrheumatic aortic valve stenosis, orthostatic hypotension, atrial fibrillation, presence of cardiac pacemaker, hypertension, and mild cognitive impairment. On [DATE], resident 6's Quarterly MDS Assessment documented a BIMS score of 15 which would indicate that the resident was cognitively intact. The assessment documented that resident 6 required supervision with set-up help for eating, and that resident 6 had a swallowing disorder with symptoms of holding food in the mouth/cheeks or residual food in the mouth after meals. Review of resident 6's physician orders revealed a diet order for a regular diet mechanical soft texture, think liquids consistency that was initiated on [DATE]. On [DATE], resident 6 had a care plan for at risk for altered nutrition status due to edentulous status with mechanical altered texture required for ease of chewing initiated. Interventions identified included monitor/document/report any signs and symptoms of dysphagia such as Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing; to provide and serve the diet as ordered; and the Registered Dietician to evaluate and make diet change recommendations as needed. 3. Resident 5 was admitted to the facility on [DATE] with diagnoses of dementia, emphysema, hypertension, alcohol abuse, and malignant neoplasm of pancreas. On [DATE], resident 5's Quarterly MDS Assessment documented a BIMS score of ,d+[DATE], which would indicate a severe cognitive impairment. The assessment documented that resident 5 required a one person physical assist with supervision for eating. The assessment documented that resident 5 had a swallowing disorder with symptoms of holding food in the mouth/cheeks or residual food in the mouth after meals. Review of resident 5's physician orders revealed a diet order for a regular diet chopped texture, thin liquids consistency that was initiated on [DATE]. On [DATE], resident 5 had a physician order for SLP to evaluate for possible diet texture upgrade. No documentation could be found of the SLP evaluation. On [DATE], resident 5 had a care plan for at risk for altered nutrition status related to medical condition initiated. Interventions identified included monitor/document/report any signs and symptoms of chewing swallowing problems related to dysphagia or oral health problems such as Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing; to provide and serve the diet as ordered; and the Registered Dietician to evaluate and make diet change recommendations as needed. 4. Resident 14 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, benign paroxysmal vertigo, dementia, obstructive sleep apnea, and low back pain. On [DATE], resident 14's Quarterly MDS Assessment documented that a BIMS score was not obtained due to the resident was rarely/never understood. The assessment documented that resident 14 required a one person extensive physical assist for eating. The assessment documented that resident 14 had a swallowing disorder with symptoms of loss of liquids/solids from mouth when eating or drinking; holding food in mouth/cheeks or residual food in mouth after meals; and coughing or choking during meals or when swallowing medications. Review of resident 14's physician orders revealed a diet order for a regular diet minced and moist texture, thin liquids consistency that was initiated on [DATE]. On [DATE], resident 14 had a care plan for at risk for malnutrition initiated. Interventions identified included monitor/document/report any signs and symptoms of chewing swallowing problems related to dysphagia or oral health problems such as Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing; refer to SLP or dentist as indicated to address dysphagia; to provide and serve the diet as ordered; and the Registered Dietician to evaluate and make diet change recommendations as needed. On [DATE] at 11:33 AM, an interview was conducted with the Dietary Manager (DM) 2. The DM 2 stated that the kitchen staff were responsible for plating resident meal trays, but nursing staff were responsible for delivering the trays to residents. On [DATE] at 12:15 PM, an interview was conducted with the hospitality aide. The hospitality aide was observed delivering food trays to residents in their rooms. The hospitality aide stated she passed out meal trays to residents often. The hospitality aide stated she would check the diet card on the resident's food tray for their preferences and put a drink on the resident's tray. Several cups of fluid were observed on top of the food cart. The hospitality aide further stated she does not look on the diet card to see if a resident was on thickened liquids or any special diet before giving the food tray to the resident and that she only looked at the resident's preferences. The hospitality aide stated the kitchen would know the diet and takes care of that. On [DATE] at 12:17 PM, an observation was made of CNA 1 delivering food to resident 6's room. The resident diet ticket documented a mechanical soft diet with thin liquids. Resident 6's meal was observed as shrimp tacos with refried pinto beans. The taco was made with a corn tortilla and a shredded cabbage topping. Resident 1 refused the meal and stated she did not like shrimp. On [DATE] at 12:17 PM, an observation was made of resident 5 sitting at a table in the dining room eating lunch. The dietary manager (DM 2) approached resident 5 and removed his plate. The plate had 2 whole corn tortillas and 1 uncut shrimp. An interview was conducted with DM 2 at 12:18 PM. DM 2 stated the uncut shrimp on resident 5's plate was a regular texture diet. DM 2 stated a chopped diet would have no tortillas or shrimp. Resident 5's meal ticket documented regular chopped thin liquids diet. On [DATE] at 12:39 PM, an observation was made of resident 1's meal tray. Resident 1's meal ticket documented a pureed diet texture with honey thick liquids. Resident 1's meal was observed as a regular diet with shrimp tacos with shredded cabbage on a corn tortilla and refried beans. CNA 1 identified the incorrect diet order and returned the meal tray to the kitchen. On [DATE] at 12:57 PM, an interview was conducted with CNA 1. CNA 1 stated that she had worked at the facility for a long time and she should have looked at the meal ticket to identify the diet before delivering the tray to resident 6. On [DATE] at 3:24 PM, a telephone interview was conducted with Licensed Nurse (LN) 1. LN 1 stated that on [DATE] resident 1 was found on the floor with his elbows on the bed. Resident 1 had dried blood on his forehead. LN 1 stated she obtained supplies to clean resident 1's wound. Resident 1 was assisted to bed and was sitting up in bed when he started to cough. LN 1 stated that resident 1 was attempting to clear his airway. LN 1 stated that she observed pork inside resident 1's mouth. LN 1 stated she asked resident 1 if he was choking and he did not respond. LN 1 stated that she performed the Heimlich maneuver and the aide took over while she called 911 and checked the resident's code status. LN 1 stated that they were also giving back blows to resident 1. LN 1 stated that the aide identified that resident 1 did not have a pulse, the resident was blue/gray in color and they began chest compressions. LN 1 stated that resident 1 became responsive and opened his eyes and CPR was stopped. LN 1 stated that EMTs [Emergency Medical Technicians] arrived and suctioned resident 1's airway and transported him to the emergency room . LN 1 stated that the aide removed a piece of pork that was hanging out of resident 1's lip. LN 1 stated that resident 1 was supposed to have a pureed diet texture and when she looked at the resident's meal tray it was a regular texture diet of pork and mashed potatoes. LN 1 stated that the kitchen had made resident 1 two dinner trays and when resident 1 saw the regular tray had told the CNA that he wanted to eat that one instead of the pureed diet. LN 1 stated that none of the aides had reported the diet change to her. LN 1 stated that the aides should know that resident 1 was to have a pureed diet because it was noted on his meal ticket. LN 1 stated that the aides should have notified her when resident 1 requested a regular diet. On [DATE] at 3:51 PM, an interview was conducted with the Registered Dietician (RD). The RD stated they put together a weekly extension of the meals that detailed the modified diet and this showed the kitchen staff what modifications should be made to the diet for the different textures. The RD stated that DM should be able to print off the menu system with the extensions. The RD stated that the DM 2 was new and she provided training to him last week on the menu and the extensions for different diet textures. The RD stated that as a consultant she was in the facility one time a week. The RD stated that the previous DM 1 was an assistant DM at a sister facility and she had interacted with him 2 or 3 times. The RD stated that she checked in on DM 1 to see how he was doing. The RD stated that DM 1 did not attend the nutrition at risk meetings but they encouraged the DM to attend them also. The RD stated that she did not recall having any concerns with DM 1 and did not address the diets and extensions for textures. The RD stated that her understanding was that DM 1 was familiar with the menu system, diets, and textures. The RD stated that she completed audits every 30 days unless deemed more frequently. The RD stated that she had been auditing more frequently due to reports that residents were requesting different diets from their speech therapy (ST) evaluation. The RD stated that she did not change the diet order and that the ST was to evaluate the resident to see what the appropriate diet would be. On [DATE] at 4:16 PM, an interview was conducted with the DM 2. DM 2 stated that he had been doing the online training and had been provided some education by the RD. DM 2 stated that he and the RD had gone over the mechanically altered diet textures and how to identify the differences. DM 2 stated that before meal service he separated the different textured diets into piles so that he could do all one texture at a time and could plate them according to the meal ticket. The DM 2 stated that either himself, the dietary aide (DA) 3, or the hospitality aide plated the food in the kitchen. DM 2 stated that the hospitality aide had her food handlers permit and was allowed to assist in the kitchen. DM 2 stated that at the time of plating he had the meal ticket under the heat lamp so that he could visualize the therapeutic meal texture. DM 2 stated that he was informed of one meal at lunch time that one meal was plated wrong and not according to the meal ticket and diet order. DM 2 stated that it was supposed to be a pureed diet plated was a chopped diet. DM 2 stated that he did not see the returned meal and could not recall which resident the meal was for. On [DATE] at 5:13 PM, an observation was conducted of resident 14 eating dinner in the dining room with the Corporate Resource Nurse (CRN) 1 assisting. Resident 14 was observed eating a baked roll that was dry and cut into bite-sized pieces, green beans, and ziti noodles with red sauce. Resident 14's meal ticket indicated Minced & Moist MM5. On [DATE] at 7:57 AM, a telephone interview was conducted with a Speech Language Pathologist (SLP). The SLP stated that a corn tortilla, salad texture and whole shrimp was a regular diet texture. The SLP stated that a mechanical soft diet was like a sloppy [NAME], a minced and moist was chopped with a gravy over top to bring more moisture into the food, and a mechanical soft was chopped. The SLP stated that she did not conduct an evaluation for resident 5 and resident 6. On [DATE] at 8:35 PM, a follow-up interview was conducted with the DON. The DON stated that resident 6 had a diet order for a mechanical soft texture diet because of her teeth and difficulty with chewing. The DON stated that resident 6's dentures were being refitted currently. The DON stated that resident 6 had been on a mechanical soft diet since being admitted and she had issues with her shoulder so she could not cut her food independently. The DON stated that resident 5 had a stroke, did not have any teeth and did not want any dentures and that was the rationale for the chopped texture diet order. The DON stated that resident 5 had not been evaluated by the SLP for any swallowing difficulties. The DON stated that diets were reviewed in the Nutrition at Risk (NAR) meetings and recommendations for changes to the diet order could be referred to the MD for any changes to the diet orders. The DON stated that the DM could then make changes to the diet order in the electronic medical records, but that DM 1 did not have access to the risk management and was unable to put diet orders into the electronic medical records. The DON stated that on [DATE] resident 1 had received a regular meal tray with pork on it and the kitchen had prepared the incorrect diet order for the resident. The DON stated that she had argued with DM 1 several times because the residents were asking for different diet textures and he was providing the residents their requests, and that he had done this at his previous facility. The DON stated that she informed DM 1 that he needed to provide the residents with the diet that was ordered or else talk to her about any diet changes. The DON stated that she did not have any concerns with diet changes prior to the incident with resident 1. The DON stated that LN 1 had reported to her that DM 1 did not like LN 1 and DM 1 had told LN 1 that he could give the resident's whatever he wanted. The DON stated that DM 1 was let go because of the incident with resident 1 and she was not okay with him changing the diet orders especially since she had provided him with education regarding this prior to the incident with resident 1. The DON stated she instructed DM 1 to follow the meal ticket, and that they could have the resident evaluated by the SLP for a diet change and then notify the MD. The DON stated that DM 1 did not bring the subject back up with her because her instructions were very specific, you need to follow the diet orders. The DON stated that she had to depend on him to follow his training, but that DM 1 was not certified. The DON stated that the staff were educated on checking the meal ticket for the diet order and then checking the meal tray to verify that it was the correct diet per the orders. The DON stated that the staff were educated to know what a mechanical soft or chopped diet looked like and that this training was completed upon hire. The DON stated that after resident 1's choking incident she and the ADM, and DM 2 had training with the RD on how to put diet orders into the electronic medical records and how to verify and check those orders. The DON stated that the meal trays should not be coming out of the kitchen plated wrong against the diet orders now. On [DATE] at 9:55 AM, an interview was conducted with the ADM. The ADM stated that education on ITSY [International Dysphagia Standardization Initiative] was provided to the kitchen staff and should be provided to the CNA Coordinator. The ADM stated that it would be the CNA coordinator should go through the education with her staff. However, the ADM stated that he had been trying to hire a new CNA Coordinator for months now. The ADM stated that education was not provided to the CNA staff in the interim during the hiring process. The ADM stated that diet education was provided by the RD to the DON, ADON, Transportation staff, and himself. The ADM stated that DM 2 would provide education to the kitchen staff. The ADM stated that he was auditing the diets for the textures, and personally viewed every meal service for a week after the incident with resident 1. The ADM stated that he also worked with the RD to verify that all diet orders were correct. The ADM stated that he was initiating audits again today. On [DATE] at 11:00 AM, an interview was conducted with CNA 2. CNA 2 stated that she had been hired last Wednesday, [DATE]th 2023. CNA 2 stated that she had been trained on her first day to look at meal tickets when delivering meals to ensure that each resident received the correct meal. On [DATE] at 11:05 AM, an interview was conducted with CNA 1. CNA 1 stated that she had received training about delivering the correct diet order to residents prior to the beginning of the complaint survey on [DATE]. CNA 1 stated that she was supposed to ensure meal tickets matched the meal tray delivered to each resident. CNA 1 also described the differences between a puree diet, a mechanical soft diet, and a regular diet. A puree diet was pureed, a mechanical soft diet was chopped up, and a regular diet was normal. On [DATE] at 11:14 AM, an interview was conducted with Dietary Aide (DA) 1. DA 1 stated that she had been working at the facility for three days. DA 1 listed the different types of diets available at the facility: Regular, mechanical soft, and puree. DA 1 was unable to describe the differences between the different diets offered by the kitchen. On ,d+[DATE] [TRUNCATED]

Based on observation, interview and record review, it was determined for 4 out of 13 sampled residents, that the facility failed to ensure that the residents environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident received and partially consumed a meal that had not been mechanically altered per the physician orders which resulted in the resident choking on the food and requiring emergency medical attention. Additionally, 3 other residents received and/or consumed meals that were not mechanically altered per the physician orders. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. Resident identifier: 1, 5, 6, and 14. NOTICE On [DATE] at 4:30 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to identify hazard(s) and risk(s); evaluate and analyze the hazard(s) and risk(s); implement interventions to reduce the hazard(s) and risk(s); and monitor for effectiveness and modify the interventions when necessary. Specifically, the facility failed to ensure that residents who were evaluated for and prescribed a mechanically altered diet had those diet modifications implemented to reduce the hazard(s) and risk(s); were monitored to ensure the effectiveness of those interventions; were supervised for the appropriate preparation and delivery of the prescribed modified diet texture to reduce or eliminate the hazard(s) and risk(s); and were monitored and modified when necessary in accordance with current professional standards of practice. Notice of IJ was given verbally to the facility Administrator (ADM), Director of Nursing (DON), the Corporate Resource Nurse (CRN) 2, and the Regional Administrator. On [DATE] at 10:01 PM, the facility provided the following written abatement plan for the removal of the Immediate Jeopardy effective on [DATE] at 2:00 PM. IJ Abatement Plan For F805 and F689 at Alpine Meadow Rehabilitation and Nursing [DATE] Immediate Actions Taken to Correct Deficient Practices Administrator has hired a Certified Dietary Manager who is competently trained and educated on therapeutic/mechanically altered diets and the menu system who will take on the role of dietary manager effective [DATE] at 0600 [6:00 AM]. On [DATE], a Diet and Tray Card audit was completed by the regional nurse consultant to ensure that correct physician prescribed diet orders in PointClickCare match the meal tickets in Nutrition Management. Beginning on [DATE] at lunch meal, regional nurse consultant implemented a Therapeutic Diet audit to be completed for all residents with mechanically altered diet textures at all meals by the regional nurse consultant or appropriately trained and competent designee to ensure correct physician prescribed diet orders are followed to prevent further harm to any residents. Measures to Ensure the Deficient Practice Does Not Recur Regional nurse consultant will complete an inservice on [DATE] by 2 PM with all nursing, dietary, activity and social service staff on requirements for their respective departments regarding resident diet orders and meal tray delivery to residents, including the different types of diets offered at the facility and how to recognize and verify each type of diet before serving the diet to each resident. Administrator will print and laminate visual aids with information on all diet types offered at the facility that will be placed at each nursing station, aide station, on each meal cart and in the kitchen for ease of reference by nursing, dietary, activity and social service staff. To be completed [DATE] by 2 PM. Speech language pathologist (SLP) will complete a screen and/or evaluation as indicated with all residents on mechanically altered diets to verify that each resident has the correct physician prescribed diet type in place. Any recommendations for diet type changes will be referred to the Medical Director for approval before the diet order is changed. To be completed [DATE] by 2 PM. Beginning [DATE], regional nurse consultant or appropriately trained and competent designee will complete a Therapeutic Diet audit for all residents with mechanically altered diet textures at all meals daily x [times] 2 weeks then at one meal daily Monday through Friday x 2 weeks to ensure correct physician prescribed diet orders are followed to prevent further harm to any residents. Beginning [DATE], Human Resources Director (HR) will complete a New Hire audit for all newly hired employees daily Monday through Friday x 4 weeks in the nursing, dietary, social service and activity department and verify that the appropriate competency checklist is completed before the end of the on-boarding process. Measures to Monitor and Ensure Corrective Action is Achieved and Sustained QAA [Quality Assurance Assessment] committee under the direction of the administrator will review the findings from the Therapeutic Diet audit and New Hire audit monthly until a lesser frequency is determined to be appropriate. Any ongoing problems with residents of the facility receiving the correct physician prescribed diet order or the facility's training process for new staff regarding resident diet orders and meal tray delivery to residents will be addressed with modifications to the plan of correction implemented at the direction of the QAA committee. Findings included: IMMEDIATE JEOPARDY 1. Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of paranoid schizophrenia, dysphagia, anorexia, adult failure to thrive, and pneumonitis. On [DATE], the Annual Minimum Data Set (MDS) assessment of resident 1 documented a Brief Interview for Mental Status (BIMS) score of ,d+[DATE], which would indicate a severe cognitive impairment. Facility staff assessed resident 1 as having hallucinations. Facility staff assessed that resident 1 required supervision with set up help only for eating. The assessment documented that resident 1 had a swallowing disorder with loss of liquids from the mouth when eating or drinking, holding food in mouth or cheek or residual food in mouth after meals, and coughing or choking during meals or when swallowing medication. Review of resident 1's physician orders revealed a diet order for a pureed texture diet that was initiated on [DATE]. On [DATE], resident 1's diet order was changed to a pureed texture diet with honey thick liquids. Review of resident 1's progress notes revealed the following: a. On [DATE] at 10:26 AM, the progress note documented that resident 1 returned from a dental appointment after having 6 teeth extracted without complications. The note documented that the dentist recommended cool soft foods today. b. On [DATE] at 10:26 AM, the progress note documented, Resident has multiple teeth extracted on [DATE]. He has been offered a soft or puree diet as a result of dental extractions, which the resident has refused. he is very particular about the food he will accept. c. On [DATE] at 11:00 AM, the progress note documented, SLP completed initial observation/evaluation of resident yesterday. SLP reports resident drank thin water and ate a cup of pudding without any overt s/s [signs and symptoms] difficulty swallowing. Resident was impulsive during the eval and did not follow prompts or cues to take single sips of water when given. He reported, 'I am,' demonstrating a lack of insight or cognitive ability to process the instructions. He also reported to SLP that he couldn't eat pudding after finishing the cup of pudding and did not demonstrate understanding or insight when SLP drew his attention to the fact that he had just eaten a cup of pudding. It remains unclear if resident's inability to eat is related to lack of dentition and unwillingness to eat a downgraded diet texture or if there is an element of dysphagia as well. An MBS [modified barium swallow] has been scheduled for Friday for further evaluation. SLP plans to observe resident eat lunch today and will keep facility staff apprised of any recommended changes to resident's plan of care. d. On [DATE] at 11:52 AM, the progress note documented, Notified MD [Medical Director] and RD [Registered Dietician] of resident's weight loss and refusal of mechanical soft or puree diet. RD recommended to offer house supplement and ice cream as much as he'll accept, and to offer foods that are soft and tolerable. e. On [DATE] at 4:14 PM, the progress note documented, [Medical Director] requests that an appointment be made with resident's mental health provider at the [hospital name omitted]. It is suspected that there may be a mental health component associated with resident's recent change in thought processes around foods that he can or cannot tolerate. Even foods that he has previously tolerated well, such as med pass, pudding, cereal, etc., he will no longer eat. Transportation coordinator will make an appointment for the soonest the [hospital name] can accommodate. f. On [DATE] at 3:35 PM, the MD progress note documented, [Resident 1] is a [AGE] year old male with paranoid schizophrenia who was admitted to the [name of hospital omitted] ,d+[DATE] due to failure to thrive. He had been losing weight due to poor oral intake. Teeth had been removed but he had healed and no swallowing issues were identified. He had a fixed delusion that he could not swallow because of his missing teeth. At the [hospital] he was started on a pureed diet. They reported he at [sic] this well. g. On [DATE] at 5:40 PM, the progress note documented, Resident is not eating meals despite puree texture. Resident has c/o [complaints of] that he cannot chew food. Resident will drink fluids, he gulps liquids and must be reminded to slow down and to breath. Used a straw and that seamed to help. h. On [DATE] at 1:19 PM, the progress note documented, Residents STAT CXR [immediate chest x-ray] results came back, Impression: RIGHT LOWER LOBE INTERSTITIAL PNEUMONIA. IS NEW COMPARED TO CXR DONE ON [DATE]. RN [Registered Nurse] informed in house MD of results. MD wondered if resident may have aspirated and questioned if he had his swallow study completed by ST [Speech Therapist]. When resident was refusing foods last month speech therapy saw him. Resident wasn't compliant enough to get a thorough assessment done; they then planned to do a MBS but was then sent out to the hospital a day before MBS was suppose to be done. MD requested we pursue that route again; DON stated that ST will see him. i. On [DATE] at 9:20 AM, the progress note documented, Resident is still having episodes of coughing w/ [with] phlegm. Resident is unable to voice to RN if he is able to clear secretions properly. j. On [DATE] at 6:32 PM, the progress note documented, CNA [Certified Nurse Assistant] asked if RN would come into the room and assist her. RN went to assess what had happened. RN walked in and saw drops of blood on the floor, RN saw resident on his knees on the floor and with his head on head on the bed. Resident lifted his head up and RN saw a string of clotted blood. RN went to get supplies to clean wound. Resident took off his glasses, RN asked resident what had happened. Resident sat himself up and sat himself on his bed. RN asked CNA to obtain another CNA for assistance. Other CNA came in; RN noticed resident started to cough. RN noticed food in his mouth; resident pulled out pork from dinner out of his mouth, resident started coughing more. RN asked resident if he was able to breathe; resident kept coughing and unable to answer RN. RN started the Heimlich, CNA took over and RN called 911. Resident was going in and out of consciousness; CNA assessed pulse and CNA informed RN that pulse was not present, CNA started CPR, CNA did break ribs. Resident came out of consciousness, RN an CNA's [sic] were back blowing, RN during this time is getting instructions from 911 operator. At one point 911 operator was instructing RN to apply AED [automated external defibrillator] pads, RN informed 911 operator that resident was in and out of consciousness and didn't want to apply it; RN assessed residents pulse, resident had a pulse, resident was breathing, residents eyes were open. Paramedics arrived and take over. Paramedics took resident to ER; RN gave face sheet and med list. RN called and informed MD. k. On [DATE] at 9:57 PM, the progress note documented, At approximately 9:50 pm I called [local hospital] to get an update on patient. RN reported patient is currently stable, they did a food extraction just above his epiglottis with mild sedation. Patient is stable and will be admitted for pneumonia. l. On [DATE] at 11:00 PM, the progress noted for the date of service of [DATE] documented, Resident has returned from the hospital on palliative care. We will continue to monitor. We will likely order comfort meds to have available should the patient need them. He is having difficulty swallowing is still a high aspiration risk. On [DATE], the SLP evaluation documented that resident 1 had a recent onset of difficulty with chewing due to recent loss of some teeth. Resident 1 attributed all swallowing difficulty to decreased ability to chew and that resident 1 endorsed he could not chew complex texture foods and had been declining in overall oral intake. The oral peripheral exam documented impairments to the mandibular range of motion (ROM), mandibular strength/tone and mandibular coordination. The exam documented an impairment to the lingual sensation/function. The exam documented that the laryngeal/pharyngeal performance was impaired with the reflexive cough strangled and wet and the volitional throat clearance as strangled. The clinical bedside assessment of swallowing documented, Pt [patient] p/w [presented with] clinical s/s of aspiration during thin liquid PO [by mouth] trials via sequential straw sip. Pt noted to be impulsive, continue to drink thin liquid while simultaneously coughing. Pt with persistent cough following PO intake of thins, with pt endorsing choking on thin liquids. The assessment further documented, Pt p/w delayed cough following sequential PO intake of puree (pudding) consistencies. Pt with strong hyolarygeal elevation w/ [with] PO intake, however, pt with wet vocal quality and delayed cough. The assessment summary documented, Patient presents with moderate oropharyngeal dysphagia characterized by decreased mandibular ROM/strength, decreased lingual ROM/strength, decreased safety awareness w/PO intake, decreased overall PO intake which necessitates skilled SLP services for dysphagia to analyze pharyngeal function, analyze oral function, assess/evaluate for safest level of oral intake, develop and instruct in compensatory strategies, maximize nutrition/hydration with oral motor facilitation and minimize risk of weight loss with swallow analysis in order to improve ability to decrease risk of malnutrition/weight loss, safely consume highest level of oral intake and safely swallow without signs/symptoms of aspiration. On [DATE], resident 1's SLP Discharge summary documented that resident 1 was discharged to the hospital and they were unable to complete the modified barium swallow study on site. On [DATE], the menu documented country style pork ribs, potato salad, mixed vegetables, peach jello, and a salad were scheduled. On [DATE], the hospital discharge summary documented that resident 1 was given the wrong plate of food at dinner in the facility. He was given a regular consistency instead of a pureed diet. The summary documented resident 1 ' s diagnosis as aspiration pneumonia secondary to foreign body aspiration of his dinner. The History of Present Illness documented that the facility DON reported that resident 1 had an order for a pureed diet but was served the wrong plate of food at dinner this evening. The resident aspirated the food, lost consciousness and a staff member performed the Heimlich maneuver that was unsuccessful. They also performed CPR and when EMS [emergency medical services] arrived the patient was found to be hypoxic but with a pulse. In the ER [emergency room ] patient was given ketamine and the food was retrieved from his trachea. ER physician reports he had stridorous respirations off and on and there was a high suspicion that there is still material in the lower trachea. The director of nursing reported the patient had multiple teeth extracted earlier this year and ever since then has had dysphagia and was treated for aspiration pneumonia on [DATE]th. It was determined in May of this year that he needed a feeding tube but he refused .Also noted that patient has excessive secretions the oropharynx and is likely chronically aspirating his secretions. The discharge summary documented that on [DATE] resident 1 underwent a barium swallow and failed the test. He was explained that he needs a feeding tube to prevent further aspiration events. Patient does not believe he has aspirated, does not believe he has pneumonia He says he absolutely refuses to have a feeding tube placed. He wants to eat and go home. Representative from his facility came to see patient. They discussed hospice and he decided he wants to go home on hospice. He wants abx [antibiotics] and o2 [oxygen] discontinued and asked code status to be changed to DNR [Do Not Resuscitate]. On [DATE], resident 1 had a care plan for at risk for nutritional status initiated. Interventions identified included to monitor/document/report any signs and symptoms of dysphagia such as Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing; to provide and serve the diet as ordered; Registered Dietician to evaluate and make diet change recommendations; and staff to provide supervision and encouragement with meals as needed. 2. Resident 6 was admitted to the facility on [DATE] with diagnoses which consisted of, but were not limited to, type 2 diabetes mellitus, pain, dementia, pulmonary hypertension, nonrheumatic aortic valve stenosis, orthostatic hypotension, atrial fibrillation, presence of cardiac pacemaker, hypertension, and mild cognitive impairment. On [DATE], resident 6's Quarterly MDS Assessment documented a BIMS score of 15 which would indicate that the resident was cognitively intact. The assessment documented that resident 6 required supervision with set-up help for eating, and that resident 6 had a swallowing disorder with symptoms of holding food in the mouth/cheeks or residual food in the mouth after meals. Review of resident 6's physician orders revealed a diet order for a regular diet mechanical soft texture, think liquids consistency that was initiated on [DATE]. On [DATE], resident 6 had a care plan for at risk for altered nutrition status due to edentulous status with mechanical altered texture required for ease of chewing initiated. Interventions identified included monitor/document/report any signs and symptoms of dysphagia such as Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing; to provide and serve the diet as ordered; and the Registered Dietician to evaluate and make diet change recommendations as needed. 3. Resident 5 was admitted to the facility on [DATE] with diagnoses of dementia, emphysema, hypertension, alcohol abuse, and malignant neoplasm of pancreas. On [DATE], resident 5's Quarterly MDS Assessment documented a BIMS score of ,d+[DATE], which would indicate a severe cognitive impairment. The assessment documented that resident 5 required a one person physical assist with supervision for eating. The assessment documented that resident 5 had a swallowing disorder with symptoms of holding food in the mouth/cheeks or residual food in the mouth after meals. Review of resident 5's physician orders revealed a diet order for a regular diet chopped texture, thin liquids consistency that was initiated on [DATE]. On [DATE], resident 5 had a physician order for SLP to evaluate for possible diet texture upgrade. No documentation could be found of the SLP evaluation. On [DATE], resident 5 had a care plan for at risk for altered nutrition status related to medical condition initiated. Interventions identified included monitor/document/report any signs and symptoms of chewing swallowing problems related to dysphagia or oral health problems such as Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing; to provide and serve the diet as ordered; and the Registered Dietician to evaluate and make diet change recommendations as needed. 4. Resident 14 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, benign paroxysmal vertigo, dementia, obstructive sleep apnea, and low back pain. On [DATE], resident 14's Quarterly MDS Assessment documented that a BIMS score was not obtained due to the resident was rarely/never understood. The assessment documented that resident 14 required a one person extensive physical assist for eating. The assessment documented that resident 14 had a swallowing disorder with symptoms of loss of liquids/solids from mouth when eating or drinking; holding food in mouth/cheeks or residual food in mouth after meals; and coughing or choking during meals or when swallowing medications. Review of resident 14's physician orders revealed a diet order for a regular diet minced and moist texture, thin liquids consistency that was initiated on [DATE]. On [DATE], resident 14 had a care plan for at risk for malnutrition initiated. Interventions identified included monitor/document/report any signs and symptoms of chewing swallowing problems related to dysphagia or oral health problems such as Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing; refer to SLP or dentist as indicated to address dysphagia; to provide and serve the diet as ordered; and the Registered Dietician to evaluate and make diet change recommendations as needed. On [DATE] at 11:33 AM, an interview was conducted with the Dietary Manager (DM) 2. The DM 2 stated that the kitchen staff were responsible for plating resident meal trays, but nursing staff were responsible for delivering the trays to residents. On [DATE] at 12:15 PM, an interview was conducted with the hospitality aide. The hospitality aide was observed delivering food trays to residents in their rooms. The hospitality aide stated she passed out meal trays to residents often. The hospitality aide stated she would check the diet card on the resident ' s food tray for their preferences and put a drink on the resident ' s tray. Several cups of fluid were observed on top of the food cart. The hospitality aide further stated she does not look on the diet card to see if a resident was on thickened liquids or any special diet before giving the food tray to the resident and that she only looked at the resident ' s preferences. The hospitality aide stated the kitchen would know the diet and takes care of that. On [DATE] at 12:17 PM, an observation was made of CNA 1 delivering food to resident 6 ' s room. The resident diet ticket documented a mechanical soft diet with thin liquids. Resident 6 ' s meal was observed as shrimp tacos with refried pinto beans. The taco was made with a corn tortilla and a shredded cabbage topping. Resident 1 refused the meal and stated she did not like shrimp. On [DATE] at 12:17 PM, an observation was made of resident 5 sitting at a table in the dining room eating lunch. The dietary manager (DM 2) approached resident 5 and removed his plate. The plate had 2 whole corn tortillas and 1 uncut shrimp. An interview was conducted with DM 2 at 12:18 PM. DM 2 stated the uncut shrimp on resident 5 ' s plate was a regular texture diet. DM 2 stated a chopped diet would have no tortillas or shrimp. Resident 5 ' s meal ticket documented regular chopped thin liquids diet. On [DATE] at 12:39 PM, an observation was made of resident 1 ' s meal tray. Resident 1 ' s meal ticket documented a pureed diet texture with honey thick liquids. Resident 1 ' s meal was observed as a regular diet with shrimp tacos with shredded cabbage on a corn tortilla and refried beans. CNA 1 identified the incorrect diet order and returned the meal tray to the kitchen. On [DATE] at approximately 12:45 PM, an interview was conducted with the DON. The DON stated that after resident 1 ' s most recent hospitalization the hospital recommended a diet of NPO [nothing by mouth] with a feeding tube. The DON stated that resident 1 was found unresponsive and choking on food and that he had a history of chronic aspiration. The DON stated that resident 1 failed his swallow study in the hospital. The DON stated that resident 1 had aspiration pneumonia in [DATE] and after that illness was downgraded to a pureed diet. On [DATE] at 12:57 PM, an interview was conducted with CNA 1. CNA 1 stated that she had worked at the facility for a long time and she should have looked at the meal ticket to identify the diet before delivering the tray to resident 6. On [DATE] at 1:17 PM, a follow-up interview was conducted with the DON. The DON stated that resident 1 refused the feeding tube and all treatment during his last hospitalization and was now on palliative care. The DON stated that resident 1 was not compliant with the pureed diet. The DON stated that if the resident was noncompliant staff should notify the licensed nurse and the nurse should offer education to the resident. If the resident continued to refuse the therapeutic diet then the nurse should notify the Medical Director (MD). On [DATE] at 3:24 PM, a telephone interview was conducted with Licensed Nurse (LN) 1. LN 1 stated that on [DATE] resident 1 was found on the floor with his elbows on the bed. Resident 1 had dried blood on his forehead. LN 1 stated she obtained supplies to clean resident 1 ' s wound. Resident 1 was assisted to bed and was sitting up in bed when he started to cough. LN 1 stated that resident 1 was attempting to clear his airway. LN 1 stated that she observed pork inside resident 1 ' s mouth. LN 1 stated she asked resident 1 if he was choking and he did not respond. LN 1 stated that she performed the Heimlich maneuver and the aide took over while she called 911 and checked the resident ' s code status. LN 1 stated that they were also giving back blows to resident 1. LN 1 stated that the aide identified that resident 1 did not have a pulse, the resident was blue/gray in color and they began chest compressions. LN 1 stated that resident 1 became responsive and opened his eyes and CPR was stopped. LN 1 stated that EMT ' s [Emergency Medical Technicians] arrived and suctioned resident 1 ' s airway and transported him to the emergency room . LN 1 stated that the aide removed a piece of pork that was hanging out of resident 1 ' s lip. LN 1 stated that resident 1 was supposed to have a pureed diet texture and when she looked at the resident ' s meal tray it was a regular texture diet of pork and mashed potatoes. LN 1 stated that the kitchen had made resident 1 two dinner trays and when resident 1 saw the regular tray had told the CNA that he wanted to eat that one instead of the pureed diet. LN 1 stated that none of the aides had reported the diet change to her. LN 1 stated that the aides should know that resident 1 was to have a pureed diet because it was noted on his meal ticket. LN 1 stated that the aides should have notified her when resident 1 requested a regular diet. On [DATE] at 3:51 PM, an interview was conducted with the Registered Dietician (RD). The RD stated they put together a weekly extension of the meals that detailed the modified diet and this showed the kitchen staff what modifications should be made to the diet for the different textures. The RD stated that DM should be able to print off the menu system with the extensions. The RD stated that the DM 2 was new and she provided training to him last week on the menu and the extensions for different diet textures. The RD stated that as a consultant she was in the facility one time a week. The RD stated that the previous DM 1 was an assistant DM at a sister facility and she had interacted with him 2 or 3 times. The RD stated that she checked in on DM 1 to see how he was doing. The RD stated that DM 1 did not attend the nutrition at risk meetings but they encouraged the DM to attend them also. The RD stated that she did not recall having any concerns with DM 1 and did not address the diets and extensions for textures. The RD stated that her understanding was that DM 1 was familiar with the menu system, diets, and textures. The RD stated that she completed audits every 30 days unless deemed more frequently. The RD stated that she had been auditing more frequently due to reports that residents were requesting different diets from their speech therapy (ST) evaluation. The RD stated that she did not change the diet order and that the ST was to evaluate the resident to see what the appropriate diet would be. On [DATE] at 4:16 PM, an interview was conducted with the DM 2. DM 2 stated that he had been doing the online training and had been provided some education by the RD. DM 2 stated that he and the RD had gone over the mechanically altered diet textures and how to identify the differences. DM 2 stated that before meal service he separated the different textured diets into piles so that he could do all one texture at a time and could plate them according to the meal ticket. The DM 2 stated that either himself, the dietary aide (DA) 3, or the hospitality aide plated the food in the kitchen. DM 2 stated that the hospitality aide had her food handlers permit and was allowed to assist in the kitchen. DM 2 stated that at the time of plating he had the meal ticket under the heat lamp so that he could visualize the therapeutic meal texture. DM 2 stated that he was informed of one meal at lunch time that one meal was plated wrong and not according to the meal ticket and diet order. DM 2 stated that it was supposed to be a pureed diet plated was a chopped diet. DM 2 stated that he did not see the returned meal and could not recall which resident the meal was for. On [DATE] at 5:13 PM, an observation was conducted of resident 14 eating dinner in the dining room with the Corporate Resource Nurse (CRN) 1 assisting. Resident 14 was observed eating a baked roll that was dry and cut into bite-sized pieces, green beans, and ziti noodles with red sauce. Resident 14 ' s meal ticket indicated Minced & Moist MM5. On [DATE] at 7:57 AM, a telephone interview was conducted with a Speech Language Pathologist (SLP). The SLP stated that she evaluated the residents for a safe swallow by testing the cranial nerves and performing a bedside swallow exam. The SLP stated that she would evaluate the residents during a meal. The SLP stated that she would have the resident take a couple of bites of pudding, graham cracker, and water. The SLP stated that she would feel on the throat for hyolaryngeal excursion or movement of the epiglottis to ensure that it was inverting in the throat and covering the airway. Depending on the resident the SLP would ask if they were experiencing any pain or if they felt a globus sensation or something caught in the throat. The SLP stated that the evaluation was usually for an upgrade for the diet order. The SLP stated that on [DATE] she conducted a swallow exam of resident 1 because she was referred by nursing for changes in the PO (by Mouth) intake. The SLP stated that she attempted to get resident 1 to participate in the cranial nerve exam, but he kept telling her to leave. The SLP stated that because of resident 1's diagnosis he had certain people that he liked to interact with. The SLP stated that it was difficult to obtain any good data on that exam, and that was why she requested a Modified Barium Swallow (MBS) exam. The SLP stated that she scheduled a MBS for him but he went to the hospital, and she [TRUNCATED]