Every finding on record at Cadia Rehabilitation Broadmeadow

Based on interviews, clinical record review, and review of other pertinent records, it was determined that for one (R1) out of four residents reviewed for dysphagia, the facility failed to provide the necessary care and services to R1 when the facility failed to identify R1 as high risk for choking and aspiration. On 5/15/26, R1 was served breakfast in bed and left unsupervised. Approximately 20 minutes later, staff found R1 unresponsive. EMS (Emergency Medical Services) documents revealed severe airway obstruction with large quantities of food (ham and eggs) removed from the airway and difficulty ventilating/intubating due to obstruction. The death certificate listed the immediate cause of death as airway obstruction by food bolus while consuming food. The facility failed to implement known swallowing precautions and supervision interventions, resulting in cardiopulmonary arrest and death. Immediate Jeopardy was initiated on 5/27/26 and abated on 5/28/26 after the facility implemented corrective actions. Findings include: Cross refer F656Review of R1 's clinical record revealed:1/25/24 - R1 admitted with diagnoses including stroke, dysphagia, GERD, and aphasia.1/26/24 - A speech assessment completed by E4 (former Speech Language Pathologist [SLP]) identified swallowing impairment, oral residue, wet vocal quality, aspiration risk, and need for swallow precautions. E4 documented strategies that included: Slow rate of intake/rate modification, small bites/bolus size modification, Alternating liquids and solids and Upright positioning during and after meals.1/26/24 - A nutrition care plan intervention for R1 included monitoring for dysphagia symptoms, when necessary, but no individualized plan addressed impulsive eating behavior or supervision.1/31/24 - An admission MDS assessment revealed that R1's cognition was moderately impaired and required setup or clean - up assistance (helper sets up or cleans up) with eating. R1 had loss of liquids/solids from mouth when eating or drinking and was holding food in mouth/cheeks or had presence of residual food in mouth after meals. R1 had no natural teeth or tooth fragments and was on mechanically altered therapeutic diet. 1/31/24 - 3/18/24 - R1's speech therapy notes documented R1 as a very impulsive eater requiring cues to slow intake and reduce bolus size. Wet vocal quality and coughing noted during intake. 4/2/24 - A Speech Therapy Discharge Summary by E4 documented that staff education on safe swallow strategies (small bites, alternating liquids/solids, slow pace, upright seating) and caregiver follow-through was emphasized in discharge planning. R1's prognosis was good with consistent staff follow-through.5/2/24 - R1's quarterly MDS assessment revealed that R1 was independent with eating. 10/24/24 2:49 PM - A Care Conference note documented R1's diet as NAS (no added salt) regular texture and thin consistency. R1 was eating his lunch in the main dining room on Mondays - Fridays only. 11/24/24 - R1's was seen and evaluated again by Speech Therapy for dysphagia therapy and medication tolerance. A clinical bedside assessment was completed by E4 who noted that R1 was reported to have complaints of increased difficulty swallowing and R1 stating that he was feeling like his food was increasingly feeling stuck in his throat. E4 also noted that R1 was unable to swallow only one simulated pill stating inability to swallow resulting in expelling of larger pill.11/24/24 - A Speech Therapy note by E4 documented, .Nursing noted no complaints with medication on this date of eval however patient did verbalize during the eval to both this SLP and his primary nurse that (sic) has had some trouble with the last 5 days but it's not all the time .It was noted that from 2/2024 through 12/2024 that R1's speech notes repeatedly documented: fast eating/increased rate of eating, need for cuing and reminders, safe swallow strategies (small bites, alternating liquids/solids, slow pace, upright seating) and coughing/wet vocal quality at times. 12/3/24 - A Speech Therapy Note by E9 (part time former SLP) suggested possible GI consult for esophageal dysphagia and reinforced aspiration precautions. 12/12/24 - Speech Therapy Discharge Summary by E4 documented that R1 was at highest practical level but explicitly documented continued swallowing strategies and staff follow-through expectations.1/16/25 - An annual MDS assessment documented that R1 required setup or clean - up assistance with eating. 4/17/25 - A quarterly MDS assessment revealed that R1 required setup or clean - up assistance with eating. 5/29/25 - R1 had a physician's order for NAS (No Added Salt) diet Regular texture, thin consistency and two handle cup with sippy lid for hot beverages at all meals.7/17/25 - A quarterly MDS assessment revealed that R1 required setup or clean - up assistance with eating. 8/8/25 - A Speech Therapy (ST) Evaluation and Plan of Treatment by E13 (SLP) documented that R1's evaluation was requested to establish skilled ST interventions for memory and word finding. E13 further documented that R1's previous ST services to address dysphagia from 11/24/24 - 12/12/24 was discharged due to highest practical level achieved by R1. E13 also documented that R1 had normal swallow score but a clinical bedside assessment was not performed. 8/19/25 10:50 AM - An MDS clarification note with ARD (Assessment Reference Date) of 7/17/2025 by E14 (RNAC) documented, . there is an error coding noted on eating, per interview with therapy, it was found out that [R1] is set up with eating.10/16/25 - A quarterly MDS assessment revealed that R1 required setup or clean - up assistance with eating. 1/13/26 - An annual MDS assessment revealed that R1 required setup or clean - up assistance with eating. 1/16/26 - A Speech Therapy Discharge Summary by E13 (SLP) documented that R1 had a normal swallow and R1's oral phase, bolus control and pharyngeal phase were within functional limits. 4/9/26 - A quarterly MDS assessment revealed that R1 required setup or clean - up assistance with eating. Despite the MDS increasingly coded R1's eating status from independent on 10/22/24 to requiring set-up or clean - up assistance starting 1/16/25 until 4/9/26, a recommendation for a GI consult after R1 reported occasional episodes of larger pills being stuck on 12/3/24 and R1 was put back on SLP caseload on 8/2025 until 1/2026 for cognitive and language (word finding) therapy, the facility:Lacked evidence that a follow up swallowing re-evaluation was completed for R1.Lacked evidence that an individualized care plan was developed to address R1's dysphagia and the interventions including swallowing strategies to prevent aspiration.Lacked evidence that staff monitored R1's swallowing strategies in the CNA or nursing documentation.5/15/26 (Day of Event) - A review of E18's written statement and the town and county EMS (Emergency Medical Services) response reports revealed:8:30 AM - E18 (CNA) delivered breakfast tray to R1 in bed. R1 was repositioned upright in bed and left alone eating. R1's meal included ham, eggs, cheese and English muffin.8:50 AM - 8:52 AM - E18 returned and found R1 unresponsive. Code Blue was initiated. 8:53 AM - The town and county EMS response reports documented:- unit was notified- severe airway obstruction by food- ham and egg pieces repeatedly removed from airway- difficulty ventilating/intubating due to obstruction- airway cleared only after repeated suctioning and forceps use- CPR (cardiopulmonary resuscitation) unsuccessful5/15/26 9:39 AM - A police report documented that R1 was pronounced deceased by P7 (Medical Examiner).5/15/26 - R1's death certificate documented obstruction of airway by food bolus (accidental choking while eating).5/18/26 2:33 PM - In a telephone interview, FM1 [R1's niece] stated, [R1] was left in bed eating breakfast, and he choked. They were supposed to get him up and had him eat in the dining room. He would go there for lunch.I was told that [R1] had a new CNA taking care of him that morning and she didn't get him out of bed to eat in the dining room. He usually eats in the dining room because he needs to be watched. He eats very fast - he was high risk for choking. the speech therapist and the dietitian knew that. That should be part of his care plan. I went to the facility and was met by the medical examiner or the forensic investigator . thought to be asphyxiation (suffocation).5/19/26 9:30 AM - In an interview, E32 (CNA) stated that for residents who are identified to have difficulty swallowing and other eating problems, We get them out of bed and take them to the dining room/activity room where we watch them eat their breakfasts, lunches and dinners. Some residents prefer to eat in their rooms while others want to eat in bed, so we let them eat their breakfast in the rooms. head of bed elevated upright to 90 degrees and checked on them from time to time. For residents needing feeding assistance, we bring them to the dining room, easier to assist them there and watch them how they eat. 5/19/26 9:35 AM - In an interview, E25 (RN) stated, At the start of shift and before they do their rounds, we tell the CNAs of those residents we need to watch out for aspiration risks during mealtimes. We identify these residents, and we get them out of bed and bring them to the (unit) dining room where they can be watched and supervised while they are eating. Some residents prefer to eat in their room, so we remind the CNAs to check on them frequently that they are able to feed themselves and swallow their food with no problems or unusual behaviors.5/19/26 10:00 AM - During an interview, E20 (CNA) stated, .I get [R1] out of bed and put him in the (unit) dining room so he will not make a mess in bed when he eats. He eats fast and doesn't chew his food very well.[R1] should be supervised at least every couple of minutes while he is eating .5/19/26 10:19 AM - In an interview, E18 (CNA) stated . I delivered [R1's] food tray at 8:32 AM, he was eating regular food and used a Kennedy cup (an adaptive spill - proof drinking cup designed for individuals with limited mobility) for drinking his water or juice. He was pulled up 90 degrees, like he sat on his bed. I left him and went out to assist another resident with feeding. I did not know that he had to be watched for coughing and difficulty swallowing.I was not aware that he was high risk for choking. his food tray was on the overbed table across his chest .he had breakfast sandwiches -hamburger buns, eggs, cheese, ham, side of scrambled eggs, hot chocolate and apple juice. I went back to check [R1] at 8:51 am and found him not responding and his color looked so different I called his nurse [E19] . and she initiated CPR, and we called for Code Blue. No one told me.There were no instructions in his task in our computer to tell me what to watch out or monitor or even say that [R1] should eat in the dining room all the time so he can be observed. I was not aware that [R1] had swallowing precaution instructions. 5/19/26 10:51 AM - In an interview, E21 (CNA) stated, He could choke because he eats very fast.5/19/26 11:00 AM - In an interview, E22 (CNA) stated, He sometimes eats in bed with the head of bed elevated at 90 degrees.5/19/26 11:14 AM - During an interview, E17 (LPN) stated, When I used to work as his charge nurse on the floor, I was never informed that R1 had dysphagia and was being monitored for choking and difficulty swallowing. I did not know about his swallowing precaution instructions.5/19/26 11:35 AM - In an interview, E19 (LPN) stated, [R1] eats in the dining room or sometimes in his bed, based on his preference. I am not aware that he has had any issues with eating or that he eats very fast. I did not know about his swallowing precaution instructions.5/19/26 11:50 AM - During an interview, E16 (RN, UM) stated, I observed him at lunch during dining room duty, and I never saw him having trouble with chewing or swallowing. He liked to eat a lot. Monitoring for signs of dysphagia did not necessarily mean it will be acted or documented in the task. Staff observations will be documented if necessary. I did not know about his swallowing precaution instructions. [R1] was independent with eating and had no eating issues. Nothing was reported to me by the staff so there was nothing to document - intervention stated, 'monitor as needed' only.5/19/26 2:46 PM - In an interview, E23 (LPN) stated, For residents with dysphagia, we get them up and out of bed for meals, watch them in the dining room while eating and monitor them if they start coughing. We also instruct the CNAs, especially the new ones to check on the residents with eating issues from time to time every 10-15 minutes - after delivering the food tray.5/19/26 12:53 PM - In an interview, E24 (RN) stated, If a resident is identified to have dysphagia, it should be care planned for risk for aspiration and interventions be put in place to increase monitoring, to make sure to let the CNAs know . indicate in their tasks and talk to them prior to start of care . give them a heads up about residents' special instructions.5/19/26 1:34 PM - In an interview, P3 (NP) stated, .Unfortunately [R1] had a coronary event. He was not acutely ill. I am not aware that they (nursing staff who performed CPR on R1) suctioned some amount of food in [R1's] mouth.5/19/26 1:50 PM - During an interview, E13 stated, I was his therapist starting August 2025 until recently. I saw him for cognition, speech and language. I did not evaluate him for his swallowing; no clinical bedside assessment was done. There were times when I had sessions with him at lunch and I observed him eating at a fast rate when he got excited with the food that he ate. He eats fast. He loved to eat. No, I did not see that as an issue. I did not receive any requests or referral from the nursing staff regarding R1's swallowing and chewing issues.5/19/26 2:15 PM - In an interview, E6 (RD) stated, He was a good eater and really likes to eat a lot. During my nutrition assessments, I never observed him having difficulties with eating, chewing or swallowing.5/20/26 1:05 PM - When asked about R1's person - centered care plan to address R1's risk for aspiration and his impulsive behavior of eating fast and how the facility ensured that R1 was monitored for safe swallowing strategies and signs and symptoms of dysphagia, E1 (NHA) stated, [R1] was independent with eating and never had any issues with his eating, chewing, coughing and swallowing. The nutrition care plan interventions [Monitor/document/report PRN any s/sx of dysphagia: Pocketing, Choking, Coughing, Drooling, holding food in mouth, several attempts at swallowing, refusing to eat, Appears concerned during meals] .are the general interventions applied to all residents in the facility even to those without dysphagia issues. [R1] was cleared by the speech therapists for regular consistency, thin liquid diet. We tell the staff that if they see something, they say something. If nothing is reported, nothing is documented, then it was not observed.5/26/26 - A review of R1's MAR (Medication Administration Record) from January 2026 - May 2026 lacked evidence that R1 was monitored by licensed nurses for safe swallowing strategies.5/26/6 - A review of R1's CNA flowsheets from January 2026 - May 2026 lacked evidence that R1 was monitored by CNAs for safe swallowing strategies.5/26/26 - A review of R1's CNA Behavior flowsheets from August 2024 through October 2025 lacked evidence that R1 was monitored by CNAs for impulsive oral intake, and increased rate of food consumption.5/27/26 1:50 PM - In an interview, E7 stated, . In April, last month, [R1] has been eating meals in his room. depends on what he wants; he usually eats in his room or in the main dining room when it's open for lunch on Mondays through Fridays only. The main dining room is closed for breakfast and dinner, so he eats wherever he wants to eat. The (unit) dining room is always open - [R1] often goes there to eat as well. 5/27/26 1:55 PM - During a follow up interview, E20, stated that [R1] was always eating fast, and they said he eats like that because it stemmed from him being in the military. They (staff) all knew him - he was the former HR lady's uncle.I was with the impression that nurses and the other CNAs were aware that he eats so fast and puts a lot of food in his mouth that he could have trouble chewing. that's why we keep him in the dining room so we can all watch and remind him to slowdown and eat smaller bites. I witnessed him cough before while in the middle of eating. I know I have to keep a close eye on him because I've known him for a long time. The swallowing strategies were not specifically indicated in our task to sign off so a lot of the staff wouldn't know. There're no instructions for us to watch him closely for signs and symptoms of choking or that he has to take small bites and alternate his meal with water or anything liquid. I think it would have been helpful if the instructions were clearly added in our CNA task so we can all be aware specially those who are working part time or PRN who may not know a lot about the residents.It would have been better if those specific swallow precautions/ instructions and unsafe eating and feeding behaviors by the resident were documented as task for all of us to now. [R1] did not wear a denture, he ate with regular teeth, but he did have some few missing top and bottom teeth . I get him out of bed, sit him upright in the wheelchair, have him eat in the dining room for his meals and I cut the food on his tray for him to get small bites. He liked to drink his beverages and food at one at a time. So, he likes to drink all his hot chocolate first and when it's all done, he will eat his sandwich until it's finished, then proceed with his cake or whatever else is on his tray. We all watched him in the dining room because we had to coach him to slow down and watch him that he will not choke.5/27/26 2:16 PM - In a follow up interview, E13 stated, . I'm not aware of the recommendation for GI consult in December 2024, I was not here yet. He had natural teeth, no dentures. some missing upper and bottom teeth but was able to chew on food with no issues. I know of [R1's] safe intake strategies including alternating intake between liquid and solid food to clear his mouth and also to give verbal cues for him to slow down or slow his rate of intake. I don't know how the instructions were communicated to nursing. When I started working here as speech therapist, I was only told by nursing staff that eating at a fast rate was his baseline. I observed him eating in the dining room and E8 (former LPN) was there cueing him to slow down, repositioning him on his wheelchair upright and reminded him to alternate his drink with solid food. Nobody came to me for referrals if there were any concerns. It would have been better if the 12/12/24 discharge instructions swallow strategies for [R1] were communicated to the nursing staff. The former nurse knew about [R1's] safety precautions but she left. The new staff will never know that [R1] had swallowing strategies to observe to prevent aspiration.5/27/26 2:54 PM - In an interview, E12 (OT) stated, [R1] was able to cut his food; assessed to be capable to hold two handle adult sippy cup for hot beverages. I am aware he had dysphagia and he was a high risk for aspiration.5/27/26 3:30 PM - In a joint interview with E2, E1 re-stated that R1 was independent with eating and was cleared by speech therapists on multiple assessments that he had no problem with swallowing. The swallowing strategies identified were general swallowing precautions that all residents should be observed for. E1 further stated that R1's nutrition care plan did not require documentation as basis for monitoring. Furthermore, E2 stated, [R1] eats like that even from before - so fast, with no issues.it stemmed from him being in the military. When asked if R1's recommendation for GI consult on 12/3/24 was followed up, E2 stated, No the doctor did not make a recommendation. 5/27/26 3:22 PM - During a meeting with facility management, the Survey Team notified E1 (NHA) and E2 (DON) of an Immediate Jeopardy when the facility failed to identify R1 as high risk for choking and aspiration. Additionally, the facility failed to implement identified swallowing precautions and meal supervision interventions during breakfast service on 5/15/26 that resulted in R1 experiencing an airway obstruction while eating that led to R1's cardiopulmonary arrest and death.5/27/26 6:29 PM - E1 submitted a signed and dated abatement plan to the State Agency.The facility's abatement included:Facility reviewed all residents to determine which residents had a diagnosis of dysphagia.All residents with a diagnosis of dysphagia were reviewed by speech therapists to determine what, if any, interventions needed to be communicated to staff.Any noted interventions were added to the residents' CNA tasks.Speech therapists were educated on documentation of necessary speech interventions and communicating them to nursing staff. Education was completed on 5/27/26.Education with nursing staff on where to locate any resident - specific speech therapy interventions was initiated on 5/27/26. All nursing staff currently in-house were educated with 100% compliance on 5/27/26. An OnShift message was sent to all nursing staff. All oncoming staff will be educated before starting their shifts until 100% compliance is achieved. Education will be completed by 5/28/26.5/29/26 9:58 AM - In a telephone interview, E4 (former SLP) stated, . I saw [R1] in 2024 .[R1] had a stroke, with impulsive behavior of putting too much food in his mouth, he responded to cues for him to slow down and not to put too much food. sometimes I noticed him coughing in between bites. FEES swallow study was not done. but I watched him for chemical obstruction (tissue damage resulting from the ingestion of corrosive chemicals like when medications getting lodged or long term acid reflux). [R1] had wet vocal quality . not necessarily in the airway but close to the airway .When I discharged [R1] to long term care, written instructions in the discharge summary were provided for staff to follow through. I notified the nursing staff verbally - and they were aware. I expected that staff passed on [R1's] swallowing strategies to the other nursing staff as well during change of shift and that the regular staff nurses and CNA who were familiar with [R1] were able to communicate to the new employees those swallowing strategies as well. I communicated to nursing verbally, not necessarily in writing. I can't confirm nor deny if the other SLP [E9's] recommendation for GI consult was followed through. She probably made that recommendation because [R1] also had GERD.5/29/26 1:03 PM - In a follow up telephone interview, P3 (NP) stated, I am not aware of the referral for [R1's] GI consult for esophageal dysphagia on 12/3/24. I started seeing residents in the facility on 5/21/25.5/29/26 12:30 PM - 1:05 PM - Collective interviews with staff, resident observations and record reviews confirmed facility's completion of the abatement plan. Staff was able to articulate location of resident specific speech therapy interventions listed on the residents' task in the EHR (electronic health record). 5/29/26 1:05 PM - In an interview, E26 (LPN) stated We received education that speech therapy instructions for each resident can be located in the EHR (electronic health record) under Task which can be accessed by both nurses and CNAs. Usually, the speech therapist tells the nurse any updates, changes or orders for the resident who was seen and evaluated. It's important that specific instructions are noted in the EHR so everyone will know what they need to monitor and watch out for, especially the new nursing staff who are not familiar with the residents. 5/29/26 - In a telephone interview, E9 (former part time SLP) stated that it's been a long time since she last saw R1. Surveyor read to E9 the notes E9 wrote when she saw R1 for speech therapy session on 12/3/24. E9 stated that what she wrote on her notes where shared to the nursing staff. E9 further stated, When we find somethings, we notify the nurses and the Rehab Director verbally or in writing.the expectation was for the nurses to share the information such as swallowing strategies to the nursing staff including the CNAs. E9 stated, . At that the time of my visit, [R1] had no issues with oropharyngeal but .when he complained of occasional larger pills being stuck in his throat. it was near the esophagus and that was the reason why I recommended for a GI consult for esophageal dysphagia evaluation - and R1 also had GERD. The GI specialists are the ones looking into this. With [R1] saying that with multiple intakes of water he was able to clear medications and when seated in wheelchair he was able to tolerate it better . he had to be cued and reminded of the safe swallow strategies with meals and medications [small sips/bites, slow rate, upright seating, and alternate solids/liquids]. 5/29/26 2:00 PM - Findings were discussed with E1 (NHA) and E2 (DON).5/29/26 2:15 PM - Findings were reviewed with E1 NHA and E2 DON during the Exit Conference.

Based on record review and interview, it was determined that for one (R5) out of two (2) residents reviewed for abuse and injury of unknown origin, the facility failed to recognize and consequently report an injury of unknown origin. Findings include: Review of R5's clinical record revealed:5/1/26 - R5 was admitted to the facility. 5/1/26 11:45 PM - An admission assessment documented the following skin conditions for R5: right elbow skin tear closed; coccyx (tail bone) redness; left forearm skin tear with dressing in place (unable to assess); multiple discolorations to bilateral upper extremities and right chest; redness to sacrum (buttocks); right forearm closed skin tear with scabbed area; small discoloration to bilateral lower extremities; upper arm skin tear with transparent dressing in place. 5/14/26 1:22 PM - A weekly skin assessment documented the following skin conditions for R5: bruising to face, upper chest, and bilateral upper extremities; fading bruises bilateral lower extremities, abdomen, and bilateral tops of feet; skin tear left upper extremity; Multiple scabs to bilateral upper extremities; redness to sacrum; and scab left lower and upper lip. 5/28/26 2:22 PM - During an interview, E33 (LPN) stated she completed the skin check on R5 and recalled having faded bruises on the abdomen. E33 stated the expectation was when staff identifies a new skin area to document on the skin assessment, initiate risk management (internal incident report), initiate treatment and notify management. 5/29/26 11:24 AM - During an interview, E34 (LPN) stated that he completed the admission assessment for R5 and any skin areas noted on admission would have been documented in the assessment. E34 stated he recalled R5 having multiple areas noted to bilateral arms and bilateral legs. E34 stated he did not recall seeing any bruises noted on the abdomen when the assessment was completed and also stated he would have a CNA complete the skin assessment so all areas would be identified. 5/29/26 12:00 PM - During an interview, E3 (ADON) stated that an internal risk management report was not initiated for any skin areas for R5.Based on interview and review of clinical records it is unclear if R5 had abdominal bruising noted on admission or if the bruising occurred between 5/1/26 and 5/14/26 when it was identified. The facility lacked evidence that an injury of unknown origin was reported to the State Agency. 5/29/26 2:15 PM - Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on interview and record review, it was determined that for one (R1) out of four residents reviewed for dysphagia, the failed to develop a person - centered care plan to address R1's identified eating behaviors. Findings include: Cross refer F684 Review of R1's clinical record revealed:1/25/24 - R1 was admitted to the facility with diagnoses including stroke, GERD, dysphagia.1/26/24 - During an initial Speech Evaluation, R1 was observed to be at risk for aspiration during PO (by mouth) intake. Strategies and/or maneuvers for safe oral intake were identified by the speech therapist including alternation of liquid/solids, general swallow techniques/precautions, cyclic ingestion technique, rate modification and bolus size modifications upright posture during meals and upright posture for > (more) 30 mins (minutes) after meals.11/24/24 - A Speech Therapy Treatment Note documented R1 verbalized to both the speech therapist and his primary nurse that he has had some trouble tolerating his medications within the last 5 days. 12/3/24 - A Speech Therapy Note documented . [R1] reports to have occasional episodes of larger pills being struck, however, indicating towards proximal region of esophagus and states that with multiple intake of water is able to clear medications and reports when in seated in WC (wheelchair) is able to tolerate it better .educated patient to be seated upright in wheelchair for the medication if possible . Educated [R1] on the risk of aspiration/choking and reviewed on safe swallow strategies to be implemented with meals and medication mainly small sips/bites, slow rate, upright seating, and alternate solids/liquids, additionally, medication may be taken with puree consistency as well.12/12/24 - A Speech Discharge Summary for R1 documented that it was recommended for R1 to use the following strategies and/or maneuvers during oral intake: general swallow techniques/precautions upright posture during meals and upright posture for > 30 minutes after meals. 5/19/26 11:35 AM - In an interview, E19 (LPN) stated, [R1] eats in the dining room or sometimes in his bed, based on his preference. I am not aware that he has any issues with eating or that he eats very fast. I did not know about his swallowing precaution instructions.5/19/26 11:50 AM - During an interview, E16 (RN, UM) stated, I never saw him having trouble with chewing or swallowing .Monitoring for signs of dysphagia did not necessarily mean it will be acted or documented in the task. Staff observations will be documented if necessary. I did not know about his swallowing precaution instructions. Nothing was reported to me by the staff so there was nothing to document - intervention stated, 'monitor as needed' only.5/19/26 10:19 AM - In an interview, E18 (CAN) stated There were no instructions in his task in our computer to tell me what to watch out or monitor or even say that he should eat in the dining room all the time so he can be observed. I did not know about his swallowing precaution instructions. 5/27/26 1:55 PM - During an interview, E20, stated that [R1] was always eating fast . I was with the impression that nurses and the other CNAs are aware that he eats so fast and puts a lot of food in his mouth at a fast rate that he could have trouble chewing that's why we keep him in the dining room so we can all watch and remind him to slowdown and eat smaller bites. I witnessed him cough before while in the middle of eating. I don't sign it off in our CNA task as it's not indicated for us to sign. There were no instructions for us to watch him closely for signs and symptoms of choking or that he has to take small bites and alternate his meal with water or anything liquid. I think it would have been helpful if the instructions were clearly added in our CNA task so we can all be aware specially those who are working part time or PRN who may not know a lot about the residents. It would have been better if those specific swallow precautions/ instructions and unsafe eating and feeding behaviors were documented as task for all of us to now. 5/29/26 2:00 PM - Findings were discussed with E1 (NHA) and E2 (DON).5/29/26 2:15 PM - Findings were reviewed with E1 and E2 during the Exit Conference.

Based on record review and interview, it was determined that for one (R5) out of six residents in the investigative sample, the facility failed to provide services that meet professional standards of quality by having Licensed Practical Nurses (LPN) complete admission assessments. Findings include: Delaware State Board of Nursing - RN, LPN and NA/UAP Duties 2024 . admission Assessments * - RN .* = Once a care plan is established, the LPN may do assessments .Review of R5's clinical record revealed:5/1/26 - R5 was admitted to the facility. 5/1/26 11:45 PM - An admission assessment documented the following skin conditions for R5: right elbow skin tear closed; coccyx (tail bone) redness; left forearm skin tear with dressing in place (unable to assess); multiple discolorations to bilateral upper extremities and right chest; redness to sacrum (buttocks); right forearm closed skin tear with scabbed area; small discoloration to bilateral lower extremities; upper arm skin tear with transparent dressing in place. 5/29/26 11:24 AM - During an interview, E34 (LPN) stated that he completed the admission assessment for R5 and any skin areas noted on admission would have been documented in the assessment. E34 stated he recalled R5 having multiple areas noted to bilateral arms and bilateral legs. E34 stated he did not recall seeing any bruises noted on the abdomen when the assessment was completed and also stated he would have a CNA complete the skin assessment so all areas would be identified. 5/29/26 10:47 AM - During an interview, E16 (RN) stated that the nurse assigned to the resident's room is responsible to complete the following assessments: fall risk, pain, skin, braden, oral and full admission assessment when the resident is admitted . E16 stated that an LPN can not complete an admission assessment without an RN oversight. 5/29/26 11:53 AM - During an interview, E36 (RN) stated that she was working on 5/1/26 when R5 was admitted and was responsible for inputting new physician orders into the system. E36 confirmed that she did not complete any assessments when R5 was admitted . 5/29/26 2:15 PM - Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on observation, interview, and document review, the facility failed to ensure the Facility Assessment included an accurate and comprehensive review of the facility's resident population, including an identified population of residents receiving Comfort Care. The failure to update the Facility Assessment to accurately reflect resident needs for this specific resident population receiving care and services meant the facility assessment plan had potentially missed critical care needs specific and unique to this population. This failure had the potential to affect the care provided to the facility population and the training required for both direct and indirect care staff. These failures had the potential to impact all 108 residents in the facility related to safety, pain, person-centered environment, psycho-social services, and the number of adverse events or other resident complications. Cross reference: F684 Quality of Care. Findings include:Review of the Facility Assessment 2025-2026, dated 10/08/25 through 10/29/25, revealed it did not include any indication or recognition of an identified resident population that received Comfort Care within the facility. Facility provided documentation revealed 10 residents received Comfort Care at the facility, making up approximately 9.3% of the current facility population. Only two residents were identified with Hospice services, making up approximately 1.9% of the current facility population. The Comfort Care population was not identified in the current Facility Assessment. The current Facility Assessment identified residents on Hospice and Palliative Care services only. During staff interviews, noted below and cross-referenced with F684, the facility did not identify unique and distinctive characteristics and care need differences between residents receiving Comfort Care and Palliative Care. During an interview on 01/30/26 at 1:40 PM, the Administrator stated that they had provided the most current Facility Assessment for review.During an interview on 01/30/26 at 5:09 PM, the Director of Nursing (DON) provided an Order Listing Report, which she stated revealed the current list of residents receiving Comfort Care. The resident list identified 10 current residents, each documented with Palliative Care-Form on File. The DON said that this was the current list of residents on Comfort Care and that the facility used the term Palliative interchangeably with Comfort Care.During a follow-up interview on 01/30/26 at 6:05 PM, the Administrator confirmed that the facility had been using the terms Palliative and Comfort Care interchangeably. She said that they used a Comfort Care/Palliative Care Assessment in the nursing home setting and it was used like a wish list advanced directive, documenting preferences related to their care. The Administrator stated they were aware that they used the terminology Palliative in the Facility Assessment, and not Comfort Care. She stated that she had been told they were the same thing.

Based on record review, interviews, and facility policy review, the facility failed to ensure residents were informed of psychotropic medication side effects and the associated risks versus benefits for two out of five residents (Resident (R) 58 and R5) reviewed for unnecessary medications of 31 sample residents. This failure had the potential for residents to be uninformed of potential outcomes related to psychotropic medications. Findings include: 1. Review of R58's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R58 was admitted on [DATE] with diagnoses which included bipolar disorder, major depressive disorder (MDD), and anxiety. Review of R58's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/25 and located under the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated intact cognition. Review of the Order Summary Report located under the Orders tab of the EMR, active as of 01/29/26, revealed the following orders: -Buspirone HCL [hydrochloric acid] [antianxiety medication] oral tablet 15 MG [milligram]. Give one tablet by mouth two times a day for anxiety, dated 07/10/25. -Duloxetine HCL [antidepressant medication] oral capsule delayed release particles 60 MG. Give one capsule by mouth one time a day for MDD, dated 07/10/25. -Risperidone [antipsychotic medication] oral tablet three MG. Give one tablet by mouth at bedtime for delusional disorder, dated 07/10/25. Review of the EMR revealed no documentation of consent or risk versus benefit review with the resident or representative. During an interview on 01/29/26 at 1:09 PM, the resident stated she was told what medications she was on but not about potential effects related to the medications provided. During an interview on 01/29/26 at 8:05 AM, the Director of Nursing (DON) stated they did not have any documentation specific to the review of the potential effects of the psychotropic medications with the resident or representative. At 11:56 AM, she acknowledged that the required information was listed in the policy. 2. Review of R5's admission Record located under the Profile tab of the EMR revealed R5 was admitted on [DATE], and readmitted on [DATE], with diagnoses which included MDD and anxiety disorder. Review of R5's quarterly MDS with an ARD of 11/27/25 and located under the MDS tab of the EMR revealed a BIMS score of 15 out of 15, which indicated intact cognition. Review of the Order Summary Report located under the Orders tab of the EMR, active as of 01/29/26, revealed the following orders: -Buspirone HCL [antianxiety medication] oral tablet 10 MG. Give one tablet by mouth three times a day for anxiety, dated 08/25/25. -Duloxetine HCL [antidepressant medication] capsule delayed release particles 20 MG. Give one capsule by mouth one time a day for depression, dated 01/29/26. Review of the EMR revealed no documentation of consent or risk versus benefit review with the resident or representative. During an interview on 01/30/26 at 8:16 AM, the resident stated she did not remember having any discussion with staff about the medication effects. She stated she was unsure of what medication she was taking.During an interview on 01/30/26 at 9:38 AM, the DON stated there was no documentation of any staff conversation with R5 regarding risks versus benefits for the medications. Review of the facility's policy titled, Psychoactive Medications, reviewed 01/13/26, revealed residents are educated on the benefits and the potential risks of the drugs and education is documented in the medical record.

Based on record review, interviews, and policy review, the facility failed to notify the correct emergency contact of a change in condition for one of one resident (Resident (R) 122) reviewed for change in condition out of a total of 31 sampled residents. This failure had the potential to delay timely notification of R122's representative regarding the resident's condition change.Findings include:Review of R122's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R122 was admitted to the facility on [DATE] with diagnoses of unspecified dementia, severe, with other behavioral disturbance and chronic pain.Review of R122's annual Minimum Data Set (MDS) located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 09/12/24, indicated R122 had a Brief Interview for Mental Status (BIMS) score of two out of 15 which indicated R122 was severely cognitively impaired. R122 was also coded as not having one or more unhealed pressure ulcers.Review of R122's Nursing Progress Notes located under the Progress Note tab in the EMR indicated on 11/03/24 at 2:20 PM, Charge nurse alerted writer that the resident [R122] was noted with a blister to right heel . Message left for [emergency contact #2]; awaiting return call.During a phone interview on 01/29/26 at 4:37 PM, Family Member (FM) 1 stated, I got a phone call from a nurse on 11/06/24 that [R122] had developed a wound to her buttocks and her heel. I asked the nurse when they first saw these wounds, and she stated that the right heel blister was noted on 11/03/24, and the nurse called [emergency contact #2]. I asked why I was not contacted since I was the first one to be contacted, and the nurse did not know.During an interview on 01/29/26 at 5:10 PM, Registered Nurse/Unit Manager (RN/UM) 1 stated, The nurse would contact the person listed as the first contact and then if they cannot get that person, the nurse would notify the second person on the list to be contacted. When asked if this would be documented, RN/UM1 stated, Yes, in the progress notes. The nurse would document who she notified of the change. If the nurse could not talk to the first contact on the list, then she would document that a message was left and then contact the second person on the list.During an interview on 01/30/26 at 2:36 PM, the Director of Nursing (DON) stated, For this resident it would be emergency contact number one [FM1], and if you were unable to get ahold of that person then you would contact emergency contact number two. The nurse is to document the phone call to the emergency contact. If the first emergency contact could not be contacted, then the nurse would call the second emergency contact and would document both phone calls. The DON confirmed that emergency contact number two was called for R122. A message was left for that person to call the facility back, but it should have been emergency contact number one contacted.Review of the facility's policy titled, Provider Notification of Resident Change in Medical Condition, dated 01/13/26, indicated . Staff will notify the provider and applicable POA [Power of attorney]/responsible parties of: . Significant change in condition in physical, mental, or psychosocial status .

Based on observation, interview, and record review, the facility failed to ensure that one of 31 sampled residents (Resident (R) 28) was free from physical restraints when staff failed to identify a seatbelt worn on a motorized wheelchair as a physical restraint, restricting the resident's freedom of movement and access to their body. This failure created the potential for facility residents to receive inappropriate care and services, or a lack of, due to unidentified care needs and interventions from an unassessed lower extremity restraint. Findings include:Review of R28's Face Sheet, located in the Electronic Medical Record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnoses included traumatic subarachnoid hemorrhage with loss of consciousness, lack of coordination, abnormal posture, hemiplegia unspecified affecting right dominant side, personal history of traumatic brain injury, aphasia following cerebral infarction, and contracture of right elbow, wrist, and hand. Review of R28's quarterly Minimum Data Set (MDS) Assessment, with an assessment reference date (ARD) of 11/04/25 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) assessment score of 13 out of 15, which indicated the resident was cognitively intact. The resident was documented to have functional limitation in range of motion for upper extremity on both sides and used a motorized wheelchair. R28 required substantial/maximum assistance for sitting to lying, lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfers. R28 did not use restraints.Review of R28's Comprehensive Care Plan, dated 09/14/22 and located in the EMR under the Care Plan tab, revealed R28 had an ADL (activities of daily living) self-care performance deficit related to right [side] hemiparesis. An identified intervention, revised 02/26/24, documented that R28 had a power chair (motorized wheelchair) with back cushion on her wheelchair to maximize safety, comfort, and independence in mobility throughout the facility. The care plan did not identify a seat belt intervention.Review of R28's Comprehensive Care Plan, and located under the Care Plan tab in the EMR failed to identify any problem or associated interventions that indicated the resident used a seat belt while seated in the motorized wheelchair, as observed throughout the survey.During an observation on 01/28/26 at 1:19 PM, R28 was observed in their room seated in their motorized wheelchair, with a seat belt on, with the buckle observed off to the right side of the lap. The resident was observed with a contracted right arm. R28 was asked if they were able to release the seat belt, and they stated yes. They then proceeded to lean to the left and attempted to manipulate the wheelchair controller.During an additional observation on 01/29/26 at 8:08 AM, R28 was observed in their room in their motorized wheelchair, with a seat belt on. During an additional observation on 01/30/26 at 7:55 AM, R28 was observed in their motorized wheelchair with a seat belt on, and with a visible right arm contracture. R28 was asked if the seat belt was comfortable. The resident leaned forward in their wheelchair and stated, No. The resident used their left hand to reach back and touch her lower left back. At 7:58 AM, Certified Nursing Assistant (CNA) 1 entered the resident room and observed R28 leaning forward. CNA1 said that residents with electric wheelchairs had seat belts. CNA1 said R28 did lean forward, so that the seat belt helped with safety. CNA1 stated that all electric wheelchairs had seat belts and then said that they placed the seat belt on R28 when they were put into the wheelchair in the morning and that it was on all day until bedtime, or if R28 had to go to the bathroom.During an interview on 01/30/26 at 8:13 AM, CNA2 said residents with electric wheelchairs had seat belts for their wheelchairs. CNA2 said the CNAs were trained during orientation, and the rehab staff would educate them if a resident was using a seat belt. CNA2 confirmed that they would put the seat belt on the resident when they put them into the wheelchair and only take it off when they were removed from the wheelchair, like toileting or going back to bed. CNA2 said they thought some of the residents could remove the belts themselves.During an interview on 01/30/26 at 8:25 AM, Registered Nurse/Unit Manager (RN/UM) 1 said that they were not sure what the seat belt process was at the facility but believed the rehabilitation department assessed for them and would then educate the CNAs on how to use them. RNUM1 then reviewed the EMR for R28 and confirmed that there was no order for R28 to use a wheelchair seat belt. RNUM1 again, upon review of the EMR, confirmed there was no care plan for a seat belt. RNUM1 said that the nurses could add interventions, but that care plans were reviewed with the interdisciplinary team.During an interview on 01/30/26 at 8:35 AM, MDS Coordinator (MDS) 1 said that they did not capture the seat belts in MDS because it was their understanding that the rehabilitation department would assess the residents, and that they would be capable of removing them. MDS1 confirmed they did not review these assessments. MDS1 said they would expect staff to check for positioning, that they were secure, and the residents could remove them. MDS1 confirmed these interventions should be identified in a care plan. During an interview on 01/30/26 at 8:58 AM, the Director of Rehab (DOR) stated that the facility tried not to use restraints. They said that during orientation they discussed gait belts, but they did not use seat belts. DOR said they were aware that most electric wheelchairs came with them, but the rehab department did not assess them to be used. DOR said that they assess residents quarterly to make sure the residents were positioned well and can get around safely, but since they did not use seat belts, they did not check them. DOR confirmed they were not aware that the CNAs were putting them on, and that it was probably a miscommunication. The DOR said she had been informed that R28 did not like the seat belt, and that she would have a tough time getting it off. They stated they would review the last time they reviewed R28's seat belt.During an additional interview on 01/30/26 at 10:04 AM, the DOR said that the last full assessment for R28's wheelchair was upon admission and provided the documentation. The DOR said that the assessment stated the resident could unlock the seat belt, and it would not be a restraint.Review of the facility provided document titled Physical Therapy and Plan of Treatment, dated 10/20/22, revealed that R28, .was able to unbuckle her seatbelt upon command but needs assistance w/buckling seatbelt.due to documented physical impairments and associated functional deficits, the patient is at risk for falls, injury to RLE (right lower extremity) during power chair mobility, further decline in function, increased dependency upon caregivers and compromised general health. This documentation revealed the facility was aware that the resident had a seat belt, and that it had been in use, but there was no indication in the EMR of any ongoing follow-up to its use or safety. During a follow-up interview on 01/30/26 at 10:15 AM, DOR provided the last wheelchair assessment from physical and occupation therapy.Review of the provided Occupational Therapy Discharge summary, dated [DATE], documented R28, .demonstrates MI (modified independent) and safety with wheelchair (sic) mobility with good demonstration of safety to reduce speed through doors and include.demonstrated an increase ROM (range of motion) for right shoulder flexion to 110* from 100*. Documentation review of the last wheelchair assessment for R28 revealed no documentation or assessment related to the identification of a seat belt on the wheelchair. This was the last documentation for wheelchair or seat belt assessment. During an interview on 01/30/26 at 1:08 PM, the Director of Nursing (DON) stated that they had been informed that wheelchairs should be assessed on admission and quarterly, going forward. They said that the seat belt should be a part of the care plan. She stated that if the seat belt is not being documented as a restraint in assessments, then it should not be on the electric wheelchair. The DON said there needed to be more training for staff regarding seat belt use.Review of the facility's policy titled, Restraint and Seclusion Policy, last reviewed 01/13/26 read, in pertinent part, .residents have the right to be free from any physical or chemical restraint/or seclusion imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms.Physical Restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.In an extreme safety situation that compromises the safety of the resident or others, a provider's order may be obtained to restrain or seclude the resident until the situation has ceased or the resident has been transferred to an acute setting and the safety of the resident and others can be ensured.Documentation in the Electronic Medical Record must support the assessment for, evaluation of, and timeframe of use of a restraint or seclusion.

Based on record review, interview, and facility policy review, the facility failed to report an injury of unknown origin to the State Agency for one resident (Resident (R) 21) reviewed for injuries of unknown origin out of 31 sampled residents. The facility's failure to promptly report injuries of unknown origin limited regulatory oversight and had the potential to delay protective interventions. Findings include:Review of R21's admission Record, located under the admission tab of the electronic medical record (EMR) revealed R21 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, dementia, and transient cerebral ischemic attack. Review of R21's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/14/25, revealed that R21 had a Brief Interview for Mental Status (BIMS) score of 7 of 15, indicating that R21's cognitive function was severely impaired. Review of R21's Care Plan, initiated on 12/04/25, located under the Care Plan tab revealed that R21 had fallen and was at an increased risk for experiencing additional falls related to deconditioning, hearing problems, poor safety awareness, impulsive, muscle weakness, unsafe transfer behavior, medications, and history of falls. Interventions included following facility post fall protocol, assess for injuries, monitoring vital signs, and notifying the physician. Review of R21's Care Plan, initiated on 12/12/25, located under the Care Plan tab revealed that R21 had impaired cognitive function related to dementia with an intervention in place that included, .to cue, reorient and supervise as needed.Review of the Nurse Practitioner's (NP), note dated 01/15/26, located under the Progress Notes tab in the EMR stated, [AGE] year-old female seen today for Right arm swelling, multiple falls, dementia. She is seen sitting up in a chair in the common area. Per staff they noticed swelling on her right forearm. Patient was unaware of it, denying pain. She has had multiple falls[.] No injuries noted at the time[.] Patient is a poor historian with advanced dementia. She was able to move her right arm, no grimacing, and no pain to area. Wrist, elbow and shoulder [have] full range of motion, positive pulses, [and] cap refill less than 3 seconds.Review of the facility provided form titled, Witness Written Summary, dated 01/14/26 at 8:30 AM, written and signed by physical therapy assistant (PTA)indicated, .during therapy session, resident was noted with increased edema on right forearm and resident was unable to explain what happened and quantify pain level due to cognition. Nursing was notified.Review of the facility provided form titled, Witness Written Summary, dated 01/14/26 at 11:29 AM, written and signed by Licensed Practical Nurse (LPN) 3 stated, .resident was noted with hematoma to right forearm and unable to recall what happened. Noted with signs of pain and resident was given pain medication per physician's order and the nurse practitioner was made aware.During an interview on 01/30/26 at 11:55 AM with the Administrator, she stated .for our state, an insignificant or non-serious injury of unknown source, that we do not have to report that to them. I report and the Director of Nursing (DON) does the investigation. She and I review the reports together.During an interview on 01/30/26 at 12:07 PM with the DON, she stated, .we determine if it needs to be reported. We interview the staff, the residents and then we determine if it meets the criteria for reporting. When asked if this incident was reported to the state, she stated, No, I don't have a copy of this being reported to the state.Review of the facility's policy titled, Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime, last review date of 01/09/26, on page four of five, stated, under the item, Investigation,. All alleged incidents involving abuse, neglect, mistreatment, misappropriation of resident property, exploitation, or reasonable suspicions of crime, including injuries of unknown source, shall be reported to the Administrator or designee immediately. The Administrator or designee shall investigate allegations and report to appropriate regulatory agencies and/or law enforcement.

Based on record review, interview, and facility policy review, the facility failed to investigate an injury of unknown origin for one resident (Resident (R) 21) out of a total sample of 31 residents. The facility's failure to promptly investigate injuries of unknown origin had the potential to delay protective interventions for residents.Findings include:Review of R21's admission Record, located under the admission tab of the electronic medical record (EMR) revealed R21 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy, dementia, and transient cerebral ischemic attack. Review of R21's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/14/25, located under the MDS tab of the EMR revealed that R21 was assessed with a Brief Interview for Mental Status (BIMS) score of 7 of 15 indicating that R21's cognitive function was severely impaired. Review of R21's Care Plan, initiated on 12/04/25, located under the Care Plan tab revealed that R21 had fallen and was at an increased risk for experiencing additional falls related to deconditioning, hearing problems, poor safety awareness, impulsive, muscle weakness, unsafe transfer behavior, medications, and history of falls. Interventions included following facility post fall protocol, assessing injuries, monitoring vital signs, and notifying the physician. Review of R21's Care Plan, initiated on 12/12/25, located under the Care Plan tab revealed that R21 had impaired cognitive function related to dementia with an intervention in place that included, .to cue, reorient and supervise as needed.Review of the Nurse Practitioner's (NP) note, dated 01/15/26, located under the Progress Notes tab in the EMR stated, [AGE] year-old female seen today for Right arm swelling, multiple falls, [and]dementia. She is seen sitting up in a chair in the common area[.] Per staff they noticed swelling on her right forearm. Patient was unaware of it, denying pain. She has had multiple falls[.] No injuries noted at the time[.] Patient is a poor historian with advanced dementia. She was able to move her right arm, no grimacing, and no pain to area. Wrist, elbow and shoulder [have] full range of motion, positive pulses, [and] cap refill less than 3 seconds.Review of the paper form provided by the facility titled, Witness Written Summary, dated 01/14/26 at 8:30 AM, written and signed by physical therapy assistant (PTA ) stated, .during therapy session, resident was noted with increased edema on right forearm and resident was unable to explain what happened and quantify pain level due to cognition. Nursing was notified.Review of the paper form provided by the facility titled, Witness Written Summary, dated 01/14/26 at 11:29 AM, written and signed by Licensed Practical Nurse (LPN) 3 stated, .resident was noted with hematoma to right forearm and unable to recall what happened. Noted with signs of pain and resident was given pain medication per physician's order and the nurse practitioner was made aware.During an interview on 01/30/26 at 11:55 AM, the Administrator stated For our state, an insignificant or non-serious injury of unknown source, that we do not have to report that to them. I report and the Director of Nursing (DON) does the investigation. She and I review the reports together.During an interview on 01/30/26 at 12:07 PM, the DON stated, We determine if it needs to be reported. We interview the staff, the residents and then we determine if it meets the criteria for reporting. When asked if this incident was reported to the state, she stated, No, I don't have a copy of this being reported to the state. No, this incident was not investigated.Review of the facility's policy titled, Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime, last review date of 01/09/26, on page four of five, stated, under the item, Investigation. All alleged incidents involving abuse, neglect, mistreatment, misappropriation of resident property, exploitation, or reasonable suspicions of crime, including injuries of unknown source, shall be reported to the Administrator or designee immediately. The Administrator or designee shall investigate allegations and report to appropriate regulatory agencies and/or law enforcement.

Based on record review, interviews, and facility policy review, the facility failed to ensure one of 31 sampled residents (Resident (R) 28) care plans were reviewed and revised to identify the regular use of a wheelchair seatbelt. This failure created the potential for facility residents to receive inappropriate care and services, or a lack of, due to unidentified care needs and interventions. Cross-reference to F604, Physical Restraints.Findings include:1. Review of R28's Face Sheet, located in the Electronic Medical Record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnoses included traumatic subarachnoid hemorrhage with loss of consciousness, lack of coordination, abnormal posture, hemiplegia unspecified affecting right dominant side, personal history of traumatic brain injury, aphasia following cerebral infarction, and contracture of right elbow, wrist, and hand.Review of R28's quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 11/04/25 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) assessment score of 13 out of 15, which indicated the resident was cognitively intact. The MDS indicated R28 had functional limitations in range of motion for bilateral upper extremities and used a motorized wheelchair. R28 required substantial/maximum assistance for sitting to lying, lying to sitting on side of bed, sitting to stand, and chair/bed-to-chair transfers.Review of R28's Comprehensive Care Plan, dated 09/14/22 and located in the EMR under the Care Plan tab, revealed R28 had an ADL (activities of daily living) self-care performance deficit related to right [side] hemiparesis. An identified intervention, revised 02/26/24, documented that R28 had a power chair (motorized wheelchair) with back cushion on her wheelchair to maximize safety, comfort, and independence in mobility throughout the facility. The care plan did not identify a seat belt intervention.Further review of R28's Comprehensive Care Plan failed to identify any problem or associated interventions that indicated the resident used a seat belt while seated in the motorized wheelchair, as observed throughout the survey.During an observation on 01/28/26 at 1:19 PM, R28 was observed in their room seated in their motorized wheelchair, with a seat belt on.During an observation on 01/29/26 at 8:08 AM, R28 was observed in their room in their motorized wheelchair, with a seat belt on. During an observation on 01/30/26 at 7:55 AM, R28 was observed in their motorized wheelchair with a seat belt on.During an interview on 01/30/26 at 8:25 AM, Registered Nurse/Unit Manager (RN/UM) 1 reviewed the EMR for R28 and confirmed that there was no order for R28 to use a wheelchair seat belt. RNUM1 again, upon review of the EMR, confirmed there was no care plan for a seat belt. RNUM1 said that the nurses could add interventions, but that care plans were reviewed with the interdisciplinary team.During an interview on 01/30/26 at 8:35 AM, MDS Coordinator (MDS) 1 said that they did not capture the seat belts in MDS because it was their understanding that the rehabilitation department would assess the residents, and that they would be capable of removing them. MDS1 confirmed they did not review these assessments. MDS1 said they would expect staff to check for positioning, that they were secure, and the residents could remove them. MDS1 confirmed these interventions should be identified in a care plan. During an interview on 01/30/26 at 1:08 PM, the Director of Nursing (DON) stated that they had been informed that wheelchairs should be assessed on admission and quarterly, going forward. They said that the seat belt should be a part of the care plan. She stated that if the seat belt is not being documented as a restraint in assessments, then it should not be on the electric wheelchair. The DON said there needed to be more training for staff regarding seat belt use. During an additional interview on 01/30/26 at 5:09 PM, the DON stated that the facility did not have a policy specific to care plan revisions, just a comprehensive care plan policy.Review of the facility's policy titled, Care Planning, last reviewed 01/13/26 read, in pertinent part, .a comprehensive care plan is developed that incorporates resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practical, physical, mental, and psychosocial wellbeing.A comprehensive care plan must be prepared by an interdisciplinary team.Care plans should include: Services furnished to maintain highest practical well-being.The resident's goals for admission and desired outcomes.The resident's preferences.The comprehensive care plans should be reviewed and revised by the interdisciplinary team after each assessment.

Based on record reviews and interviews, the facility failed to ensure residents who are unable to conduct activities of daily living (ADLs) receive the necessary services for one resident (Resident (R) 73) out of a total sample of 31 residents. R73 reported that she has not received help with oral care, and she was observed to have a buildup of debris on her teeth and gums. This failure had the potential to affect nutritional status, cause dental cavities, and gum diseaseFindings include:Review of R73's admission Record, located under the admission tab of the electronic medical record (EMR) revealed R73 was admitted to the facility on [DATE] with diagnoses that included dysphagia, cognitive communication deficit, bipolar disorder, and osteoarthritis. Review of R73's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) date of 08/21/25, revealed R73 was assessed with a Brief Interview for Mental Status (BIMS) score of 12 of 15 indicating that R73 had moderately impaired cognition. The self-care functional abilities portion of the MDS for oral care revealed a score of 03 which indicated R73 required Partial/Moderate assistance, which is defined as the Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.During an interview on 01/28/26 at 11:08 AM, R73 stated she was not offered to brush her teeth in the mornings or in the evenings. During this interview, R73 was asked to open her mouth and R73's teeth and gums were observed with a buildup of white and brown debris. During an interview on 01/29/2026 at 10:26 AM, R73 did not have a toothbrush at the bedside and stated that she still had not received assistance to brush her teeth this morning or last night. During an interview on 01/29/26 at 2:17 PM, R125, assessed with a BIMS score of 15 of 15 on the quarterly MDS with an ARD of 12/16/25, stated, I brush my teeth on my own, but I have to ask for my toothbrush and toothpaste to be brought to me. It is inside my nightstand. If I don't remind them, they won't bring it to me.During an interview on 01/29/26 at 2:19 PM, R17, assessed with BIMS score of 15 of15 on the quarterly MDS with an ARD of 11/09/25, stated, I wheel myself to the bathroom to brush my teeth.During an interview on 01/29/26 at 2:20 PM, R33, assessed with a BIMS score of 15 of 15 on the quarterly MDS with an ARD of 11/11/25, stated, I wheel myself to the bathroom to brush my teeth.During an interview on 01/29/26 at 2:23 PM R66, assessed with a BIMS score of 15 of 15 on the annual MDS with an ARD of 01/17/26, stated, They have to be reminded to give me my toothpaste and toothbrush. If I don't ask for it, they won't bring it to me.During an interview on 01/30/2026 at 2:15 PM, R73 stated supplies to brush her teeth were not [NAME] to her last night or this morning and staff had not offered to assist her to brush her teeth. She stated, I still haven't brushed my teeth. I didn't ask for the supplies to be brought to me. R73 went on to say, You have to ask, if you don't, it will not be brought to you.During an interview on 01/30/26 at 11:00 AM, the Staff Development (SD) stated, The expectation is that staff should offer mouth care to residents and not have to be reminded by the residents that they need their mouth care supplies. This is all part of my orientation education upon hire for Certified Nursing Assistants (CNAs). During an interview on 01/30/26 at 12:20 PM, the Director of Nursing (DON) stated, The expectation is that the staff provide morning (AM) and evening (PM) care - personal hygiene, showers are scheduled on preferred day/time, including oral care. The CNA will take the outfit out of the closet, prepare the brief, water, washcloths, comb the resident's hair, shaving if necessary, grooming, brushing teeth or dentures, the CNA will set up toothpaste, toothbrush, and mouthwash, if any and perform the procedure if the resident is unable to perform the oral care themselves.During an interview on 01/30/26 at 3:00 PM, CNA4 stated, Oral care is part of morning (AM) care. When I come in for morning care, I let the residents know that I will help them get cleaned up from head to toe, basically.During an interview on 01/30/26 at 3:05 PM, CNA5 stated, Oral care is part of the morning care for residents. There are some residents that can't do the oral care on their own, and I make sure that I assist them.During an interview on 01/30/26 at 6:24 PM, CNA6 stated, Yes I usually work this unit. I usually work with R73 in the evenings. R73 is very chill, she is a heavy wetter so whenever I change her, I must change her sheets too. Sometimes she refuses to have her shirt changed or even her bed sheets changed. Sometimes I offer to have her brush her teeth in the evenings.Review of the educational presentation for CNAs, upon hire, titled, Oral Care, on page two of eight, revealed, Mouth care should be given in the morning, at bedtime and after meals and on page seven of eight, under the section titled, Personal Hygiene, revealed, this includes combing hair, brushing teeth, shaving, applying makeup, washing/drying of face and hands.

Based on record review, interviews, and policy review, the facility failed to assess and monitor comfort care (end of life) for one of three residents (Resident (R)122) reviewed for comfort care out of 31 total sampled residents and failed to follow physician orders for an ordered medication (Hyoscyamine Sulfate) for one of 31 residents. These failures had the potential for R122 not to receive the comfort care measures that she deserved at the end of life and not to receive physician ordered medication to control increased secretions which would cause R122 to have difficulty breathing.Findings include:Review of R122's undated Face Sheet, located under the Profile tab in the electronic medical record (EMR) indicated R122 was admitted to the facility on [DATE] with diagnoses of unspecified dementia, severe, with other behavioral disturbance, anxiety disorder, and chronic pain.Review of R122's annual Minimum Data Set (MDS), located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 09/12/24, indicated R122 had a Brief Interview for Mental Status (BIMS) score of two out of 15 which indicated R122 was severely cognitively impaired. Review of R122's Care Plan, located under the Care Plan tab in the EMR and dated 11/09/22 indicated R122 had a Focus of [R122] is on comfort care. Interventions were to . Assess for pain levels and contact physician for pain management with uncontrolled pain. Comfort Care: No hospitalization, No lab work, No tube feeding, No IV [intravenous] fluids, No weights, Yes liberalized diet and supplement, Yes antibiotics, Yes medication d/c [discontinue] per provider review.Review of the Progress Notes, located under the Progress Note tab in the EMR revealed a Provider Note dated 10/30/24 in which the Nurse Practitioner (NP) documented . slowly declining. There was no documentation that R122 was experiencing pain at that visit.Continued review of the Progress Notes, indicated from 10/31/24 through 11/07/24 the nursing progress notes did not reflect documentation of R122 having increased pain or shortness of breath (SOB).Review of R122's Medication Administration Record (MAR), dated November 2024 indicated from 11/01/24 through11/08/24 documentation reflected pain was assessed every shift using the Behavioral Pain Scale which indicated R122 had a pain level of 0 during this time.Further review of the Progress Notes, documentation indicated on 11/08/24, the NP (Nurse Practitioner) documented, . Nursing reported patient to have decreased oral intake. Patient lying in bed on room air without respiratory distress. displays no signs/symptoms of pain/discomfort. Plan: .Excessive secretions: None at this time. Ordered Hyoscyamine Sulfate [Levsin] sublingual 0.125 mg [milligram]. Give 1 [sic] tablet sublingually. Agitation/restlessness: None at this time. Ordered continue lorazepam 0.5 mg every 6 [sic] hours as needed. Pain/Shortness of breath: None at this time. Morphine Sulfate (Concentrate) 20 MG/ML [milligram per milliliter], 0.25 ml every 4 [sic] hours as needed.Review of the Nursing Progress Note, dated 11/08/24 at 4:29 PM located under the Progress Notes tab in the EMR indicated, Resident continues to decline and have poor intake. NP made aware.Review of the Administrative Note, dated 11/12/24 at 12:00 AM, located under the Progress Notes tab in the EMR revealed the nurse documented Morphine Sulfate (Concentrate) 20 MG/ML Give 0.25 ml by mouth every 4 [sic] hours as needed for Pain/SOB/Comfort. Resident was in distress and was given Morphine for comfort. The nurse did not complete a nurse note to document what distress R122 was having at this time.Review of the MAR for 11/12/24 at 12:00 AM, indicated R122's pain level was documented as a 4 out of 10 using the behavioral assessment but, the MAR did not provide documentation of how the pain level of four was determined at that time. There was no nursing note dated and timed for this administration of Morphine to indicate how the pain level of four was obtained using the behavioral assessment.Review of a Nurses Note, dated 11/12/24 at 11:51 AM, located under the Progress Notes tab in the EMR revealed the nurse documented, Resident with decreased responsiveness and not able to take po [by mouth] food/fluids. Daughter at bedside and requesting PRN [as needed] Roxanol [Morphine Sulfate] be routine to help keep resident comfortable. NP made aware of above and assessed resident. New order to add Roxanol 5 [sic] mg SL [sublingual] every 4 [sic] hours along with PRN as previously ordered.Continued review of R122's MAR dated 11/12/24, revealed R122 was assessed every shift and on day shift for this date, R122 was experiencing a pain level of 4 but the MAR did not provide documentation of how the pain level of four was determined at that time. The EMR did not contain a nursing note dated and timed for this administration of Morphine to indicate how the pain level of four was obtained using the behavioral assessment.Review of the Progress Note, dated 11/14/24, located under the Progress Notes tab in the EMR revealed the NP made a visit with R122 and changed . Hyoscyamine Sulfate 0.125 mg every 4 [sic] hours routinely.Further review of the nursing progress notes for R122 from 11/12/24 through 11/21/24 did not reflect assessments of R122 and indicate if R122 was experiencing any declines. Review of the Nursing Note, dated 11/21/24 at 10:33 AM, located under the Progress Note tab in the EMR indicated, Resident seen by NP for increased secretions. New order: Increase Levsin 0.25 Q2h [sic] [every two hours] for increased secretions/end of life. Order updated in MAR.Review of the Administrative Note, dated 11/21/24 at 9:44 PM, located under the Progress Note tab in the EMR indicated the nurse documented Hyoscyamine Sulfate Oral Tablet 0.125 mg Give 1 [sic] tablet by mouth every 2 hours for increased secretions/end of life Resident not able to swallow.Review of the Nursing Progress Note, dated 11/22/14 at 3:27 AM, located under the Progress Note tab in the EMR indicated Resident stopped breathing at 0215.Review of the nursing notes from 1/21/24 at 9:44 PM through 11/22/24 at 3:27 AM, the nursing notes did not reflect an assessment of R122 or if there were any further signs of R122's of impending death.During an interview on 01/29/26 at 5:15 PM, Registered Nurse/Unit Manager (RN/UM)1 stated, [R122] was only alert to self. The nurse does a behavioral assessment for pain which comes up each shift and each time you administer pain medication. The behavioral assessment has certain different behaviors that you assess and depending on what you are seeing then you click on that behavior and at the end, the computer gives you a number pain level. RN/UM1 confirmed the only training/education she received was in nursing school and she stated she graduated from this in 2010. The RN/UM1 was asked what resources she as a supervisor used to make sure your staff deliver the most updated care to a resident on comfort care. RN/UM1 stated, I would follow the orders that the MD [medical doctor] or NP wrote for us to follow.During an interview on 01/29/26 at 5:30 PM, the Infection Preventionist/Staff Coordinator (IP/SC) stated, I have only been in this role for 29 days. I have not prepared for any additional education other than what staff gets on hire in orientation. We empower the staff to call the provider if they have any questions about unclear orders or if there is a problem with the order that has been given. For pain assessments, the nurse can assess particular behaviors if the resident is unable to verbalize pain and for alert residents the nurse can ask the resident to describe the level of pain they are experiencing. If the nurse is performing a behavioral pain assessment, the nurse goes through each behavior on the behavioral assessment and at the end the computer will add up the nurses' responses and a pain level will be documented as a number that correlates with the nurses' responses. The IP/SC was asked how the surveyor could review the responses that the nurse clicked on to get the pain level number and she stated, I don't believe that you can. The nurse should make a note as to her assessment of what she is seeing at the time the pain medication was given along with the pain level score. If the nurse notices a decline in the resident's condition, then that should be documented as well.During an interview on 01/30/26 at 2:53 PM, the Director of Nursing (DON) reviewed the nursing progress notes, under the evaluations and vital signs tab, and MAR from 11/01/26 through 11/07/26 and stated, I don't see anything documented before the 8th of November that the resident was experiencing pain. I see where they discontinued the order for Levsin 0.125 mg for one tablet every two hours and put in an order for Levsin 0.125 mg Give two tablets every two hours but under the administrative times, the boxes have x's in them and no documentation of this order being given to [R122]. I can't explain why this happened. The nurses' chart by exception and only chart if there is a noted change in condition of the resident. Asked the DON when the medication changes were made for increased pain medication, increased secretions or the resident was unable to swallow, would these be changes in condition that would warrant alert charting. The DON stated, The nurse could have started the alert charting at that time. Anyone can initiate alert charting when it is needed. The nurses receive education on comfort care in the module on Advance Directives. We do not have a Comfort Care Policy, but we have a Palliate/Hospice Care Policy.During an interview on 01/30/26 at 7:46 AM, Licensed Practical Nurse (LPN)2 was asked about her assessment on the night shift on 11/21/24 and LPN2 stated, I didn't document in detail what she was doing. I should have documented exactly what I was seeing. She also stated, From what I saw in my documentation that I read last night she [R122] was restless and I gave her Morphine. I should have documented her restlessness instead of distress. I don't see any assessments charted. LPN2 was asked if assessments should have been completed for this resident? LPN2 replied Yes, we should have definitely charted assessments done on this resident. LPN2 stated ,[The RN/UM1] usually does that when she was asked who could initiate alert charting. Asked LPN2 if she initiated the alert charting during her shift on 11/21/24 due to the resident not being able to swallow on 11/21/24 at 9:44 PM. LPN2 stated, No, I didn't but I should have. LPN2 was asked if she had received any education on comfort care during her employment with the facility and LPN2 stated, No, what we have is usually on Relais that we do. I had some education on comfort care in nursing school and I graduated in 2006. LPN2 was asked if she assessed the resident on her shift and noted any changes in these assessments in the nursing progress notes. LPN2 stated, I probably went in there every two hours to check in on her, but I did not make any notes of this in her chart. I had some education on comfort care in nursing school and I charted this way. I have had patients pass away lately and it is more detailed than this. LPN2 was asked what should have been charted/documented and LPN2 stated, That I checked her vital signs, and notified the supervisor, checked for lung sounds, heart rate, and temperature. I see that I should document everything even if they are not on alert charting. I cannot believe that I charted this way and left important information out that should have been charted.Review of staff education for Comfort Care provided during training on Advance Directives . Comfort Care stated, Residents on hospice, palliative care and comfort care should have orders for pain medication. Morphine is often ordered for end of life as a pain regimen and to help with shortness of breath/air hunger.Review of the facility's policy titled, Alert Charting, dated 01/09/26 indicated, . Whenever a significant change occurs in a resident's condition, the resident may be placed on alert charting. Residents placed on alert charting are assessed by the nurse each shift and assessment data entered into nursing notes. Nursing judgement determines when a resident is placed on and removed from alert charting notes. Document objective data related to the resident's condition. presence or absence of pain, and response or lack of response to treatment.The facility did not have a comfort care policy to direct the nursing care of the resident receiving this service while in the facility.Review of the online training module titled, Advance Directives, under the section Comfort Measures indicated, Residents on hospice, palliative, and comfort care should have orders for pain medication. Morphine is often ordered to end of life care as a pain regimen and to help with shortness of breath/air hunger.

Based on observations, record review, interviews, and policy review, the facility failed to administer oxygen in accordance with physician orders for one of one resident (Resident (R) 4) reviewed for oxygen therapy out of a total of 31 residents sampled. This failure had the potential to cause R4 to retain carbon dioxide and increased the risk of oxygen toxicity.Findings Include:Review of R4's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R4 was admitted to the facility on [DATE] with the diagnosis of chronic obstructive pulmonary disease (COPD).Review of R4's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 01/01/26 indicated R4 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated R4 was cognitively intact. R4 was also coded as receiving oxygen therapy while a resident in the facility. Review of R4's Care Plan located under the Care Plan tab in the EMR and dated 07/22/24 indicated a Focus which stated, [R4] has altered respiratory status/difficulty breathing r/t [related to] Chronic [sic] respiratory failure, COPD, CHF [congested heart failure], Sleep Apnea [sic]. The intervention indicated, Oxygen as ordered.Review of R4's Physician Orders located under the Orders tab in the EMR indicated an order dated 06/30/25 for Oxygen at 4 LPM [liters per minute] via [by] NC [nasal cannula] . During observations on 01/27/26 at 12:45 PM, 01/28/26 at 11:25 AM, and 01/30/26 at 10:40 AM, R4 was lying in bed with the oxygen concentrator approximately two feet from the left side of the bed, administering oxygen at 4.5 LPM via nasal cannula.On 10/30/26 at 10:43 AM, Registered Nurse/Unit Manager (RN/UM) 1 accompanied the surveyor to R4's room. RN/UM1 confirmed the oxygen was being administered at 4.5 LPM via nasal cannula. RN/UM1 reviewed the Physician Orders in the surveyor's laptop and confirmed the order for R4's oxygen administration was to be at 4 LPM instead of 4.5 LPM. RN/UM1 adjusted the oxygen concentrator to administer oxygen to R4 at 4 LPM. When asked if R4 was able to get out of bed to adjust the oxygen concentrator on her own, RN/UM1 stated, No. She [R4] cannot.During an interview on 01/30/26 at 2:36 PM, the Director of Nursing (DON) confirmed the orders for R4's oxygen were for 4 LPM.Review of the facility's policy titled, Nasal Oxygen Administration, dated 01/13/26, indicated, . Read and note the physician's written order for nasal oxygen with stated flow rate in liters per minute.

Based on record review and interviews, the facility failed to ensure the medical record was complete and accurate for one resident (Resident (R) 48) out of 31 total sampled residents. The facility failed to ensure current Physician Orders reflected an active order for R48's Comfort Care Program. This failure had the potential for residents to have unmet care needs. Findings include:Review of R48's admission Record, located under the admission tab of the electronic medical record (EMR) revealed R48 was admitted to the facility on [DATE] with diagnoses that included heart failure, peripheral vascular disease, cerebral infarction with right-sided weakness, history of falls, and chronic obstructive pulmonary disease. Review of R48's Clinical Profile, in the EMR, revealed that R48 had Special Instructions: COMFORT CARE: NO further hospitalization, NO IV fluids, NO discontinuation of medication, NO weights, YES lab work, YES supplements, YES antibiotics.Review of R48's Order Summary, located under the Orders tab in the EMR revealed that the order, COMFORT CARE: NO further hospitalization, NO IV fluids, NO discontinuation of medication, NO weights, YES lab work, YES supplements, YES antibiotics were discontinued on 02/27/25 and 05/29/25. During an interview on 01/30/26 at 9:36 AM, Licensed Practical Nurse (LPN) 4 stated, R48 is able to make her needs known. When she is up to it, she wheels herself around the building. When asked to describe what Comfort Care was, she stated, Comfort care is just one level down palliative care, we make them comfortable, pain free, I believe by the time the patient is on comfort care, I'm trying to find the words to say, they are just trying to be comfortable, no more invasive or aggressive procedure, if with infection such as a Urinary Tract Infection (UTI) it can still be treated. LPN4 was asked how she would know if a resident was on the Comfort Care Program? LPN4 stated, The Unit manager will let us know that the resident was placed on comfort care. For example, I would verify the order with RN/UM2 that she [the resident] was on comfort care. When asked to check for a Comfort Care physician order in the EMR for R48, she stated, There is supposed to be an active order for comfort care for R48. I am checking just to be sure because it might be somewhere else. I might be missing it; I'm looking through, but I don't see it. Not that I can't see. It's just not there.During an interview on 01/30/26 at 9:57 AM, RN/UM2 was asked if there should be an active physician order in R48's list of Physicians' orders and RN/UM2 stated, Do you mean in the orders? Yes, it should be listed in the active orders. RN/UM2 was asked to show where the active physicians' order for Comfort Care was located in the EMR, and she confirmed that there was no active physician order listed.

Based on record review, interviews, document review, and review of McGeer's criteria, the facility failed to have an Antibiotic Stewardship Program consistent with current standards of practice for the prescribing of an antibiotic for one of five residents (Resident (R) 71) reviewed for antibiotic stewardship out of a total sample of 31 residents. This failure had the potential to result in the unnecessary use of antibiotics, increasing the risk of antibiotic resistance and adverse medication-related side effects for residents. Findings include:Review of R71's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R71 was admitted to the facility on [DATE] with the diagnosis of Parkinson's Disease.Review of R71's Nursing Progress Notes located under the Progress Note tab in the EMR indicated on 05/25/25 at 12:10 PM the nurse documented, Resident was not feeling well. O2 [Oxygen saturation] 89-90% [percent] on room air. 96% on 2L [liters] of oxygen; right upper lobe congested; [name of NP] notified and order for albuterol nebulizer Q6H [every six hours] prn [as needed] and stat chest x-ray.Review of R71's chest x-ray results dated 05/25/25 and provided by the facility indicated the reason for this test was Wheezing. The findings were . Bilateral lower lobes infiltrates. Right pleural effusion . Review of R71's Physician Orders located under the Orders tab in the EMR indicated an order dated 05/25/25 for Amoxicillin-Clavulanate Potassium (antibiotic medication) 875-125 milligram give one tablet by mouth twice a day for bilateral lobe infiltrates for seven days.Review of R71's Medication Administration Record (MAR) dated May and June 2025, indicated R71 completed the course of the antibiotic that was prescribed on 05/25/25.Review of R71's Potential Infection Evaluation provided by the facility and dated 05/27/25 indicated documentation as follows: -Temperature 97.8 degrees Fahrenheit on 05/25/25-Most Recent O2 sats (saturation) 89% on 05/25/25- . Lower Tract Infection-Does the resident have a fever? . No fever . -Does the resident have chronic obstructive pulmonary disease (COPD)? Yes . -Is the resident over 65? Yes . -Does the resident have a new or increased cough with purulent sputum production? . No [Does not MEET criteria for LRI] . Nursing home protocol criteria are . NOT MET, The resident does not need an immediate prescription for an antibiotic, but may need additional observation . Review of R71's Provider Progress Notes located under the Progress Note tab in the EMR and dated for 05/27/25 indicated, . Plan . Pneumonia, acute - CXR [chest x-ray] showed bilateral lower lobe infiltrates. Pt. [patient] was started on Augmentin for pneumonia on 5/25 . Monitor clinically . Review of the EMR revealed R71 had no lab work completed prior to the start of the antibiotic, had no documented fever, and had no change in function or mental status.Review of the facility's Infection Control Surveillance Log dated January through December 2025 and provided by the facility indicated the logs had missing documentation to reflect the signs and symptoms the resident was experiencing, organism that was present on the culture results if one was obtained, and if the McGeer's criteria were met. During an interview on 01/30/26 at 5:00 PM, the Infection Preventionist/Staff Coordinator (IP/SC) confirmed that R71 did not meet criteria for use of an antibiotic according to the Potential Infection Evaluation form used the facility, since she had no cough. The IP/SC stated that was a form used by the prior IP, and she had not realized it did not coincide with McGeer's criteria, which the facility used.During an interview on 01/30/26 at 5:00 PM, the Director of Nursing was asked her expectations for residents receiving antibiotics and the DON stated, The symptoms that the resident is having meets McGeer's criteria for the use of the antibiotics prescribed.Review of the McGeer's Criteria located at www.nursinghomehelp.org/educational/infection-control-guidelines indicated the following for Revised McGeer Criteria for Infection Control Surveillance Checklist for Pneumonia: Must fulfill 1, 2, and 31. Chest X-ray with pneumonia or a new infiltrate2. At least one of the following criteria-New or increased cough-New or increased sputum production-O2 sat < [less than] 94% on room air, or > [greater than] 3% decrease from baseline O2 sat-New or changed lung exam abnormalities -Pleuritic chest pain-Respiratory rate >/= [greater than or equal] 25 beats/ [per] minute3. At least one of the following criteria -Fever-Leukocytosis-Acute mental changes-Acute functional declineReview of the facility policy Antibiotic Stewardship dated 01/13/26 indicated, It is the policy of [name of facility] to establish an antimicrobial stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance . utilize McGeer's Criteria for assessing residents and appropriate diagnostic testing .

Based on observation, interview, record review and review of other facility documentation, it was determined that for one (R1) out of three residents sampled for accidents, the facility failed to ensure that R1received adequate supervision to prevent accidents. R1, a completely dependent resident, fell on her face from the bed to the floor while receiving care from a staff member and sustained multiple rib fractures, clavicle fracture and splenic laceration. The facility's failure to provide adequate supervision caused harm to R1. Findings include: 1/20/09 - A facility document entitled, Fall Assessment, Prevention, and Management, revised 1/20/23 and 1/3/25 included, It is the policy of [name of facility] to assess for all risks and implement measure to prevent and manage the identified risks. The document also included, Factors that may result in resident falls include, but are not limited to. environmental hazards. functional impairments.R1's clinical record revealed:3/17/21 - R1 was admitted to the facility with diagnoses including but not limited to dementia, muscle weakness, contractures of left knee and both ankles, hemiplegia and hemiparesis.3/18/21 - R1's admission fall care plan [revised 5/28/24] documented, At risk for falls related to weakness, cognitive deficits, incontinence.3/29/21 - R1's activities of daily living [ADLs]care plan [revised 9/21/21] documented, .ADLs - self-care performance deficient r/t [related to] muscle weakness, decreased mobility. The interventions included, Assist with daily hygiene, eating toileting, dressing .The care plan lacked documentation of how many staff members were needed to assist with the ADLs.4/3/24 - R1's mobility/transfer form documented, Potential for impaired mobility. The interventions included, Resident requires Hoyer lift [mechanical lift] with transfers (assist of 2.) Resident requires assist of two [persons] with rolling side to side.5/29/25 - R1's clinical record documented, LAL [low air loss mattress].R1's clinical record lacked evidence of a care plan for safety/bed mobility for the use of the low air loss mattress.11/4/25 - R1's quarterly MDS assessment documented impairments on both upper and lower extremities, required set up/clean up assistance with eating, and complete dependence on staff for all other activities of daily living, including incontinence care and rolling from side to side in bed.11/5/25 - R1's quarterly fall assessment documented a fall risk score of 5 (high).11/7/25 10:51 AM - R1's clinical record documented, .Resident was receiving morning care by CNA. When turning onto her right side, resident was rolled onto the floor. When nurse responded, resident was seen lying face down leaning on her left side.11/7/25 2:08 PM - A facility reported document submitted to the Division documented, Fall from bed to floor, resident c/o [complained of] pain to her head, and left flank. Physician present and made aware, orders obtained to transfer her to the ER [emergency room] for further evaluation.11/9/25 7:45 PM - A hospital reported document submitted to the Division documented, Immobile pt. [patient] fell out of bed while being changed. Multiple rib fx [fractures], clavicular fx and splenic lac [laceration].11/13/25 1:15 PM - During an interview, E7 (UM) stated, The residents' transfer, and bed mobility status are in the closet. That is how the staff knows how to transfer and move them. [R1] required 2 persons for rolling from side to side, and 2 persons with the Hoyer lift for transfers.11/13/25 1:30 PM - During an interview, E4 (OT) stated, [R1] required 2 persons assistance to roll from side to side for the staff to wash and clean her. She was not able to help with her care.11/13/25 2:00 PM - During a telephone interview, E5 (CNA) stated, I have been an aide for four years, but I was new to this facility. I was told that this resident [R1] was on my assignment for the shift. I rolled her on her side to clean her bottom, and she rolled out of the bed on to her face. The Surveyor asked E5 if she knew where the transfer/bed mobility/rolling side to side information for the resident was located. E5 stated, I was told it was in the closet, but I was not actually shown where it was located. I saw other aides take care of her by themselves, so I thought I have to do her care by myself. No one ever told me I had to have another aide with me when I was taking care of her. The Surveyor asked E5 whether R1 was able to move, hold herself to the side in the bed or assist in her ADLs, E5 stated, No, she was not able to move herself or help with anything. The staff did everything for her.11/13/24 2:20 PM - The facility 5 day follow up report submitted to the Division included, .Resident remains hospitalized at this time. Upon return she is to be evaluated by therapy and care plan will be updated to include concave LAL and bilateral fall mats while in bed.11/14/25 10:00 AM - During a combined interview with E1 (NHA) and E2 (DON), the Surveyor asked what the facility's investigation revealed to be the root cause of R1's fall. E1 stated, The aide did not position her properly in the bed and she rolled out. The Surveyor asked E1 whether the facility had identified that the R1's plan of care for two persons assistance with rolling side to side was not implemented during incontinent care. E1 stated, The resident did not have to be rolled side to side for incontinent care. The aide's statement said that she had positioned her [R1] on her side for 5 minutes before she rolled out of the bed.11/14/25 2:00 PM - During an interview, E2 provided the Surveyor with an undated document, entitled, Plan of Correction. The document included, The facility conducted a root cause analysis, and it was determined that the assigned CNA did not safely position the resident during incontinence care to avoid the resident from rolling out of bed. Ad hoc QAPI meeting was conducted facility leadership. Employee was immediately educated and suspended pending investigation. A house wide audit was conducted of all mobility care plans for residents who are assist of two. No issues were identified. All nurses and CNAs were re-inserviced on safe positioning during care and transfer status/bed mobility care plans.The facility's investigation failed to identify that R1, a completely dependent resident, who was care planned for the assistance of two staff members with rolling side to side, required two persons assistance for moving and turning in bed to prevent her from rolling out of the bed during incontinence care.The facility failed to ensure that R1's incontinence care was completed with the required number of staff members according to her plan of care. This failure resulted in R1 falling from the bed and sustaining injuries.11/14/25 2:30 PM - Findings were reviewed with E1 (NHA) and E2 (DON) at the exit conference.

Based on observation, interview, record review and review of other documentation as indicated, it was determined for one (R1) out of three residents reviewed for change of condition, the facility failed to initiate CPR for R1, who was choking and became hypoxic and unresponsive. The RN supervisor did not assess R1's airway or respiratory status after choking and only delegated applying a non-rebreather mask and preparing for transfer without initiating CPR or further emergency intervention. The facility's failure resulted in R1 death. Due to this failure an Immediate Jeopardy (IJ) was called at 1:58 PM on 7/3/25. Findings include: Cross Refer F726A facility policy last reviewed 1/3/25 for Code Status Policy documented. Staff will initiate CPR when cardiac or respiratory arrest occurs for residents who have requested CPR on their Code Status Form. Review of R1's clinical record revealed:6/6/25 - R1 was admitted to the facility with diagnoses including, but were not limited to, stroke with right-sided paralysis, chronic respiratory failure with hypoxia (low oxygen concentration), and dysphagia (trouble swallowing).6/12/25 - R1's admission MDS revealed R1 was cognitively intact. 6/20/25 - R1's facility resuscitation form for CPR revealed. Full code means use CPR to attempt resuscitation. The form was signed and dated by R1 on 6/20/25. 6/29/25 3:35 PM - E8 (LPN) was notified by R1's F1(wife) the resident was choking. 6/29/25 3:43:20 PM - Review of a prehospital paramedic report revealed upon arrival to the facility on patient contact BLS (Basic Life Support) advised staff member was holding the head of R1 in a neutral sniffing position and R1 was gasping for air. CPR was started R1 was placed on monitor and found to be in asystole. A tube was attempted to be placed in R1's throat and was met with resistance then chewed up food was observed coming up the tube.7/2/25 10:03 AM - During a phone interview E9 (Paramedic) revealed and confirmed. EMT's arrived a minute, before the Paramedics. R1 was sitting up in the wheelchair in the chin to chest position, very pale and did not appear to be breathing. A nurse standing behind R1 and no CPR was being performed. R1 was transferred to the stretcher took a gasping breath and was pulseless and in cardiac arrest (heart stops beating) Paramedics started CPR. 7/2/25 1:03 PM - During a phone interview, F1 revealed. The family brought food in from a restaurant and R1 had cheesesteak. R1 was eating the meat out of the bread so she could have more meat and less bread, R1 choked and inhaled after coughing and somehow inhaled part of the cheesesteak. F1 stated, I told [E8] [R1] was choking. The RN supervisor came and looked at her and talked to her, and then [E7 (RN Supervisor)] called 911. F1 confirmed, [R1] was not able to speak words. 7/2/25 1:14 PM - During a phone interview, E7 stated, I was notified that [R1] had choked while eating and was hypoxic, [R1] exhibited signs of respiratory distress and was not verbally responsive I instructed [E8] to put a non-rebreather mask on [R1], I went to call 911. E7 confirmed and stated, No I did not listen to [R1's] lungs.7/2/25 1:30 PM - During a phone interview, E8 reported that the nurse was notified R1 was choking on food. R1 was unable to speak in full sentences and was slow to respond. At the time, R1 was receiving continuous oxygen at 3/lpm via nasal cannula, with an oxygen saturation of 64% and a heart rate ranging from 149 - 150 bpm. R1 was brought back to the room and switched to an oxygen concentrator; however, the non-rebreather mask was not inflating. R1 was then placed back on the oxygen tank at a flow rate of 15/lpm. R1's oxygen saturation improved slightly to around 77%, with respirations noted at 10 per minute. E8 stated, Typically [R1'] s oxygen saturation is 92% or higher. E8 also confirmed, I did not listen to [R1's] lungs during this time.The RN supervisor and other staff did not assess R1's airway or respiratory status, nor did they take appropriate emergency measures such as listening to lung sounds or abdominal thrusts. The facility also failed to initiate CPR for R1 who was hypoxic and unresponsive, despite R1's documented full code status. 7/3/25 1:58 PM - The facility's response to abatement for R1's incident was reviewed. All staff in the facility and staff reporting for scheduled shifts were provided with In-service education on responding appropriately to clinical emergencies inclusive of conducting thorough assessments and initiating appropriate interventions, for airway management, complete physical assessments and the initiation of life-saving interventions presented by the staff educator. A clinical tool was created Rapid Response Team/Code Blue. The RN Supervisor will utilize this form to document the residents' clinical situation, background, assessment, intervention (staff member to stay with resident until condition resolves or transfer to hospital, code and outcome.) Facility staff interviews were conducted starting 7/3/25 to verify in-service education, staff interviews concluded on 7/7/25 at 2:30 PM. Staff training records were reviewed; the facility's date of abatement is 7/5/25 at 4:00 PM. 7/7/25 2:45 PM - Findings were reviewed with E1(NHA), E2 (DON), E3 (ADON) and E4 (CNO) at the exit conference.

Based on observation, interview, and record review it was determined that for one (R1) out of three residents reviewed for change in condition the facility failed to ensure that licensed nursing staff had the skill set to recognize an emergent situation. R1 had a choking episode that progressed to respiratory distress which compromised R1's breathing. Nursing staff failed to provide competent nursing care for R1 that included assessments and interventions for a resident that had a change in respiratory status. Additionally, R1 was a full code and staff failed to initiate CPR on R1's behalf. The facility's failure resulted in R1's in death. Due to this failure an Immediate Jeopardy (IJ) was called at 2:20 PM on 7/3/25. Findings include:Cross Refer F678A facility policy last reviewed 1/23/25 for Provider Notification of Resident Change in Medical Condition documented. That a resident experiencing a significant change in condition is monitored continuously until the resident is stable or transferred to another level of care. A review of R1's clinical record revealed:6/6/25 - R1 was admitted to the facility with a diagnosis including, but were not limited to, stroke with right sided paralysis, chronic respiratory failure with hypoxia (low oxygen concentration) trouble swallowing. 6/20/25 - R1's facility resuscitation form for CPR revealed. Full code means use CPR to attempt resuscitation. The form was signed and dated by R1 on 6/20/25. 6/29/25 1:22 PM - A review of R1's vital signs documented. Oxygen saturation of 95% via nasal cannula. 6/29/25 3:35 PM - E8 (LPN) was notified by R1's F1 (wife) the resident was choking. E8 reported R1 was in respiratory distress. R1's oxygen saturation was 64% on 3 Liters of oxygen and heart rate was 149 - 150 beats a minute. 6/29/25 3:40 PM - Facility video surveillance revealed R1 was taken back to the room in the wheelchair with her head down and chin to chest. 6/29/25 3:48 PM - A review of R1's vital signs documented. Oxygen saturation of 77% via oxygen mask. 6/29/25 3:50:14 PM - Facility video surveillance revealed EMT's arrived to R1's room.PM Paramedics entered [R1's] room at 3:51:12 PM. 7/2/25 10:03 AM - A phone interview, with E9 (Paramedic) revealed upon entering the room R1 was in the wheelchair chin to chest, very pale and did not appear to be breathing. E9 confirmed R1 was pulseless and in asystole in (cardiac arrest) and no CPR had been performed. 7/2/25 1:30 PM - During a phone interview E8 reported that the nurse was notified R1 was choking on food. R1 was unable to speak in full sentences and was slow to respond. At the time, R1 was receiving continuous oxygen 2 liters per minute via nasal cannula, with an oxygen saturation of 64% and a heart rate ranging from 149 to 150 beats per minute. R1 was brought back to the room and switched to an oxygen concentrator; however, the non-rebreather mask was not inflating. R1 was then placed back on the oxygen tank at a flow rate of 15 liters per minute. R1's oxygen saturation improved slightly to 77%, with respirations noted at 10 per minute. E8 stated, Typically R1's oxygen saturation is 92% or higher. E8 also confirmed, I did not listen to [R1's] lung's during this time.7/2/25 9:22 AM - During an interview, E2 (DON) stated, Staff stated R1 was responsive, and she was not choking.7/3/25 1:58 PM - The facility's response to abatement for R1's incident was reviewed. All staff in the facility and staff reporting for scheduled shifts were provided with In-service education on responding appropriately to clinical emergencies inclusive of conducting thorough assessments and initiating appropriate interventions, for airway management, complete physical assessments and the initiation of life - saving interventions presented by the staff educator. A clinical tool was created Rapid Response Team/Code Blue the RN Supervisor will utilize this form to document the residents' clinical situation, background, assessment, intervention (staff member to stay with resident until condition resolves or transfer to hospital, code and outcome.) 7/3/25 4:55 PM - An interview with E8 confirmed, In-service training and education had been provided prior to the start of the 3PM - 11PM shift. 7/5/25 - Review of the facility's attendance in-service training record for Recognizing and Responding to Medical Emergencies confirmed, E7 had been provided in-service training and education prior to the start of the shift.Facility staff interviews were conducted starting 7/3/25 to verify in-service education, staff interviews concluded on 7/7/25 at 2:30 PM. Staff training records was reviewed; the facility's date of abatement is 7/5/25 at 4:00 PM. 7/7/25 2:45 PM -Findings were reviewed with E1 (NHA), E2 (DON), E3 (NHA) and E4 (CNO) at the exit conference.

Based on record review and interview, it was determined that for one (R1) out of three residents reviewed for Neglect, the facility failed to identify and report an allegation of neglect when on [DATE], R1 had a choking episode and the present staff failed to provide essential services (airway clearance, assess lung air movement and initiate CPR) required to intervene on behalf of R1. Findings include: Cross refer F678 and F726Facility's Abuse, Neglect. policy stated, Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress and includes: lack of attention to physical needs of the resident; . Identification- Abuse may be identified through assessment of residents with unexplained changes in behavior and/or suspicious injuries and review of grievances and events for patterns and trends. Reviewed [DATE]. [DATE] - R1 was admitted to the facility with diagnoses including, but were not limited to, stroke with right-sided paralysis, chronic respiratory failure with hypoxia (low oxygen concentration), and dysphagia (trouble swallowing)XXX[DATE] approximately 3:41 PM - From the paramedic records, E9 (paramedic) arrived at the facility and found R1 pulseless with agonal (irregular, gasping breaths that occur when the body is not receiving enough oxygen) respirations. The report documented that staff provided no life-saving interventions for the patient and failed to recognize the patient was in cardiac arrest. [DATE] 1:30 PM - During a telephone interview, E8 (LPN) stated that F1 (R1's wife) approached him around 4:30 PM (sic) stating, [R1] is choking. Come here, hurry up. E8 stated that he obtained vital signs and R1's pulse oximetry was 64% with a heart rate of 149 or 150. E8 stated that he checked R1's supplemental oxygen flow and increased it. When asked about lung sounds, E8 stated, I did not listen to her lungs. E8 stated that the paramedics took over once they were on the scene and the paramedics were the people who initiated CPR (cardio-pulmonary resuscitation) on R1. The facility failed to identify and report of an allegation of neglect when staff failed to provide lifesaving servicesXXX[DATE] 9:30 AM - During an interview, E2 (DON) stated that the facility did not report the incident to the State as he was unaware that of any allegations of inappropriate care.The facility failed to identify and report that nursing staff failed to perform an essential assessment of R1's airway after a choking incident. [DATE] - Findings were reviewed at the exit conference with E1 (NHA), E2 (DON), E3 (ADON) and E4 (CNO).

Based on record review, observation and interview, it was determined that for two (R97 and R114) out of two residents reviewed for hydration, the facility failed to offer R97 sufficient fluid intake in an accessible manner for her to maintain proper hydration. For R114, the facility failed to ensure that R114 received sufficient fluids to maintain proper hydration or provide additional interventions when R114's oral intake significantly dropped. This failure resulted in harm with R114 being transferred to the hospital on [DATE] with a BUN of 100. Findings include: The BUN (blood urea nitrogen) lab measures the amount of urea nitrogen in the blood. The BUN is directly related to the metabolic function of the liver and the excretory function of the kidney . BUN levels also may vary according to the state of hydration, with increased levels seen in dehydration and decreased levels seen in overhydration. Mosby's Diagnostic and Laboratory Test Reference 2023 1. Review of R114's clinical record revealed: [DATE] - R114 was admitted to the facility with diagnoses including but were not limited to, dementia and stroke with resultant difficulty swallowing and language/speech deficits. [DATE] - R114 was care planned for several problems including: has nutritional problem d/t (due to) . hx (history) need for feeding assistance, advanced age, .poor intake .Interventions for this problem included: . Monitor intake and record q (every) meal .provide assistance cueing meals as needed . [DATE] - R114's care plan was updated with several additional problems including: .(1) has the potential for pressure ulcers, decreeased functional mobility .Interventions for this problem included : .encourage adequate nutrition/hydration . (2) has an ADL (activities of daily living) self- care performance deficit r/t (related to) weakness . Interventions for this problem included: . Eating- [R114] is supervision of one person with feeding . [DATE] - E33 (dietician) documented in R114's EMR, . [Facility] Nutrition Risk Assessment . Estimated fluids - ml (milliliter) -1200 - 1440 . Feeding status - Needs some assistance with meal set up or eating . Assessment - .[R114] is able to feed herself after set up with some cueing . [R114] meets criteria for malnutrition d/t (due to) dementia and variable intake . [DATE] - E27 (MD) ordered in R114's EMR, .Med Pass (medication pass) three times a day 120 ml (additional water) . This order added 360 mls of additional water that R114 consumed each day. [DATE] - E34 (NP) documented in R114's EMR a follow up progress note, .History of present illness: Pt (patient) appears clinically stable . Labs [DATE] . Na (sodium) 141 mmol (millimole)/L (liter) (normal range ,d+[DATE]) . BUN 20.0 mg (milligram) /dL (deciLiter) (normal range 7XXX,d+[DATE].0), creatinine 0.70 mg/dL (normal range 0.52 - 1.04) . Plan: weight stable: appetite variable but mostly acceptable . Continue Remeron .and encourage fluids . R114's BUN at the time of this encounter was elevated at 20.0, which was reflective of R114 being intravascularly dry or dehydrated. Of note, this note was not signed by the provider until [DATE], which was five and a half months after the encounter. The notes are only available to be read in the resident's EMR after they are signed off by the provider so this note was not available to be read until [DATE]. [DATE] - E22 (NP) reviewed R114's labs, which documented a sodium level of 141, a BUN of 18 and a creatinine level of 0.90. The BUN was slightly elevated at 18, where the normal range was 7.0 to 17.0. The daily totals of R114's oral intake was: [DATE] - 1560 mls, ,d+[DATE]% consumption of meals for 2 out of 3 meals, dinner was 0 - 25% consumed, [DATE] - 1440 mls, ,d+[DATE]% consumption of meals for 2 out of 3 meals, dinner was 0 - 25% consumed, [DATE] - 1320 mls, ,d+[DATE]% consumption of meals for 2 out of 3 meals, dinner was 76 -100% consumed, [DATE] - 1320 mls, 26- 50% consumption of 2 out of 3 meals, dinner was 76 - 100% consumed. [DATE] - E35 (RN supervisor) documented in R114's EMR, [R114] is asymptomatic. Roommate with positive results [COVID]. Resident with room change to [room number] and contact/droplet isolation precautions initiated per protocol . [DATE] - 1380 mls, 26 - 50% consumption of breakfast, lunch and dinner were ,d+[DATE]% consumed, [DATE] - 1080 mls, 0 - 25% consumption of breakfast and lunch, dinner was ,d+[DATE]% consumed. CNA documented under ADL - Eating Self performance task that the Activity (eating) did not occur for lunch. [DATE] - 960 mls, 0 - 25 % consumption of all 3 meals, [DATE] - 880 mls, 0 - 25 % consumption of breakfast and lunch, dinner was ,d+[DATE]% consumed. CNA documented under ADL - Eating Self performance task that the Activity (eating) did not occur for lunch. [DATE] - 1080 mls, 0 - 25 % consumption for all 3 meals. CNA documented under ADL - Eating Self performance task that the Activity (eating) did not occur for breakfast. [DATE] - 780 mls, 0 - 25 % consumption for breakfast, lunch and dinner were ,d+[DATE]% consumed. Of note, R114's oral intake dramatically dropped after she was placed on isolation precautions for a COVID exposure on [DATE]. R114's oral intake for the four days prior to the isolation precautions all fell within R114's normal oral intake range. For the seven days that R114 was on isolation precautions prior to her transfer tot he hospital, on six of those days R114's oral intake was documented to be significantly lower then normal. Additionally from [DATE] to [DATE], out of the twenty meals offered during these seven days, R114 was documented as not eating an entire meal five times. R114 failed to eat twenty-five percent of her meals during this period. The facility failed to ensure R114 met her stated hydration goals by supervising, cueing and monitoring R114's intake at meals. R114's EMR lacked evidence that the facility notified the providers of R114's decrease in oral intake. [DATE] 6:17 AM- E22 gave a verbal telephone order entered into R114's EMR, CBC (complete blood count) CMP (complete metabolic panel) one time only for increase in lethargy for 1 day. [DATE] 6:23 AM - E36 (LPN) documented in R114's EMR progress note, Noted with increase lethargy. Hydration unsuccessful. New order for CBC, CMP . Until this [DATE] note, despite five days (,d+[DATE] to [DATE]) of R114 poor oral intake, the facility lacked evidence that this decrease in R114's oral intake was acknowledged by the staff and/or reported to the providers. [DATE]- 300 mls, 0 - 25 % consumption of breakfast and lunch prior to transfer to the hospital. CNA documented under ADL - Eating Self performance task that the Activity (eating) did not occur for both breakfast and lunch. [DATE] 12:58 PM - Per the [county paramedic's] Prehospital Care Report, R114 was transferred to the hospital for an altered mental status . patient is noted to be in Atrial fibrillation at a rate of 170 bpm (beats per minute). Patient is also tachypnic (sic) (rapid breathing) at a rate of about 40. Patient is an obligate mouth breather and her oral cavity is noted to be dry . [DATE] 2:27 PM - R114's facility lab results documented a sodium of 158 mmol/dL (normal range ,d+[DATE]), creatinine 1.80 mg/dL (normal range 0.52- 1.04). There was no reported BUN value on this lab report. [DATE] 2:01 PM - [Hospital] laboratory report documented R97's admission/emergency room labwork with a BUN result of 101mg/dL, with this lab's normal range as 8- 22 mg/dL. From [DATE] to [DATE], R114's BUN elevated from 18 ([DATE] lab work) to 100 ([DATE] hospital lab work). [DATE] 00:25 AM - C2's [hospital] history and physical documented in R114's hospital EMR, . [R114]'s lab work was significant for sodium of 157 and a creatinine of 2.21 from a baseline of 0.9, and a BUN of 101 .Assessment/Plan: Sepsis, unspecified organism- unclear source but patient has mulit-organ failure including her kidneys, her liver as well as evidence of new onset A-fib . [DATE] - R114 expired at [hospital] on hospice service. [DATE] 11:45 AM - Review of R114's EMR progress notes lacked evidence of any notation regarding R114's decreased oral fluid intake or any notification of R114's providers regarding her decreased oral intake until [DATE] 6:23 AM progress note in which E36 (LPN) documented, .Hydration unsuccessful . [DATE] 2:33 PM - During an interview, E4 (RN/unit manager) stated, It was not unusual for [R114] to ignore you if she did not want to deal with you. She played possum. She often refused her meds. Her vital signs were normal but as the day [[DATE]] progressed she became tachycardic and her breathing changed so we sent her out. She had had labs drawn that morning but they were not back when we sent her out. [DATE] 8:16 AM - During an interview, E36 (LPN) stated, . [R114] was her normal self. (neurologically) I was trying to give her water to drink because I was worried about dehydration. Cross refer F656 and F810. 2. Review of R97's clinical record revealed: [DATE] - R97 was admitted to the facility with diagnoses including but were not limited to, dementia and difficulty swallowing. [DATE] 9:56 AM - E13 (dietician) documented on the [facility] Nutrition Risk Assessment in R97's EMR, . Estimated fluids- ml (milliliter) - 1500 - 1800 ml (,d+[DATE] ml/kg) (kilogram) . Feeding status - Needs some assistance with meal set up or eating . Assessment - .Daughter reports good oral intake but has had to assist with meals . [DATE] 10:05 AM - E13 (dietician) ordered in R97S EMR, Regular diet .Adaptove equipment: please issue divided plate, built up utensils ands [NAME] cup with straw at all meals. [DATE] 1:00 PM - E27 (MD) ordered in R97's EMR, Med Pass one time a day 120 mls and Juven two times a day for 4 weeks. Mix with 240 mls water. These two orders accounted for 600 mls of R97's documented oral intake during this time period. [DATE] - R97 was care planned for several problems including: .(1) a potential nutritional problem r/t (related to) advanced age, . self-feeding difficulty requiring adaptive equipment . Interventions for this problem included: provide adaptive equipment for feeding as needed .Monitor intake and record .[R97] has an ADL (activities of daily living) self-care performance deficit r/t limited mobility . (2) has impaired cognitive function/dementia . Interventions for this problem included: Cue, reorient and supervise as needed . (3) has an ADL (activities of daily living) self-care performance deficit r/t (related to) limited mobility .Interventions for this problem included: Assist with eating as needed . The daily totals of R97's fluid intake were: [DATE] - 1440 mls [DATE] - 1200 mls. [DATE] - 1680 mls. [DATE] - 1080 mls. [DATE] - 1800 mls. [DATE] - 1410 mls. [DATE] - 1800 mls. [DATE] - 1760 mls. [DATE] - 1560 mls. [DATE] 1:31 PM - R97's lab revealed a BUN (blood urea nitrogen) level of 61.0 mg(milligrams)/ dL (deciliter). The BUN normal reference level for this lab was 7.0 to 17.0 mg/dL so R97's BUN result of 61.0 was elevated and reflective of a state of dehydration. [DATE] 2:32 PM - E29 (NP) documented in R97's EMR reviewing these lab results. R97's EMR lacked evidence of E29 addressing R97's elevated BUN in either a progress note or with any new orders. [DATE] - 1920 mls. [DATE] - 1680 mls. [DATE] - 1320 mls. [DATE] 4:06 PM- The surveyor observed R97's bedside table with a full, white styrofoam cup with a straw and ice water in it. [DATE] 10:30 AM - The surveyor observed R97's bedside table with a full, white styrofoam cup with a straw and ice water in it [DATE] - 1310 mls. [DATE] - 1430 mls R97's stated hydration goals were 1500 - 1800 mls per day. From [DATE] to [DATE], there were seven out of fourteen days, where it was documented that R97's oral fluid intake was less than her documented minimum fluid goal. The facility failed to ensure R97 met her stated hydration goal by failing to provide bedside water in a Kennedyadaptive cup that R97 could independently consume, failing to assist and cue R97 to drink her bedside water, and failing to address R97's decreased oral fluid intake with R97's provider. From [DATE] to [DATE], the CNA staff documented in R97's CNA tasks list report under Eating Self-performance- How resident eats and drinks, regardless of skill? that for twenty-nine times of the thirty-nine recorded entries, R97 was Total dependence - full staff performance with regards to this task. [DATE] 10:30 AM - Review of R97's EMR progress notes lacked evidence of any notation regarding R97's decreased oral fluid intake or any notification of R97's providers regarding her decreased oral intake. [DATE] 1:01 PM - During an interview, E30 (LPN) stated, [R97] gets an adaptive cup on her meal trays. But I have never seen one on her bedside tray during non-mealtimes. She usually gets her bedside water in a white styrofoam cup . [DATE] 1:07 PM - During an Interview, E32 (OT) stated, [R97] is ordered specialized dining utensils. it is part of the diet order . She [R97] is ordered a Kennedy cup because the handle allows her to pick the cup up independently. [DATE] 1:35 PM - Review of R97's orders and CNA tasks list report lacked evidence of an order related to R97 utilizing a [NAME] adaptive cup outside of her meal tray. [DATE] 2:45 PM - During an interview, E24 (CNA) stated, When we pass the [bedside] water, we use the white styrofoam cups for [R97]. There is no any documentation in the tasks regarding specialty cups. There is not an order. If there3 is a specialty cup on her bedside table, I would pour the water from the styrofoam cup to the specialty cup. Most times, the specil cups come on the food trays. [DATE] 3:28 PM - E15 (CNO) presented the surveyor with a copy of a new order for R97 stating offer water in Kennedy cup q (every) shift. E15 also provided a copy of R97's CNA tasks list report with a new task Provide Q (every) shift water in Kennedy cup. [DATE] 3:04 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E8 (Staff Educator), E14 (COO) and E15 (CNO).