Every finding on record at Club Healthcare and Rehabilitation Center at the V

Based on interviews, observation, and record review, the facility failed to ensure assistance with activities of daily living (ADLs) for nail care for 1 of 5 residents, Resident #59, reviewed for ADL (Activities of Daily Living) care. Findings include:During an observation on 06/15/2026 at 09:35 AM Resident #59 was reclining in bed with her hands resting on her lap. The resident's nails on both hands were jagged and had dark matter under the length of the nails. The nails were approximately 5 to 8 millimeters in length and all the nails on both hands had jagged edges.During an observation on 06/16/2026 at 10:25 AM Resident #59 was sitting in a wheelchair in the resident's room conversing with her spouse. The resident's nails on both hands had been filed and no longer continued to have jagged edges. The nails on both hands continued to have a dark matter substance under the length of the resident's nails.During an interview on 06/16/2026 at 10:30 AM Resident #59 stated, They do not give me wipes or a washcloth to wipe my hands before I eat or after I go to the bathroom.During an interview on 06/16/2026 at 10:35 AM Resident #59's spouse stated, We had discussed the appearance of her nails, and I ended up bringing in a nail brush and brought her a file. We worked on them a little yesterday.During an interview on 06/17/2026 at 9:05 AM Staff #D stated [Resident #59's name] needs assistance due to being weaker on one side. Her hands need to be cleaned before she eats. I know the husband was working on her nails, I didn't think I needed to.During an interview on 06/18/2026 at 2:05 PM the Director of Nursing (DON) stated her expectations for nail care is it should be completed. Review of Resident #59's care plan dated 06/12/2026 read, Resident has a self-care deficit with dressing, grooming, bathing r/t [related to]: generalized weakness, CVA [cerebrovascular accident/stroke] with left side hemiparesis. Goal: Resident will have clean, neat appearance daily thru the next review date. Interventions: Provide hands on assistance with dressing, grooming, bathing as needed and Staff to anticipate resident's needs with ADLs.Review of the policy and procedure titled Policy and Procedure Manual: Clinical ADL Care and Assistance, last approved 01/22/2026 read, It will be the policy of this facility to provide the resident with Activities of Daily Living (ADL) care and assistance while attempting to maintain the highest practicable level of function for the resident. Personal Hygiene: How resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands.

Based on observation, interview, and record review the facility failed to prevent the possible spread of infection by not donning personal protective equipment when providing direct care for 1 of 3 residents, Resident #37, reviewed for enhanced barrier precautions and failing to performed hand hygiene during mealtime for Residents #55 and #42. Finding including: 1) During an observation on 6/16/2026 at 8:15 AM on the outside of Resident #37's room door there was an Enhanced Barrier Precaution sign. Staff E, Certified Nursing Assistant (CNA) entered with Resident #37's breakfast tray and placed it on the bedside table. Without wearing gloves or a gown Staff E began to reposition Resident #37 in bed. Staff E reposition Resident #37's pillow and proceeded to readjust the resident's head on the pillow. 2) During an observation on 6/16/2026 at 12:31 PM Staff E, CNA entered Resident #55's room and removed the lunch tray from the room. Staff E return to the tray cart and placed Resident #55's tray inside the cart. Without performing hand hygiene Staff E walked over to Resident #42's room. Resident #42's room had a contact precaution sign on the doorway and a plastic bin with personal protective equipment. Staff E did not perform hand hygiene, proceeded to remove a gown from the bin to don the personal protective equipment in order to enter Resident #42's room. Resident #42 brought the meal tray to the door and Staff E began to remove and fold the gown placing it back into the plastic bin which contained the unused/new gowns. Staff E collected Resident #42's tray and placed it inside the meal tray cart. Staff E walked down the hall and performed hand hygiene. During an interview on 6/16/2026 at 12:45 PM Staff E, CNA stated, I should have put on a gown and gloves before providing direct care to [Resident #37's name] he has a wound and is under enhance barrier precautions. I should have preformed hand hygiene after removing the tray from [Resident #55's name] room and going to another room. I should have discarded the gown once I realized I was not going to use it instead of putting it back in the bin. During an interview on 6/17/2026 at 9:21 AM the Director of Nursing stated, Staff are to wear gown and gloves when providing direct care to residents under enhance barrier precautions. If dropping a tray off staff does not have to wear a gown or gloves but as soon as they are going to provide care the expectation is for them to gown PPE [personal protective equipment]. If the staff touches the gown they should have discarded it and washed their hands.During an interview 6/18/2026 at 8:29 AM the Assistant Director of Nursing/Infection Presentationist stated, From my education when staff are entering a room if determined that direct care is going to be provided they need to gown and glove. Staff are expected to do hand hygiene in between resident contact. The gown should have been disposed of once staff handled the gown and it was outside of the bin.Review of the facility policy and procedure titled Hand Hygiene with a last review date of 1/22/2026 read, Policy: The facility considers hand hygiene the primary means to prevent the spread of infections. Procedure: 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 5. Use an alcohol-based hand rub containing at least 62% alcohol or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. before and after direct contact with residents. Review of the facility policy and procedure titled Enhanced Barrier Precautions with a last review date of 1/22/2026 read, Policy: It will be the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organism.

Based on interview and record review the facility failed to provide laboratory and diagnostic testing as ordered for 2 of 6 residents reviewed for laboratory services (Resident #11 and #74).Finding including:1) Review of Resident #11's physician order dated 6/8/2026 read, UA [urine analysis] & culture take sample on 06/11/2026.Review of Resident #11's laboratory documentation did not document a urinalysis and culture and sensitivity dated 6/11/2026.During an interview on 6/17/2026 at 9:33 AM Staff C, Licensed Practical Nurse stated, I spoke to the provider yesterday [6/16/2026]. I saw the order and asked the patient [Resident #11] he had no signs and symptoms and I called the provider. I didn't see any results in the system. Generally, we collect the sample the same day. During an interview on 6/17/2026 at 9:48 AM the Advance Practice Registered Nurse #3 stated, I spoke to [Staff C's name] yesterday and I said the patient was stable and the UA could be discontinued. I would say there is no set time for collection some patients will not void on demand. I would logically have to answer yes, I would expect the nurses to attempt to collect when ordered and if unable to do so contact the provider to let them know. In this case I would not be able to say if they did there is other providers that go into the building. The provider saw him [Resident #11] the day before yesterday. His pain had improved and the patient wanted to discharge. They are good about collection but sometimes one can fall through the cracks. During an interview 6/18/2026 at 8:29 AM the Assistant Director of Nursing stated, Once I see there is an order for a UA I make sure it is collected. That is one that I missed [Resident #11's UA]. During an interview on 6/18/2026 at 9:00 AM Medical Doctor #1 stated, The nurses should follow the orders and collect the specimen. That is best practice. No one had called me regarding the collection of the specimen.During an interview on 6/18/2026 at 9:29 AM Medical Doctor #2 stated, The staff should follow the order for labs being ordered. No one had called me regarding the specimen prior to this week [for Resident #11].2) Review of Resident #74's progress note dated 6/5/2026 read, Patient seen today; she reports increased pain in both shoulders, worse on the right. Will obtain x-ray and continue to use lidocaine patches in addition to oral pain meds for relief. She denies any CP [chest pain], SOB [shortness of breath], dizziness. Review of Resident #74's physician order dated 6/3/2026 read, STAT [immediately] XR [x-ray] right shoulder- 3 views. Portable due to fall risk one time only for pain for 2 Days.Review of Resident #74's Treatment Administration Record for the Month of June 2026 documented XR right shoulder was completed on 6/5/2026 at 1435 [2:35 PM]. Review of Resident #74's diagnostic results did not document an x-ray for the right shoulder. During an interview on 6/18/2026 at 10:23 AM the Director of Nursing stated, The x-ray was not completed as ordered. The nurse is new and checked off the order as if she was acknowledging the order and when she checked it off; that is like she completed the order. When that happens it [the order] will disappear from the orders. During an interview on 6/18/2026 at 11:00 AM Advance Practice Registered Nurse #2 stated, [Resident #74's name] pain is more of a chronic pain. There was no harm caused to the resident. During an interview on 6/18/2026 at 11:57 AM Staff E, Licensed Practical Nurse stated, I don't recall. I was under the wrong impression for the one-time order. Under the protocol it is to be checked if it was actually done, I was under the wrong impression. Review of the facility policy and procedure titled Diagnostics Labs Radiology Notification with a last review date of 1/22/2026 read, Policy: It will be the policy of this facility to provide or obtain timely laboratory, radiology and diagnostic services when ordered by a physician; physician assistant (PA); nurse practitioner (NP) or clinical nurse specialist (CNS) in accordance with State law, including scope or practice laws. Procedure: 1. Laboratory services will be received when ordered by the physician, PA, NP, CNS according to the physician's order. 8. Documentation of pertinent information related to further diagnostic testing and notification should be placed in the clinical record.

Based on interview and record review the facility failed to ensure blood pressure medication administration per the physician's ordered parameters for 1 of 6 residents, Resident #46, reviewed for medication management. Findings include:Review of Resident #46 physician order dated 3/9/2026 read, Clonidine HCl [Hydrochloride] Oral Tablet 0.1 MG [milligram] (Clonidine HCl) Give 1 tablet by mouth every 6 hours as needed for BP [blood pressure] systolic greater than 150 or diastolic over 90.Review of Resident #46 Weight and Vital Summary for the month of June 2026 documented on 6/13/2026 at 07:44 [7:44 AM] blood pressure was 174/93.Review of Resident #46's Medication Administration Record for the month of June 2026 did not document Clonidine 0.1 mg was administered.Review of Resident #46 Weight and Vital Summary for the month of May 2026 documented on 5/1/2026 at 09:02 [9:02 AM] blood pressure was 161/105, on 5/2/2026 at 07:38 [7:38 AM] blood pressure was 174/85, on 5/3/2026 at 07:21 [7:21 AM] blood pressure was 162/92, on 5/3/2026 at 17:26 [5:26 PM] blood pressure was 156/92, on 5/14/2026 at 08:03 [8:03 AM] and at 08:04 [8:04 AM] blood pressure was 190/90, on 5/16/2026 at 07:52 [7:52 AM] blood pressure was 153/91, on 5/17/2026 at 07:32 [7:32 AM] blood pressure was 167/91 and at 12:15 [12:15 PM]blood pressure was 153/91, on 5/24/2026 at 07:42 [7:42 AM] blood pressure was 167/95,and on 5/31/2026 at 10:18 [10:18 AM] blood pressure was 161/98.Review of Resident #46 Medication Administration Record for the month of May 2026 documented Clonidine was on administered don 5/14/2026.Review of Resident #46 Weight and Vital Summary for the month of April 2026 documented on 4/1/2026 at 09:40 [9:40 AM] blood pressure 161/90, on 4/2/2026 at 10:07 [10:07 AM] blood pressure 168/96, on 4/3/2026 at 13:05 [1:05 PM] blood pressure 160/85, 4/4/2026 at 07:31 [7:31 AM] blood pressure 168/98, on 4/6/2026 at 10:27 [10:27 AM] blood pressure 156/98, on 4/6/2026 at 15:35 [3:35 PM] blood pressure 156/80, 4/7/2026 at 12:52 [12:52 PM] blood pressure 167/95, 4/8/2026 at 12:37 [12:37 PM] blood pressure 152/71, 4/11/2026 at 10:00 [10:00 AM] blood pressure 165/92, 4/13/2026 at 09:57 [9:57 AM] blood pressure 155/98, 4/13/2026 at 10:10 [10:10 AM] blood pressure 155/98, on 4/15/2026 at 10:30 [10:30 AM] blood pressure 157/94, 4/15/2026 at 21:15 [9:15 PM] blood pressure 155/74, 4/19/2026 at 09:07 [9:07 AM] blood pressure 152/89, 4/23/2026 at 09:53 [9:53 AM] blood pressure 152/87, 4/23/2026 at 15:49 [3:49 PM] blood pressure 155/85, and 4/24/2026 at 07:18 [7:18 AM] blood pressure 164/101.Review of Resident #46's Medication Administration Record for the month of April 2026 did not document Clonidine 0.1 mg was administered.During an interview on 6/17/2026 at 12:13 PM with Staff A, Licensed Practical Nurse stated, I do not recall [Resident #46's name] or that medication [Clonidine to be given when SBP greater than 150 or diastolic greater than 90].During an interview on 6/17/2026 at 3:06 PM with Staff B, Registered Nurse stated, I do not recall [Resident #46's name] having an order in place for Clonidine and those parameters.During an interview on 6/18/2026 at 10:32 AM with the Director of Nursing stated, I spoke to the provider in order to make the order a routine medication with parameters in place where it will always populate to the nurse o see if the resident needs the medication and not a as needed medication. The nurse might not thing there is a as needed blood pressure medication. Nursing staff is expected to follow physician orders. During an interview on 6/18/2026 at 10:37 AM with Cardiology Advance Practice Registered Nurse #1 stated, There has not been any cardiovascular emergencies related to this resident [Resident #46]. I have not seen her since April because she has refused. Her blood pressures have been stable.During an interview on 6/18/2026 at 11:00 AM with Advance Practice Registered Nurse #2 stated, There has been no harm cause to [Resident #46's name]. She has been stable.Review of the facility policy and procedure titled Medication Administration with a last review date of 1/22/2026 read, Policy: It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medication by the resident.

Based on interview and record review the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed when a mental illness was identified for 1 of 3 residents, Resident #20, review for PASRR screening.Findings include:During an interview on 06/17/2026 at 1:42 PM the Social Services Director (SSD) with the Social Services Assistant (SSA) the SSD said she had started working for the facility three weeks ago. We need to assist with ensuring PASRRs (Preadmission Screening and Resident Review) are up to date moving forward during the psychiatry meeting we have once a week to discuss GDR's [gradual dose reductions]. During an interview on 06/18/2026 at 9:42 AM the Director of Nursing stated, It is a joint effort between the social services and clinical team to ensure they [PASRRs] are updated. We have a PASRR performance improvement plan that was started on 3/13/2026. It was for the newly admitted residents' PASRRs to be reviewed, it did not include updating the PASRRs to reflect the existing residents' diagnoses.Review of Resident #20's medical record revealed two PASRRs. One was dated 5/8/2026 and the second was dated 5/11/2026. The PASRRs did not have Resident #20's diagnosis of major depressive disorder. There were no additional PASRRs in the record.Review of the Psychiatry Subsequent Note dated 05/12/2026 at 18:30 (6:30 PM) read, Chief Complaint: Depression and insomnia. Reason for Encounter: This is a [AGE] years old patient with a past psychiatric history of depression and insomnia. During last visit, patient had side effects of medication. Patient was sad and sleepy. Dated 05/16/2026 with a signature time of 4:22 PM read, Assessment and Plan: Psychiatric Condition: As per collected information and interview, it appears that the patient is unstable. I feel the symptoms are occurring due to exacerbation of underlying depression disorder. Plan of Action; Recurrent: The history suggest that this patient has suffered from episodes of depression lasting for more than 2 weeks. The symptoms have caused significant distress and functional impairment to the patient, and they have occurred without any underlying substance use or organic brain pathology. ICD [International Classification of Disease] Codes: Major depressive disorder, recurrent, moderate.Review of the policy and procedure titled P&P Role of Admissions and Social Services in PASRR read, The facility shall ensure that all individuals admitted to the nursing facility are screened for Serious Mental Illness (SMI), Intellectual Disability (ID), or Related Conditions in accordance with federal and state regulations prior to admission. Residents identified with SMI, ID, or related conditions shall receive services in the most integrated and appropriate setting and shall continue to receive appropriate care and services following any significant change in status. Purpose: To establish procedures for compliance with Preadmission Screening and Resident Review (PASRR) requirements. Procedure - Preadmission Screening: The Social Services Director/Credentialed User shall initiate a PASRR Resident Review for residents previously identified with SMI, ID, or related conditions when a significant change in status occurs or when newly evident symptoms indicate possible SMI, ID, or related conditions.

Based on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 2 of 5 residents reviewed (Residents #11 and #90).Findings include: 1) Review of Resident #90 physician order dated 6/3/2026 read, Flomax Capsule 0.4 MG [milligram] give 1 capsule by mouth one time a day for benign prostatic hyperplasia. Review of Resident #90 Minimum Data Set titled Medicare 5 Day dated 6/4/2026 Section I Active Diagnoses did not document Benign Prostatic Hyperplasia. During an interview on 6/17/2026 at 10:56 AM with MDS Coordinator stated, [Resident #90's name] MDS needs to be corrected to add Benign Prostatic Hyperplasia he was ordered Flomax for that diagnosis. 2) Review of Resident #11 progress note dated 5/30/2026 read, cervical collar to be worn at all times every shift when this writer arrived on shift and completed rounds, I observed resident without his collar on, I woke resident up and asked if i [sic] could put his collar back on resident stated no and went back to sleep. Review of Resident #11 MDS titled Modification of Admission/ Medicare 5 Day dated 5/31/2026 Section E Behavior did not document refusals of care. Review of Resident #11 comprehensive care plan initiated on 5/30/2026 read, prefers to deviate from plan of care with: Resident non complainant with c collar at times, refuses wound care and medications at times. Review of Resident #11 physician order dated 5/25/2026 read, cervical collar to be worn at all times every shift. During an interview on 6/17/2026 at 10:56 AM with MDS Coordinator stated, [Resident #11's name] MDS needs to be corrected to show resident has behaviors of refusals. During an interview on 6/18/2026 at 11:18 AM with the Director of Nursing stated, We do not have a policy for MDS we follow the RAI [Resident Assessment Instrument].

Based on record review and interview, the facility failed to submit accurate direct care staffing information to CMS for the fourth quarter of 2024. Findings include: Review of the Payroll Based Journal (PBJ) for the fourth quarter of 2024 (July 1 - September 30) showed low weekend registered nurse (RN) staffing for Saturday and Sunday on September 7-8, 2024. During an interview on 1/28/2025 at 2:00 PM, the Administrator stated, The PBJ staffing trigger of low weekend staffing for nurses was because an RN who was covering for the RN Supervisor on the weekend of September 7th and 8th, while the weekend supervisor was on vacation was coded for another sister facility and not here at this facility. Upon request, the Administrator did not provide a policy and procedure on PBJ submission. During an interview on 1/29/2025 at 8:16 AM, Staff D, RN, stated, I worked at the Club back in September, the first weekend to cover for the weekend supervisor. My hours worked were coded for the facility I normally work in and not for the Club.

Based on observation, record review and interview, the facility failed to ensure resident records were complete and accurate for 6 of 8 residents reviewed for nutrition (Residents #1, #12, #21, #38, #41, and #256), 2 of 6 residents reviewed for wound care (Residents #158 and #42), and 2 of 5 residents reviewed for blood pressure medication (Residents #17 and #32). Findings include: 1) Review of Resident #12's physician order dated 1/16/2025 showed it read, House Protein two times a day for risk of malnutrition, wound healing, Offer 30 ml [milliliters] and document amount consumed. Review of Resident #12's medication administration record for January 2025 showed no entry documented for the amount of House Protein consumed from 1/17/2025 through 1/27/2025. Review of Resident #21's physician order dated 12/16/2024 showed it read, House Protein two times a day for risk of malnutrition, wound healing, Offer 30 ml and document amount consumed. Review of Resident #21's medication administration record for January 2025 showed no entries documented for the amount of House Protein consumed from 1/1/2025 through 1/27/2025. Review of Resident #41's physician order dated 11/15/2024 showed it read, House Protein two times a day for risk of malnutrition, Offer 30 ml and document amount consumed. Review of Resident #41's medication administration record for January 2025 showed no entries documented for the amount of House Protein consumed from 1/1/2025 through 1/27/2025. Review of Resident #256's physician order dated 1/21/2025 showed it read, House Protein three times a day for risk of malnutrition, wound healing, Offer 30 ml and document amount consumed. Review of Resident #256's medication administration record for January 2025 showed no entries documented for the amount of House Protein consumed from 1/22/2025 through 1/27/2025. 46523 Review of Resident #1's physician order dated 12/25/2024 showed it read, House Nutritional Supplement two times a day for Nutritional Supplement, risk of malnutrition, Offer 240 ml and document amount consumed. Review of Resident #1's physician order dated 12/25/2024 showed it read, House Protein two times a day for risk of malnutrition, Offer 30 ml and document amount consumed. Review of Resident #1's medication administration record for January 2025 showed no entries documented for the amount of House Protein consumed or the amount of House Nutritional Supplement consumed from 1/1/2025 through 1/27/2025. Review of Resident #38's physician order dated 1/1/2025 showed it read, House Nutritional Supplement two times a day for Nutritional supplement, risk of malnutrition, Offer 240 ml and document amount consumed. Review of Resident #38's physician order dated 1/2/2025 showed it read, House Protein two times a day for risk of malnutrition, offer 30 ml and document amount consumed. Review of Resident #38's medication administration record for January 2025 showed no entries documented for the amount of House Nutritional Supplement consumed or the amount of House Protein consumed from 1/1/2025 through 1/27/2025. During an interview on 1/30/2025 at 9:31 AM, the Director of Nursing (DON) confirmed Residents #1, #12, #21, #41, #256, and #41's medication administration records for January 2025 did not contain documentation of the amount of House Protein or House Supplement consumed and the physician orders did include document amount consumed. 2) Review of Resident #42's physician order dated 12/14/2025 showed it read, Cleanse sacrum with NS [normal saline], pat dry, cover with calcium alginate, and border foam, skin prep surrounding tissue, every day shift . Order Status: Discontinued. Review of Resident #42's physician order dated 1/28/2025 showed it read, Late order entry: for 1/17/2025, 1/19/2025, 1/25/2025, 1/26/2025, 1/28/2025. The order is as such, cleanse sacrum, pat dry. Cover wound bed with calcium alginate, add border foam dressing. Skin prep surrounding tissue every 7-3 shift and PRN soiling or dislodgement. Review of Resident #42's treatment administration record for January 2025 showed two orders for sacrum wound care, one with a start date of 12/15/2024 and a discontinue date of 1/2/2025, and another with the start date of 1/3/2025 and discontinue date of 1/15/2024. There was no entries documented on 1/3/2025, 1/7/2025, 1/9/2025, and 1/10/2025. Review of Resident #42's physician orders showed no active orders for sacral wound care after 1/15/2025. Review of Resident #42's Wound Assessment Report dated 1/20/2025 showed it read, Location: sacrococcygeal . Wound status: Stable . Treatment: Dressing Change Frequency: Daily and PRN. Clean wound with: Cleanse with normal saline. Primary Treatment: Calcium alginate, skin prep surrounding tissue or peri wound, Collagen. Other Dressings: Bordered foam, Recommended air mattress. Review of Resident #42's Wound Assessment Report dated 1/27/2025 showed it read, Location: sacrococcygeal . Wound status: Improving without complications . Treatment: Dressing Change Frequency: Daily, and PRN. Clean wound with: Cleanse with normal saline. Primary Treatment: Calcium alginate, skin prep surrounding tissue or peri wound, Collagen. Other Dressings: Bordered foam. During an interview on 1/28/2025 at 3:50 PM, the DON stated, I spoke to the nurse. It [the physician order] was deleted by error, but wound care was provided as ordered. During an interview on 1/29/2025 at 9:23AM, Staff A, Licensed Practical Nurse (LPN), stated, We discontinued the Santyl order, and I don't know what happened that I didn't put in the new order. I did all wound care for the resident. Review of the facility policy and procedure titled Wound Care with the last review date of 1/23/2025 showed it read, Procedure . 10. Document in the clinical record when treatments are performed. 3) During an observation on 1/26/2025 at 10:10 AM, Resident #158 was lying in bed. There was a single lumen midline on her left arm with a transparent dressing dated 1/22. During an observation on 1/28/2025 at 11:11 AM, Resident #158 was lying in bed with a midline on her left arm with a transparent dressing dated 1/22. Review of Resident #158's physician order dated 1/23/2025 showed it read, Change needleless connector every day shift every 7 day(s). Review of Resident #158's physician order dated 1/23/2025 showed it read, Change transparent dressing. Measure external catheter length every day shift every 7 day(s), Observe site for signs and symptoms of infection, infiltration and or/ extravasation. Review of Resident #158's medication administration record for January 2025 showed the needleless connector was changed on 1/24/2025. Review of Resident #158's medication administration record for January 2025 showed the transparent dressing was changed on 1/24/2025. During an interview on 1/28/2025 at 1:30 PM, the DON stated, I spoke to the nurse and she stated she had documented incorrectly in the system. During an interview on 1/28/2025 at 2:05 PM, Staff A, LPN, stated, It was a mistake. It was clicked off by accident. Review of the facility policy and procedure titled PICC [Peripherally Inserted Central Catheter]/Midline IV [Intravenous] Line with the last review date of 1/23/2025 showed it read, Dressing Changes . 2. Dressing changes will be documented in the clinical record. 4) Review of Resident #32's physician order dated 11/10/2024 showed it read, Hydralazine HCl Oral Tablet 25 MG [milligram] (Hydralazine HCl), Give 1 tablet by mouth three times a day for htn [hypertension], hold for SPB<110 or DBP <60 [systolic blood pressure less than 110 and diastolic blood pressure less than 60]. Review of Resident #32's medication administration record for January 2025 showed the resident received Hydralazine HCl on 1/3/2025 at 6:00 AM for a systolic blood pressure of 92, on 1/18/2025 for a systolic blood pressure of 107, and on 1/27/2025 for a systolic blood pressure of 101. During an interview on 1/28/2025 at 3:40 PM, the DON stated, I spoke to the physician and order was correct. He wants to keep both the systolic and diastolic blood pressures separate. The medication was given out of parameters, and it should have been held. Review of Resident #17's physician order dated 1/22/2025 showed it read, Metoprolol Succinate ER [Extended Release] Tablet Extended Release 24 hour 25 MG, Give 1 tablet by mouth one time a day for HTN, Hold if SBP <115 or HR <60 [heart rate less than 60]. Review of Resident #17's medication administration record for January 2025 showed the resident received Metoprolol Succinate ER 25 mg tablet on 1/22/2025, 1/23/2025, and 1/24/2025 at 9:00 AM when systolic blood pressure was 111. Review of Resident #17's physician order dated 11/25/2024 showed it read, Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG, Give 1 table by mouth one time a day for HTN, Hold if SBP <110 or HR <60. The order was discontinued on 1/21/2025. Review of Resident #17's medication administration record for January 2025 showed the resident received Metoprolol Succinate ER 25 mg tablet on 1/4/2025 at 9:00 AM with the HR of 53, on 1/6/2025 at 9:00 AM with the SBP of 100 and HR of 57, on 1/12/2025 at 9:00 AM with the HR of 57, on 1/13/2025 and 1/14/2025 at 9:00 AM with the SBP of 94 and HR of 59. During an interview on 1/29/2025 at 7:51 AM, the Medical Director stated, The staff notify me about the vital signs and ask if blood pressure medication should be given. We are starting to change the parameters because the one we had in place were pretty high. When vitals are out of parameters, they notify me. There can always be improvements on documentation. One should expect if the staff is asking us what parameters are and we say it is okay for the medication to be given, they should be documenting in the system. Review of the facility policy and procedure titled Charting and Documentation with the last review date of 1/23/2025 showed it read, Policy: It is the policy of this facility that services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's clinical record as is needed.

Based on record review and interview, the facility failed to ensure resident's physician was notified of a change in condition for 1 of 3 residents reviewed for significant weight loss, Resident #38. Findings include: Review of Resident #38's admission record showed the resident was most recently admitted on [DATE] with the diagnoses including unspecified severe protein-calorie malnutrition, muscle wasting and atrophy, unspecified dementia, acute kidney failure and adult failure to thrive. Review of Resident #38's Weights and Vitals Summary showed the resident weighed 76.4 lbs. (pounds) on 12/30/2024, and 71.2 lbs. on 1/4/2025, which indicates -6.44% loss. The resident's weight on 1/11/2025 was 66.9 lbs., which indicates -12.09% loss compared to the weight on 12/30/2024, and the resident's weight on 1/25/2025 was 62.2 lbs., which indicates -18.59% loss compared to the weight on 12/30/2024. Review of Resident #38's dietary profile dated 1/2/2025 showed it read, New admit. Nutrition Evaluation and recommendations completed . Per her daughter she has not been eating or drinking for the last month per H and P [History and Physical] . Eating an estimated 26-75% at most meals, however PO [by mouth] intake is variable . Admit body weight is 76.4# [pounds], with BMI [Body Mass Index] of 13.9 indicating underweight and malnourished. Medications reviewed. Receiving Furosemide/Diuretic which may cause weight fluctuations . Labs 12/31 indicating low protein levels, high creatinine and high calcium levels . Continue to monitor PO intake, labs, weight changes and skin and adjust nutrition interventions prn [as needed]. Proceed with poc [plan of care]. During an interview on 1/28/2025 at 12:57 PM, the Registered Dietitian (RD) stated, [Resident #38's name] was malnourished when she got to the facility. She has poor PO intake and daughter said she was not eating that much prior to coming here. [Resident #38's name] came in at 76.4 pounds. She should be on fortified foods. I was consulted and encouraged an appetite stimulant. The provider puts in the orders. She should be on an appetite stimulant. I have asked about it twice and still nothing is in there. It would be great to put her on one. During an interview on 1/28/2025 at 3:42 PM, the Director of Nursing (DON) stated, She [the RD] looks in the record and looks at our notes. The RD knows how to read the notes. She knows when a weight is available and knows how to request weights. During an interview on 1/29/2025 at 1:12 PM, the Advanced Practice Registered Nurse (APRN) #1 stated, I did see [Resident #38's name]. I oversee pain management. Not overall appetite and weights. I focus on pain management and physiatry [physical medicine and rehabilitation]. During an interview on 1/29/2025 at 3:30 PM, the Medical Doctor #2 (MD #2) stated, The RD should have been monitoring the [Resident #38's name] weights. The RD never contacted me in regards to [Resident #38's name] weight loss. If I am not responding, I can get a text all the time. During an interview on 1/29/2024 at 3:49 PM, the APRN #2 stated, I recall the patient [Resident #38]. I do not have the record in front of me. I was not notified of any weight changes with the resident [Resident #38]. During an interview on 1/30/2025 at 1:15 PM, the DON stated, I did not see a change in condition in the system for the weight changes of 1/4/2025 and 1/11/2025 for [Resident #38's name]. I didn't see one I cannot make it up. I would not be able to say if the provider or the family was notified of the significant weight change. Review of the facility policy and procedure titled Change in Condition with the last review date of 1/23/2025 showed it read, Policy: It will be the policy of this facility to notify the physician, family, resident, and/or responsible party/resident representative (as is applicable) of significant changes in condition and providing treatment(s) according to the resident's wishes and physician's orders. Procedure: 1. Observe resident during routine care and during monthly/quarterly/annual assessment periods to identify significant changes in physical or mental conditions, orientation, change in vital signs, weights, etc. 2 When a change is noted, gather pertinent data such as vital signs, weights and other clinical observations . 4. When significant changes in skin or weight are noted it is appropriate to contact the physician and responsible party/resident representative (if applicable) to notify them and receive orders such as consultations, root cause analysis or implementation of further monitoring . 7. Contact the primary physician to update him/her to the change in condition. In the event the primary physician cannot be notified, attempt to contact the facility's medical director.

Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles (Photographic evidence obtained). Findings include: During an observation on 1/26/2025 at 10:06 AM, Resident #160 was lying in bed. There was one bottle of Tylenol tablets on top of the resident's drawer. During an interview on 1/26/2025 at 10:06 AM, Resident #160 stated, I had a headache and my daughter brought the Tylenol for me. I took the medication, and it has been there ever since. During an observation on 1/26/2025 at 10:18 AM, Resident #1 was lying in bed. There was one tube of 1% Silver Sulfadiazine Cream on top of the bedside table next to the resident's bed. During an interview on 1/26/2025 at 10:18 AM, Resident #1 stated, The nurses will apply the cream to my wound when I ask them too. During an observation on 1/26/2025 at 10:41 AM, Resident #32 was lying in bed. There was one tube of Goodsense extra strength itch relief cream on top of the resident's bedside table. During an interview on 1/26/2025 at 10:41 AM, Resident #32 stated, The itch cream is for my neck to stop it from itching. During an interview on 1/29/2025 at 11:17 AM, the Director of Nursing (DON) stated, If a resident can self-administer, they will have a self-administration assessment, physician order and care. The resident should not have meds [medications] at bedside. The family is in and out. We will take the medication out if deem unsafe. The nightstand locks so the resident is given a key. Review of the facility policy and procedure titled Medication/Biological Storage with the last review date of 1/23/2025 showed it read, Policy: It will be the policy of this facility to store medications, drugs and biologicals in a safe, secure and orderly manner. Procedure . 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing medications, drugs and biologicals shall be locked when not in use and trays or carts used to transport such items shall not be left unlocked if out of a nurse's view.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for 1 of 5 residents reviewed for nutrition, Resident #17. Findings include: Review of Resident #17's admission record showed the resident was most recently admitted on [DATE] with the diagnoses including unspecified protein-calorie malnutrition, anemia, gastro-esophageal reflux disease without esophagitis, and acute kidney failure. Review of Resident #17's quarterly Minimum Data Set, dated dated dated [DATE] showed it read, Section K- Swallowing/Nutritional Status . K0310. Weight Gain: Gain of 5% or more in the last month or gain of 10% or more in last 6 months . 2. Yes, not on physician-prescribed weight-gain regiment. Section K did not indicate the resident was on therapeutic diet. Review of Resident #17's progress note dated 12/27/2024 showed it read, Weight Note. 12/18: 118.8# [pounds], 7/30/2024: 134.6#. Weight loss of 11.7% in 6 months. Review of Resident #17's physician order dated 12/2/2024 showed it read, Boost with meals for moderate protein energy malnutrition, albumin 2.6, Document percent consumed. Review of Resident #17's physician order dated 5/21/2024 showed it read, Regular diet, Regular texture, Thin consistency, Add Fortified Foods to all meals. Review of Resident #17's physician order dated 5/21/2024 showed it read, House Shake No Sugar Added two times a day varied PO [by mouth] intake Glucerna Shake by mouth. During an interview on 1/28/2025 at 12:47 PM, the Registered Dietitian stated, [Resident #17's Name] has been declining and losing weight for some time now. We have all nutritional interventions in place, but she does keep losing weight. During an interview on 1/29/2025 at 2:17 PM, the MDS Coordinator stated, I did have to make a modification for section K. It was coded for weight gain and she had weight loss. During an interview on 1/30/2025 at approximately 8:30 AM, the MDS Coordinator stated, [Resident #17's name] Section K in the MDS is not current. She should be coded for therapeutic diet since she has fortified foods ordered and supplements.

Based on record review and interview, the facility failed to reassess the effectiveness of the interventions, review and revise the resident's care plan when necessary for 1 of 3 residents reviewed for significant weight loss, Resident #38. Findings include: Review of Resident #38's admission record showed the resident was most recently admitted on [DATE] with the diagnoses including unspecified severe protein-calorie malnutrition, muscle wasting and atrophy, unspecified dementia, acute kidney failure and adult failure to thrive. Review of Resident #38's Weights and Vitals Summary showed the resident weighed 76.4 lbs. (pounds) on 12/30/2024, and 71.2 lbs. on 1/4/2025, which indicates -6.44% loss. The resident's weight on 1/11/2025 was 66.9 lbs., which indicates -12.09% loss compared to the weight on 12/30/2024, and the resident's weight on 1/25/2025 was 62.2 lbs., which indicates -18.59% loss compared to the weight on 12/30/2024. Review of the Intradisciplinary Plan of Care review meeting summary dated 12/31/2024 showed it read, Nursing reviewed meds and diet due to resident's weight loss due to weight loss. Resident weight loss is from poor appetite @ [at] home. Review of Resident #38's care plan initiated on 1/2/2025 showed it read, Focus. [Resident #38's name] is at risk for an alteration in nutrition and/or hydration r/t [related to]: has a chewing problem, has a swallowing problem, receives therapeutic diet, receives mechanically altered diet, underweight BMI [Body Mass Index] of 13.9, UTI [urinary tract infection], HTN [hypertension], Bradycardia, HLD [hyperlipidemia], COPD [chronic obstructive pulmonary disease], Dementia, Adult FTT [failure to thrive], AKF [acute kidney failure] . Interventions/Tasks: Provide tray set up; assist as needed . Provide diet as ordered. Offer and provide alternate as needed . Honor food preferences . Encourage adequate intake at meals . Keep fresh water at bedside . Encourage adequate fluid intake . Educate resident of importance in adhering to prescribed diet and of consequences of deviation from diet as needed . Supplements as ordered . Registered dietician consult as needed . Allow adequate time to eat. Review of Resident #38's records showed no revised care plan. During an interview on 1/30/2025 at 10:17 AM, the Director of Nursing (DON) stated, After the 1/11/2025 significant weight loss, I do not see any interventions put in place for [Resident #38's name] other than what was already in place. Looking back, I would have addressed gastric tube with the family or palliative care. During an interview on 1/30/2025 at 12:26 PM, the Minimum Data Set (MDS) Coordinator stated, Typically the RD will revise the care plan and we will also review it. Typically, the care plan will be revised if a person has a significant weight change. We would revise the care plan and make sure she is taking all the supplements and any changes that can be made. We have a clinical meeting every morning and that's when we are notified of the significant weight loss. IDT [Intradisciplinary Team] meeting is where I am alerted what needs to go into the care plan and I would add it. We would review and revise and discuss weight loss as a team. On 1/4/2025, it should have triggered a care plan revision. I was not aware of her weight loss. During an interview on 1/30/2025 at 1:15 PM, the DON stated, [Resident #38's name]'s care plan should have been revised after significant weight loss. Review of the facility policy and procedure titled Comprehensive Assessments and Care Plans with the last review date of 1/23/2025 showed it read, Standard: It will be the standard of this facility to make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS . Guidelines . 6. The facility will maintain all resident assessments completed within the previous 15 months in the resident's active record and use the results of the assessment to develop, review, and revise the residents' comprehensive care plan.

Based on record review and interview, the facility failed to ensure residents received adequate nutrition for 1 of 3 residents reviewed for significant weight loss, Resident #38. Findings include: Review of Resident #38's admission record showed the resident was most recently admitted on [DATE] with the diagnoses including unspecified severe protein-calorie malnutrition, muscle wasting and atrophy, unspecified dementia, acute kidney failure and adult failure to thrive. Review of Resident #38's Weights and Vitals Summary showed the resident weighed 76.4 lbs. (pounds) on 12/30/2024, and 71.2 lbs. on 1/4/2025, which indicates -6.44% loss. The resident's weight on 1/11/2025 was 66.9 lbs., which indicates -12.09% loss compared to the weight on 12/30/2024, and the resident's weight on 1/25/2025 was 62.2 lbs., which indicates -18.59% loss compared to the weight on 12/30/2024. Review of Resident #38's physician order dated 12/30/2024 showed it read, Regular diet, Mechanical soft texture, nectar thick consistency. Review of Resident #38's physician order dated 12/30/2024 showed it read, Obtain weight upon admission then weigh weekly x 4 [4 times] and then weight monthly. Review of Resident #38's physician order dated 12/30/2024 showed it read, Cholecalciferol Tablet 1000 unit, give 2 tablets by mouth one time a day form supplemental. Review of Resident #38's physician order dated 1/1/2025 showed it read, House Nutritional Supplement two times a day for nutritional supplement, risk of malnutrition, offer 240 ml [milliliters] and document amount consumed. Review of Resident #38's physician order dated 1/2/2025 showed it read, Regular diet, Mechanical soft texture, nectar thick consistency, add: Fortified foods to all meals for risk of malnutrition. Review of Resident #38's physician order dated 1/2/2025 showed it read, House Protein two times a day for risk of malnutrition, offer 30 ml and document amount consumed. Review of Resident #38's physician order dated 1/2/2025 showed it read, Multivitamin-Minerals Oral Tablet (Multiple Vitamins w/ [with] Minerals), Give 1 tablet by mouth one time a day for risk if malnutrition. Review of Resident #38's physician order dated 1/15/2025 showed it read, Regular diet, mechanical soft texture, thin consistency. Review of Resident #38's physician orders showed no appetite stimulant ordered. Review of Resident #38's dietary profile dated 1/2/2025 showed it read, New admit. Nutrition Evaluation and recommendations completed . Per her daughter she has not been eating or drinking for the last month per H and P [History and Physical]. NKFA [no known food allergies). Diet is Regular, Mechanical Soft texture with thin liquids. Eating an estimated 26-75% at most meals, however PO [by mouth] intake is variable. Can feed self needing help with set up . Admit body weight is 76.4# [pounds], with BMI [Body Mass Index] of 13.9 indicating underweight and malnourished. Medications reviewed. Receiving Furosemide/Diuretic which may cause weight fluctuations. Also receiving Vitamin D 3 as vitamin supplementation. Labs 12/31 indicating low protein levels, high creatinine and high calcium levels . Continue to monitor PO intake, labs, weight changes and skin and adjust nutrition interventions prn [as needed]. Proceed with poc [plan of care]. During an interview on 1/28/2025 at 12:57 PM, the Registered Dietitian (RD) stated, [Resident #38's name] was malnourished when she got to the facility. She has poor PO intake and daughter said she was not eating that much prior to coming here. [Resident #38's name] came in at 76.4 pounds. She should be on fortified foods. I was consulted and encouraged an appetite stimulant. The provider puts in the orders. She should be on an appetite stimulant. I have asked about it twice and still nothing is in there. It would be great to put her on one. Review of Resident #38's medical visit note dated 1/6/2025 authored by Advanced Practice Registered Nurse #2 (APRN #2) showed it read, History of Presenting Problem: Patient starter [Sic.] stated that she has not been eating or drinking. During an interview on 1/28/2025 at 3:42 PM, the Director of Nursing (DON) stated, She [the RD] looks in the record and looks at our notes. The RD knows how to read the notes. She knows when a weight is available and knows how to request weights. During an interview on 1/29/2025 at 1:12 PM, the APRN #1 stated, I did see [Resident #38's name]. I oversee pain management. Not overall appetite and weights. I focus on pain management and physiatry [physical medicine and rehabilitation]. During an interview on 1/29/2025 at 3:30 PM, the Medical Doctor #2 (MD #2) stated, The patient had weight loss prior to coming in. She [Resident #38] had severe protein calorie malnutrition. I consulted the dietitian and started on protein shakes. The nursing staff said she [Resident #38] was finishing her meals, and the registered dietitian should have been monitoring, but sometimes patients will not respond to treatment. The patient might not respond with protein shakes and fortified meal. The RD never contacted me in regards to [Resident #38's name] weight loss. Maybe she contacted my nurse practitioner. Keep in mind she lost weight and that does not stop when you leave the hospital you can continue to lose weight until recovery because of weakness, sickness, inflammation and being bedridden. I believe that dietitian has been following, and they would tell me if she would need an appetite stimulant, but I was never notified to start her on an appetite stimulant. She came with weight loss. I rounded at the beginning and was never told. I don't know if my NP [Nurse Practitioner] was notified. She left a week ago. If the facility is saying they notified me, they should be able to prove that. If I am not responding, I can get a text all the time. When she continued to lose weight, the next thing would have been talk to the RD, go with an appetite stimulant and finally g-tube, or do nothing depending on the family. Weight loss is not uncommon to be seen in patients with dementia. They need to be encouraged to eat and be assisted with hand feeding. Common sense questions would be fortified meals, supplement does the resident like the shake, there are different variables. Supervise by staff if despite supervision and try the appetite stimulant. If resident was being weighed weekly, the facility should communicate to the nurse practitioner weekly in regards to the weights letting her know the weight changes. That would be the reason for weekly weights. During an interview on 1/29/2024 at 3:49 PM, the APRN #2 stated, I recall the patient [Resident #38]. I do not have the record in front of me. I no longer work for the facility. I was not notified of any weight changes with the resident [Resident #38]. Of course, I would have implemented the intervention. I would check thyroid levels to make sure it is not the reason of weight loss, but I do not recall the facility communicating the weight loss. During an interview on 1/30/2025 at 9:45 AM, the Dietary Manager stated, [Resident #38's name] is on fortified foods. I communicate with the RD. I am notified when residents have a significant weight loss weekly. I communicate with the RD, and she informs me. I started working here on 1/6/2025. I was not aware of her [Resident #38] significant weight loss. I would expect interventions to be put in place. I would try food first, supplement and appetite stimulant. During an interview on 1/30/2025 at 10:17AM with the DON stated, After the 1/11/2025 significant weight loss, I do not see any interventions put in place for [Resident # 38 name] other than what was already in place. Looking back, I would have addressed a gastric tube with the family or palliative care. During an interview 1/30/2025 at 11:50 AM, the Speech Language Pathologist stated, I changed her diet order after evaluating the patient [Resident #38]. We monitor, for a period of time, the residents in the facility and do trials to see if we can place residents on thin liquids. The resident [Resident #38] was not having any issues during the trials. I changed the diet from thicken liquids to thin liquids because she [Resident #38] was tolerating it well, the diet change or evaluation completed was not because of weight loss. Review of the facility policy and procedure titled Weights and Weight Loss with the last review date of 1/23/2025 showed it read, Policy: It will be the practice of this facility to implement the following systems regarding weight documentation. Procedure . 3. The RD/DTR [Dietetic Technician, Registered] is to review all admission weight for possible interventions. 4. Consistent weight loss noted during the admission weight process will be brought to the attention of the physician and/or RD and responsible party. 5. Significant weight loss shall be addressed by the physician and/or RD through discussion with the resident and/or resident representative for known preferences and desires and development and implementation of interventions to attempt to address the weight loss . 8. Weekly and Daily weights may be obtained per RD or physician orders in order to monitor clinical status of a resident requiring closer monitoring and intervention.

Based on observation, interview, and record review, the facility failed to ensure staff used appropriate personal protective equipment (PPE) while providing direct contact care for 2 of 10 residents reviewed for enhanced-barrier precautions (EBP), Residents #1 and #161, and 1 of 4 residents reviewed for transmission-based precautions, Resident #158, to prevent the possible spread of infection and communicable diseases. Findings include: During an observation on 1/26/2025 at 12:23 PM, Staff C, Activities Assistant, donned gloves and grabbed a pillow from Resident #1's chair in the residents' room. Staff C assisted Resident #1 to turn to his right side. Staff C placed the pillow on the resident's back, tucking the pillow in the left side of the resident's back to assist with repositioning and offloading the resident. Resident #1's room door had an enhanced barrier precaution sign and a plastic bin outside of Resident #1's room with personal protective equipment. Review of Resident #1's physician order dated 1/24/2025 showed it read, Requires enhanced barrier precautions R/T [related to] wound care every shift for prophylaxis. During an observation on 1/26/2025 at 2:05 PM, Staff B, Licensed Practical Nurse (LPN), was flushing Resident #158's midline with normal saline. Staff B was wearing gloves and a surgical mask. Staff B did not have a gown. Resident #158's door had a contact-precaution sign posted and there was a plastic bin with personal protective equipment outside of the room. Review of Resident #158's physician order dated 1/24/2025 showed it read, Contact isolation-MRSA [Methicillin-Resistant-Staphylococcus Aureus] in wound every shift for precaution until 3/01/2025 23:59 [11:59 PM]. During an interview on 1/28/2025 at 2:29 PM, the Infection Preventionist stated, The staff are supposed to wear gloves and gown when entering an enhanced barrier room during high contact activity; when the staff is touching the resident for more than a couple of seconds. If the staff was tucking the pillow and assisting with repositioning, the staff should have had gloves and gown on. If a staff is flushing an IV [Intravenous Catheter], I believe they should also wear a gown and gloves. During an observation on 1/29/2025 at 9:55 AM, Staff D, Registered Nurse (RN), began pouring medications in individual medication cups for Resident #161. After preparing the medications, Staff D entered Resident #161's room. Resident #161 room door had an enhanced barrier sign posted with a plastic bin containing personal protective equipment. Staff D entered Resident #161's room without donning a gown or gloves. Staff D entered Resident #161's bathroom and poured water into two plastic cups. Staff D donned gloves. Staff D did not wear a gown. Staff D premixed each medication cup with water and dissolved each medication. Staff D checked Resident #161 gastric tube for placement. Staff D proceeded to flush Resident #161 gastric tube. Review of Resident #161's physician order dated 1/13/2025 showed it read, Requires enhanced barrier precautions R/T GTUBE [gastric tube] every shift for precaution. During an interview on 1/29/2024 at approximately 10:20 AM, Staff D, RN, stated, I am covering today from another facility. I know I should have put on gloves and a gown before coming into contact with the gastric tube. During an interview on 1/29/2025 at 11:19 AM, the Director of Nursing (DON) stated, Enhanced barrier is to protect residents that have portals for infection. Staff must don gloves and gown when providing care, putting hands on and have contact with patient. During an interview on 1/29/2025 at 1:25 PM, Staff C, Activities Assistant stated, I do remember that [Resident #1's name] said he was on his bottom for a while and I asked if he wanted to be repositioned and I offered to take pressure off his bottom. I put the pillow underneath, and he said he felt better. You are supposed to gown up and stuff, but I was not sure if he was an enhanced barrier precautions. There is usually a sign on the door, but I don't recall there being a sign on the door. If they have open wounds or infection, we should follow enhanced barrier precautions. I was unaware [Resident #1's name] had wounds. If I knew he had wounds, I would have put on a gown. During an interview on 1/30/2025 at 8:22 AM, the DON stated, Staff should gown and wear gloves when going into a contact precaution room. No exceptions. It is not like the enhanced barrier precautions. Review of the facility policy and procedure titled Enhanced Barrier Precautions with the last review date of 1/23/2025 showed it read, Policy: It will be the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms. Definitions: Enhanced barrier precautions refers to the use of gown and gloves for certain residents during specific high-contact resident care activities that have been found to increase risk for transmission of multidrug-resistant organisms . Procedure . 4. For residents for whom EBP are indicated, EBP is employed when performing the following High-contact care activities- a. Dressing, b. Bathing, c. Transferring, d. Providing hygiene, e. Changing linens, f. Changing briefs or assisting with toileting, g. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, h. Wound care: any skin opening requiring a dressing. Review of the facility policy and procedure titled Transmission Based Precautions with the last review date of 1/23/2025 showed it read, Contact Precautions. Contact precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, spread by direct or indirect contact with the resident or the resident's environment . Guidelines for Contact Precautions . Gowns. 1. [NAME] gown upon entry into the room or cubicle. Remove gown and observe hand hygiene before leaving the resident care environment.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was not five percent or greater for 2 out of 31 observations of medication administration. The facility had a medication error rate of 6.45%. Findings include: 1) During an observation on 1/28/2025 at 8:25 AM, Staff E, Licensed Practical Nurse (LPN), began pouring Resident #159's medications into individual cups. Staff E removed Guaifenesin ER (Extended Release) tablet from her medication cart and placed the medication in a medication cup. Staff E finished placing all medications into individual cups and then proceeded to crush each medication. Staff E donned personal protective equipment and entered Resident #159's room. Staff E was about to begin to administer the medication via Resident #159's gastric tube. The surveyor asked Staff E to stop the medication administration process and notified Staff E that she had crushed an extended-release medication to administer enterally. During an interview on 1/28/2025 at 8:30 AM, Staff E, LPN, stated, I know she has an extended-release medication. I have not had any problem with them. But I know they should not administer. I know that they cannot be administered via g tube [gastric tube]. Review of Resident #159's physician order dated 1/13/2025 showed it read, Guaifenesin ER Tablet Extended Release 12 Hour 600 MG [milligram], Give 1 tablet via G-Tube every 12 hours for cough. Review of Resident #159's physician order dated 1/14/2025 showed it read, Nothing by mouth diet, Nothing by mouth texture, Nothing by mouth consistency. 2) During an observation on 1/29/2025 at 9:55 AM, Staff D, Registered Nurse (RN), began pouring medications in individual medication cups for Resident #161. Staff D crushed one Aspirin low dose delayed-release tablet, one Lisinopril tablet and poured one Cholestyramine oral packet of powder into a cup. Staff D entered Resident #161 room. Staff D entered Resident #161's room, and then entered Resident #161's bathroom and poured water into two plastic cups. Staff D donned gloves. Staff D premixed each medication cup with water and dissolved each medication. Staff D checked Resident #161's gastric tube for placement. Staff D proceeded to flush Resident #161's gastric tube. Staff D was going to begin administering the medications. The surveyor asked Staff D to stop the medication administration process and step outside to review the medications. During an interview on 1/29/2024 at approximately 10:20 AM, Staff D, RN, stated, I know I should not crush and administer a delayed-release medication via g-tube. Review of Resident #161's physician order dated 11/12/2024 showed it read, Aspirin Low Dose Oral Tablet Delayed Release 81 MG (Aspirin), Give 1 tablet via G-Tube one time a day for heart health. During an interview on 1/29/2025 at 11:23 AM, the Director of Nursing stated, The nursing staff should not crush and administer delayed-release or extended-release medication via the g-tube. They should call the provider and get alternative medication. Review of the facility policy and procedure titled Medication Errors with the last review date of 1/23/2025 showed it read, Policy: It will be the policy of this facility that the staff and practitioner shall try to prevent medication errors and adverse medication consequences and shall strive to identify and manage them appropriately when they occur. Review of the facility policy and procedure titled Medication Administration via Enteral Feeding Tube with the last review date of 1/23/2025 showed it read, Policy: Medication shall be prepared and administered according to the following established guidelines . Precautions: Common Medications not to crush: Some medications and dosage form should not be crushed. If there are any questions regarding the crushing of medications, call the pharmacy.

Based on observation, interview, and record review, the facility failed to ensure food items were stored in a safe and sanitary manner in bistro of the facility. Findings include: During an observation on 4/23/2024 at 9:13 AM, while conducting a tour of the facility's bistro with the Certified Dietary Manager, there were four undated and unlabeled individual containers of pureed fruit stored in the cabinet, one of which was opened; one uncovered sherbet cup of granulated sugar stored on top of the counter; one container of whipped topping with an open date of 3/3/2024 stored in the cabinet; spillage on the bottom edge of Cooler #1; one undated and unlabeled cut lemon wrapped in plastic wrap stored in Cooler #2; two top cabinet drawers containing speckled black and brown debris; one gallon of dill pickles stored in the sink, with the top of the pickle jar with inscribed warning to refrigerate after opening; no thermometer in the ice cream storage bin; and black and brown speckled debris in the ice cream scoop bin. During an interview on 4/23/2024 at 9:13 AM, the Certified Dietary Manager confirmed the opened, undated, and unlabeled food items stored in the bistro. The Certified Dietary Manager stated the bistro area needed cleaning and that there needed to be a thermometer in the ice cream storage bin. During an interview on 4/23/2024 at 11:50 AM, the Activities Director stated, I know the residents and their families really enjoy the food [in the bistro]. Review of the facility policy and procedure titled Sanitation/Infection Control reviewed on 9/28/2023, showed the policy read, Effective sanitary practices include, but are not limited to, the following: a. The Dietary Manager is responsible for supervising all sanitation and housekeeping procedures within the Dietary Department . c. The Dietary Manager is responsible for supervising and training all personnel in proper sanitation procedures for storing, preparing, and serving foods. 2. i. Leftover foods are placed in shallow containers, dated, labeled, and chilled rapidly. These foods are used within 48 hours. Review of the facility policy and procedure titled Cleaning and Sanitizing Dietary Areas and Equipment, reviewed on 9/28/2023, showed the policy read, All kitchen areas and equipment shall be maintained in a sanitary manner and be free of food, grease or other soil. The facility will provide sanitary food service that meets state and federal regulations. Review of the facility policy and procedure titled Food Storage reviewed on 9/28/2023 showed the policy read, 15. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 48 hours or discarded . 17. Freezer Temperatures: a. Temperatures for freezer should be 0 degrees or below and must be recorded daily . d. Every freezer must be equipped with an internal thermometer, even if equipped with an external thermometer.

Based on interview and record review the facility failed to ensure initial weights were obtained for 4 of 6 residents, Residents #93, #28, #196, and #198, upon admission to the facility. Findings include: 1) Review of Resident #93's record documented Resident #93 was admitted to the facility on [DATE]. Review of Resident #93's care plan, read Resident #93 was at risk for alteration in nutrition and/or hydration related to variable intake, depressive mood, anemia, hypoparathyroidism and macular degeneration. Review of Resident #93's dietary profile, dated 10/15/23, read List Other Dietary Interventions: None (Hospital wt [weight] used for assessment d/t [due to] no facility wt [weight] at time assessment completed). During an interview on 10/18/23 at 10:12 AM, the Director of Nursing stated We weigh residents upon admission. If they refuse, we try again, and go back within hours. Someone should have asked again. She [staff that weighs the residents] comes in on Mondays and does my weights. She [Resident #93] refused to get weighed. I don't know what happened, but they should have charted it. Review of Resident #93's record did not provide documentation of Resident #93 refusing to be weighed at the time of admission. During an interview on 10/19/2023 at 8:05 AM, the Registered Dietician stated, Initial weights are important because you don't know if the hospital weight is correct or not. [I] Would need an accurate weight so I could do an accurate assessment and treat the patient for what I need to treat them for. A lot of patients we get in are malnourished or have not been eating or have wounds. 46523 2) Review of Resident #28's medical record documented the resident was admitted into the facility on [DATE] with diagnoses that included radiculopathy cervical region, adult failure to thrive, major depressive disorder, gastro esophageal reflux disease, and pain. Review of Resident #28's weights documented the first weight dated 8/21/2023, six days after the resident's admission. Review of Resident #28's care plan, initiated on 8/22/2023, read, [Resident #28's name] is at risk for an alteration in nutrition and/or hydration r/t [related to]: has chewing problem, receives mechanically altered diet, hx [history] of weight loss, dx [diagnosis] of failure to thrive, Depressive D/O [disorder], GERD [gastroesophageal reflux disease], HTN [hypertension]. 3) Review of Resident #196's medical record documented the resident's most recent admission into the facility on [DATE] with diagnoses of metabolic encephalopathy, sepsis, urinary tract infection, hypokalemia, and anemia. Review of Resident #196's medical record had no weights documented for the current admission. Review of Resident #196's physician's order, dated 10/10/2023, read, regular diet, mechanical soft texture, thin consistency. Review of Resident #196's physician orders, dated 10/16/2023, read House Nutritional Supplement. House protein. Review of Resident #196's dietary profile, dated 10/15/2023, read, Weights: B. 185, five days after the resident's admission. Review of Resident #196's dietary progress note, dated 10/15/2023, read, Res [resident] states his appetite is so-so. On Mech [mechanical} Soft diet and ST [speech] to evaluate. Has open area on coccyx. Eating 25-75% of meals. Will recommend House Supplement 120ml [milliliters] po bid [by mouth two times a day] and House Protein 30ml po bid [milliliters by mouth two times a day]. Review of Resident #196's care plan, initiated 10/15/2023, read, Is at risk for an alteration in nutrition and/or hydration r/t [related/to] has a chewing problem, receives mechanically altered diet. Has variable intake . 4) Review of the medical record for Resident #198 documented the resident's most recent admission was dated as 10/9/2023 with diagnoses that included metabolic encephalopathy, enterocolitis due to clostridium difficile, cellulitis of right and left lower leg, open wound of scalp, lymphedema, unspecified protein-calorie malnutrition, chronic kidney disease, and type 2 diabetes. Review of Resident #198's physician's order, dated 10/09/2023, read Weigh weekly on every day shift Mon [Monday] for 4 weeks and one time only for 1 day. Review of Resident #198's dietary profile, dated 10/12/2023, read, Weights (lbs): 279. Three days following admission. Review of Resident #198's care plan, initiated dated 10/15/2023, read, [Resident #198's name] is at risk for alteration in nutrition and/or hydration r/t [related to]: is morbidly obese, receives diuretics, C-Diff [enterocolitis due to clostridium difficile], IV [intravenous] antibiotic, Cellulitis BLE [bilateral lower extremities], CKD 3 [chronic kidney disease], Wound on scalp, PVD [peripheral vascular disease] , HPLD [hyperlipidemia], Protein-Calorie Malnutrition, CAD [coronary artery disease, Polyneuropathy. Interventions: Weights as ordered and as needed. Notify physician of significant weight changes if noted. Review of the policy and procedure titled, Weights and Weight Loss, last reviewed 9/28/2023, read Policy: It will be the practice of this facility to implement the following systems regarding weight documentation. Procedure: New Admits and readmissions will be weighed upon admission, monthly and/or as ordered by the physician. 1. Staff will be responsible for obtaining weights for these admits and will have this information available for morning stand-up meeting. Weights will be recorded. 2. Off-hour admissions (late evenings) will need to be weighed by a member of the nursing staff on the off-hour shift to obtain initial weight if possible; obtaining weight the following day for late night admissions may be acceptable for resident comfort.

Based on observation, interview, and record review the facility failed to ensure residents' medical records were complete and accurately documented for 2 of 7 residents, Residents #4, and #198 reviewed for care treatments. Findings include: 1) During an interview on 10/18/2023 at 8:50 AM, Resident #4 stated, The nurse came yesterday and did wound care for me, they changed my dressings. During an observation on 10/18/2023 at 9:33 AM of Resident #4 it showed the wound dressing to his coccyx and left lower buttock was dated 10/17/2023. Review of Resident #4's Treatment Administration Record (TAR) for the month of October 2023, read, Wound Care Right Lower Abdomen Surgical Site. Cleanse with soap and water pat dry. Then apply skin prep, hydrogel, and cover with bordered foam, every day shift for wound care start date 9/26/2023 d/c [discontinue] 10/3/2023. The TAR had a blank entry, no staff initials to document the care was provided on 10/02/2023. Review of Resident #4's TAR for the month of October 2023, read, Wound care coccyx clean with n/s [normal saline], apply medi honey, calcium alginate, and border foam, every day shift for wound care start date 10/04/2023. The TAR had blank entries, no staff initials to document the care was provided on 10/5/2023, 10/6/2023, 10/10/2023, 10/12/2023 and 10/17/2023. Review of Resident #4's TAR for the month of October 2023, read, Wound care L [left] lower leg cleanse with normal saline, apply xeroform, nonstick dressing, cover with rolled gauze, every day shift for wound care start date 10/04/2023 and d/c date of 10/08/2023. The TAR had blank entries, no staff initials to document the care was provided on 10/5/2023 and 10/6/2023. Review of Resident #4's TAR for the month of October 2023, read, Wound care left buttock (cluster) clean with soap and water, pat dry, apply medi honey and calcium alginate and cover with bordered foam, every day shift for wound care start date 10/11/2023. The TAR had blank entries, no staff initials to document the care was provided on 10/12/2023 and 10/17/2023. Review of Resident #4's TAR for the month of October 2023, read, Wound care left buttock ischium clean with n/s [normal saline], apply medi honey, calcium alginate, cover with border gauze, every day shift for wound care start date 10/4/2023. The TAR had blank entries, no staff initials to document the care was provided on 10/5/2023, 10/6/2023, 10/10/2023, 10/12/2023, and 10/17/2023. Review of Resident #4's TAR for the month of October 2023, read, Wound care left lateral ankle clean with n/s, apply skin prep, collagen and cover with border gauze, every day shift for wound care start date 10/4/2023 d/c date10/8/2023. The TAR had blank entries, no staff initials to document the care was provided on 10/5/2023 and 10/6/2023. Review of Resident #4's TAR for the month of October 2023, read, Wound care Right buttock clean with n/s, apply medi honey, calcium alginate, cover with border gauze, every day shift for wound care start date 10/04/2023. The TAR had blank entries, no staff initials to document the care was provided on 10/5/2023, 10/6/2023, 10/10/2023, 10/12/2023, and 10/17/2023. During an interview on 10/19/2023 at 8:10 AM, the Director of Nursing stated, The nurses did the wound care but did not document the care. The nurses should document any refusals or call the physician or get orders. The nurses should be checking off when they are providing the care. Review of the policy and procedure titled, Charting and Documentation, last review date of 9/28/2023, read, Policy: It is the policy of this facility that services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's clinical record as is needed. 2) During an observation on 10/16/2023 at approximately 10:00 AM, Resident #198 was lying in bed. A signal lumen PICC (peripherally inserted central catheter) line with a transparent dressing dated 10/8/2023 was observed to the resident's right upper arm. There was dried blood observed at the insertion site. During an interview on 10/16/2023 at approximately 10:00 AM, Resident #198 stated, I came from the hospital with this IV [intravenous catheter], it has not been changed here at the facility. Review of Resident #198's physician's order, dated 10/9/2023, read, Change dressing post PICC insertion and routinely one time for 1 day observe site for signs/symptoms of infiltration/extravasation/infection. Review of the TAR dated 10/10/2023 staff initialed the PICC line dressing change procedure had been completed on 10/10/2023. During an interview on 10/19/2023 at 8:16 AM, the Director of Nursing stated, Staff should be checking off the MAR [Medication Administration Record] or TAR when they actually do the procedure. Review of policy and procedure titled, PICC IV Line, last review date of 9/28/2023, read, Dressing Changes: 2. Dressing changes will be documented in the clinical record.

Based on observation, interview, and record review the facility failed to ensure care plan fall precautions were fully implemented for 1 of 4 residents, Resident #18, reviewed for accidents. Findings include: Review of Resident #18's census record documented Resident #18 was admitted to the facility on [DATE]. Review of Resident #18's care plan, initiated 7/19/2023, read Resident #18 was at risk for falls and/or fall related injury related to impaired balance and a history of falls. Resident #18's care plan documented fall prevention interventions that included Keep bed in lowest position acceptable to resident. Review of Resident #18's progress notes revealed Resident #18 had fallen on 6/17/2023 with resulting complaints of back pain, had fallen on 6/20/2023 with no resulting discomfort, had fallen on 6/23/23 with resulting pain in his right hip/groin area, had fallen on 8/27/2023 with no resulting discomfort, had fallen on 8/28/2023 with no injury documented and had fallen on 9/30/2023 with no resulting discomfort. Review of the radiology results examination dated 7/6/2023, read, Impacted and displaced subcapital femoral neck fracture .Soft tissue swelling overlies the fracture. During an observation on 10/18/2023 beginning at 8:44 AM Resident #18 was observed sitting up in bed eating his breakfast meal. Resident #18's bed was raised to a high position. During an interview on 10/18/2023 at 8:48 AM, with Staff A, Licensed Practical Nurse (LPN), an observation was made of Resident #18. Resident #18's bed was in a high position. Staff A, LPN confirm the bed was in a high position and should not be. During an interview on 10/18/2023 beginning at 9:32 AM, the Director of Rehabilitation stated, [Resident #18's name] has been falling out of bed a lot lately. During an interview on 10/18/2023 at 10:21 AM, the Director of Nursing stated staff should have lowered Resident #18's bed in accordance with his care plan fall precaution interventions after they delivered his meal tray. [Resident #18's name] has fallen frequently.

Based on record review and interview the facility failed to provide a bed hold notice to the resident or the resident's representative when the resident was transferred to the hospital for 1 of 4 residents, Resident #195, reviewed for discharge. Findings include: Review of Resident #195's medical record revealed Resident #195's was most recently admitted on [DATE] with diagnoses including, but not limited to, acute respiratory failure with hypoxia, sarcoidosis of lung, type 2 diabetes, acute on chronic systolic heart failure, lobar pneumonia, cardiomegaly, major depressive disorder, chronic obstructive pulmonary disease, acute kidney failure, essential hypertension, morbid obesity due to excess calories, dysphagia, altered mental status, and anemia. Review of Resident #195's Nursing Home to Hospital Transfer Form read, Sent to: [name of local hospital]. Date of Transfer 6/19/2023. Reason for Transfer. Shortness of Breath (bronchitis, pneumonia). Review of Resident #195's medical record did not reveal a bed hold notice had been given to Resident #195 or the resident's representative when the resident was transfer to the hospital. During an interview on 10/18/2023 at 1:15 PM, the Director of Regulatory Compliance stated, The facility is not able to locate a Bed Hold Notice for [Resident #195's name]. Review of the facility policy and procedures titled P&P [Policy and Procedure] Bed Hold, last reviewed on 9/28/2023, read, Policy: It will be the policy of this facility to provide residents with bed-hold polices upon admission to the facility and at the time of transfer (i.e. when transferring to hospital or going on therapeutic leave) in accordance with federal and state regulations.

Based on facility medical record review, interview, and policy and procedure review, the facility failed to ensure the physician ordered diet was provided to meet the resident's special nutritional needs when providing a regular diet to a resident that had a physician's order to have nothing by mouth (NPO) for 1 of 3 residents sampled who are NPO, Resident #249. This deficient practice has the potential to affect three residents who were ordered an NPO diets and ten residents out of the 60 total residents in the facility who are ordered a mechanically altered diet. Findings include: Review of the facility medical record for Resident #249 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the sending hospital records of Agency for Health Care Administration (ACHA) Form 3008 dated [DATE] provided to the facility upon transfer, under Section O, titled Nutrition/Hydration read: Dietary Instruction: NPO (nothing by mouth), Tube Feeding: G tube (gastrostomy tube), Supplements: [MEDICATION NAME] 1.2 at 70 ml/hr (milliliters per hour). Review of the physician orders dated [DATE] at 8:14 PM read: NPO diet. At 11:23 PM [MEDICATION NAME] 1.5 via feeding tube at 70 ml/hr. Review of the computerized medical record revealed NPO texture for Resident #249. At 11:23 PM [MEDICATION NAME] 1.5 via feeding tube at 70 ml/hr was entered into the computerized medical record, Point Click Care (PCC). A review of the facility nursing progress note dated [DATE] at 10:12 AM authored by Staff E, Registered Nurse (RN) read: Notified of the resident's change of condition, SSA (Social Service Assistant) relayed that resident told SSA that he should not have eaten breakfast. Floor nurse notified of resident's comment, who verified resident's diet as NPO, and prior education being provided. Upon assessment a rapid response was initiated. During this time, the resident became unresponsive as verified by absence of pulse and respirations. Code blue was called, and CPR (Cardiopulmonary Resuscitation) was started at 10:16 AM. CPR was terminated by facility staff at 10:23 AM due to EMS (Emergency Medical Service) onsite and took control of resuscitative efforts. Resident was transferred to hospital. (Doctor's name) notified via telephone on [DATE] at 10:26 AM. Physician response was send resident to ER (emergency room ). (Friend's name) notified on [DATE] 10:35 AM. Review of a typed staff interview dated [DATE] at 1:00 PM conducted with Staff D, SSA, read: At approximately 10:10 AM (Staff D's name) approached the resident's room and he motioned for her with his arm to come in. (Staff D's name) states she approached the resident he was sitting in an upright angle and his feet were also elevated. He had a tray in front of him with a plate of scrambled eggs with half a slice of toast, the patient was able to speak and stated, I shouldn't have eaten. She was able to understand him but that he was making gurgling noises, in between speaking. His color appeared normal, (Staff D's name) then moved the bedside table with tray out of reach of the resident and asked him How did you get that; you're not allowed to have that. She told the nurse (Staff B's name), Your patient is NPO and had food. Nurse entered the resident's room and at the time the resident was no longer able to speak. She went out of the room to get another nurse and notified (Staff E's name) who immediately responded. (Staff D's name) states (Staff E's name) paged for all available nurses and a short time later paged a code blue. Review of a handwritten statement authored by Staff E, Registered Nurse (RN), read: At approximately 10:12 AM on [DATE], I was walking toward polo dining area to give nurse meds (medications) for her cart. (Staff D's name) approached me stating room [ROOM NUMBER] is choking, he's eating and NPO. I went into the room, upon entering, member in bed, (Staff B's name) was to his left side trying to sit him up. I assisted her to pull him forward and put the head of the bed up. Left the room to page a rapid response (10:13 AM). (Staff H's name), (Staff G's name), (Staff F's name) were trying to clear members airway, suction was set up, visible egg contents from member's mouth and nose were removed, member became unresponsive, code blue was called by me at 10:15 AM. CPR initiated and continued until EMS arrived at 10:23 AM and took over. Review of a handwritten statement authored by Staff C, Dietary Aide, dated [DATE] read: I, (Staff C's name) arrived at work at 9:16 AM on [DATE] to assist in the morning before my scheduled shift at 10:00 AM. I clocked in and then came into the kitchen to see where they were at. Breakfast was already done being served, so I just helped with clean up and few meal preps for residents that did not receive trays. One request was made by phone call received in the kitchen. They had asked for scrambled eggs and toast for room [ROOM NUMBER]. After hanging up I checked the sheet for room [ROOM NUMBER] to verify the diet and made the plate. The CNA had actually arrived at the kitchen door where I gave her the tray for the resident. Review of the handwritten statement authored by Staff A, Certified Nursing Assistant (CNA), dated [DATE] read: After trays were passed, I went in to check on (Resident #249's name) because when I initially took his vital his O2 (oxygen) was extremely low which I notified (Staff B's name) about it and we put him on O2. He told me he was hungry, and I noticed he didn't have a tray. So I told (Staff B's name) he didn't get one and asked what his diet was, she said she'll see and to call the kitchen, so I did and when I was on the phone they just said ok so I went to go get it and the kitchen aid was already carrying it out and I asked is that for 52? She said yes and I said I got it. I was coming to get it anyway and I got his drink and brought him his food. Then I told (Staff B's name) that me and (staff's name) set him back up because he took out his oxygen and it went up to 81 and I told her I got him his tray and she said ok just put the vitals in. Then I went to pick up trays and 53 had the light on and I was cleaning him and that's when the code blue happened. There wasn't an NPO sign on his door. (Staff B's name) and the dietary staff ok'd the tray. I didn't know and I was just doing my job and trying to make sure he was comfortable and happy. Review of the handwritten statement authored by Staff B, Licensed Practical Nurse (LPN), read: Patient was alert x 3 (person, place, time). Staff attempted to explain to patient his medical condition regarding abnormal vital signs (Oxygen saturation 62%). Patient did not verbalize understanding of education. Shortly after (Staff A's name) informed me that (Resident #249's name) did not have a breakfast tray. I stated, I will check his diet order and get back with you. At approximately 10 AM, I was notified by a staff member that (Resident #249's name) had been given a tray and he appears to be choking. I immediately entered the patient room to assess patient. Patient did not respond to verbal stimuli. Additional staff entered the room and began CPR. EMS was notified. EMS arrived at 10:19 AM. At no point did I tell any staff member to give patient food. During an interview with Staff D, Social Services Assistant, on [DATE] at 2:31 PM, she stated, I went in to complete my assessment about 10 after 10 (10:10 AM). I knocked and (Resident #249's name) motioned me to come in. He spoke to me briefly, and stated, I shouldn't be eating. I agreed and removed the tray. He was not coughing or short of breath then. I stepped out the door to get the nurse because she was giving medicine near the room. When we got back in the room, he was coughing, choking and no longer able to speak, and I left to get another nurse to get her some help. During an interview with Staff E, RN, on [DATE] at 2:39 PM, she stated, I was told by (Staff D's name) the SSA that a nurse needs help with room [ROOM NUMBER]. When I got in the room the resident was coughing and choking. I assisted in sitting him up higher in bed and paged a rapid response all nurses assistance to room [ROOM NUMBER]. The patient became unresponsive and we checked for a pulse and called a code blue. We started CPR and called 911 for EMS. When they came, they took over the care of the resident and we stopped CPR and they continued it and he went to the hospital. I do understand how to check on PCC to find out a resident's diet. We have always had to check the resident's diet against the ticket on the tray. The nurse should have been shown the tray before it was delivered to the resident. During an interview with Staff B, LPN, on [DATE] at 2:46 PM, she stated, The SSA reported to me (Resident #249's name) had been eating and asked if he was NPO. I went to the room and assessed him, and he could not respond. CPR was started and EMS activated. There was nothing in his mouth, but food particles were on his shirt. The CNA asked about his diet and I told her that I would check and print out a diet order. I did not tell the CNA to get a tray while I checked the diet. I did not know that she had gotten one. I knew that he needed a feeding at 10:00 AM and I was going to administer it after I had done some other resident's medications. I did know how to check a resident's diet. We cannot change a resident's diet to give them food if they are NPO, but we can make them NPO if we see them coughing and choking. We have a system where a nurse checks the meals before they get served. I do not remember the CNA telling me she got food for any resident. I would have asked to check it. Any resident who is NPO has an orange sticker on the door. (Resident #249's name) had a sticker on the door. I think he ate about half of his eggs and a bite or two of toast. During an interview with Staff A, CNA, on [DATE] at 3:00 PM, via telephone interview, she stated, Earlier in the morning, I had checked the resident and his oxygen saturation was in the 60's. (Staff B's name) put more oxygen on him and asked me to recheck his oxygen saturation. I went back to check his oxygen level and he was sitting up and told me he was hungry and wanted to eat. I saw he didn't get a tray, so I ordered one from the kitchen. I asked him what he wanted, and he said scrambled eggs and toast and orange juice. When I went to the kitchen, the kitchen aid was walking out, and I asked if that was the tray for room [ROOM NUMBER]. I told her I could bring the tray and that he wanted orange juice instead of milk. He was not demanding food. He was angry earlier when I wanted to put oxygen on him, and when the nurse came in, but once I checked on him again, he was fine. He was asking for other things like butter and I got it for him. He was thanking me and apologized for yelling at me earlier. I began to answer other call lights and heard the call for all nurses and code blue called. I did not check his diet or ask the nurse what his diet was. When I called into the kitchen, they okayed it, they should know the diet. After I had the tray, I told (Staff B's name). She asked me to put his new vital signs in the computer because his oxygen levels were higher. I would normally ask the nurses and they would tell me what the diet was, or I would ask the dietary aid and they would know. I was taught how to look up a resident's diet, but I don't remember how to get it myself so I would just always ask the nurse or call the kitchen. I didn't know that I wasn't supposed to give him food. I thought that the kitchen wouldn't give it to me if he couldn't have it. I should have had the nurse check the diet before I gave it to him, but I just thought that I was trying to save time for her and me. I should have told the kitchen his name instead of just saying the room number. During an interview with Staff C, Cook/Dietary Aide, on [DATE] at 12:45 PM, she stated, I came in on [DATE] early at 9:15 (AM) or so to help as a dietary aide before my shift started as the cook. I started cleaning up as it was after the tray line was completed when I received a call to have scrambled eggs, and rye toast for room [ROOM NUMBER]. So, I checked the diet orders and I had been called before for the resident in room [ROOM NUMBER] for more food so I didn't think anything about it. I was not told the resident's name, just the room number. I should have gotten the resident's name. The resident in room [ROOM NUMBER] (Resident #249's name) was ordered NPO. If I had gotten his room number or name, I would have known that he had an NPO order and I would not have given the CNA the tray. We should not have used just the room number. I should have asked for the name. It is our policy to identify a resident's diet before giving out the tray. During an interview with Staff H, LPN, Unit Manager, on [DATE] at 2:25 PM, she stated, I responded to the code blue. The resident was non-responsive, so I got the AED (Automated External Defibrillator) hooked up and he had no pulse, so we started CPR and continued CPR until EMS arrived. He did not have a pulse and wasn't breathing, when we were doing CPR. We could see food bits of eggs and toast. Diets are entered into the computer after being ordered. I distinctly remember there being an orange NPO dot present on door when I went in his room. The policy was that nurses should check the tray prior to giving it to the residents. The nurse should have checked the tray prior to it getting to the resident, that was not done. The CNA just gave the resident the tray and did not follow our policies. We use at least two identifiers to identify a resident, like the name and date of birth. We should never use a room number as a resident identifier. During an interview with Staff G, LPN, on [DATE] at 2:40 PM, she stated, I responded to a page for all nurses to respond to his room. I went in and saw (Staff F's name) was there attempting back blows. We realized that the resident had no respirations and called a code blue and started CPR. There were some eggs in his mouth, but we didn't suction anything out. When we started CPR there were some eggs coming up with compressions. We do have a procedure to check residents' diets in place before this happened. We also put orange stickers on the door to quickly identify NPO residents before this happened. The CNA should have brought the tray to the nurse before she gave the tray to the resident. We use the resident's name and date of birth as identifiers. We should not use a room number as a way to identify a resident. During an interview with Staff F, LPN, on [DATE] at 3:05 PM, he stated, I was in room [ROOM NUMBER] and (Staff E's name) asked me to assist with a patient that was unresponsive. When I walked in the room, he was not responsive, and he was grey. I did an abdominal thrust and sat him up, delivered a few back blows and checked his pulse. He didn't have one and we started CPR; by then the code cart and suction were there. There were food particles of eggs when we did CPR coming out of his mouth and nose. We continued CPR until EMS arrived and they took over. We have always checked a resident's diet before they got it. The CNA should have brought the tray to the nurse to check before she gave it to him. When we check diets, we check for the right diet, texture and if liquids are thickened and any allergies [REDACTED]. When we do anything for a resident, we use two identifiers usually the name and date of birth. We should not use a room number as an identifier. During an interview with the Certified Dietary Manager (CDM) on [DATE] at 11:18 AM, she stated, The cooks serve as managers when I am not present. In order to get a diet, there must be a diet order entered into the computer. This will generate an up to date list of residents' diets. If a resident is admitted after a meal, the nurses would enter the order and it would have a paper order with a yellow slip that came to the department. We would have a paper copy even when a resident is NPO when they are admitted off hours. There must be a diet order for anyone who is admitted before a tray is delivered. Residents are identified by both name and room number. When we receive a telephone call, we must have the name of the resident and room number. This has been in place prior to this incident. We should not have delivered a tray without confirming the resident's name. During an interview with the Director of Nursing (DON) on [DATE] at 2:15 PM, she stated, It is my expectation that all staff check to make sure the right diet is getting delivered. We have always had a policy that when meal trays come out, a licensed nurse checks the tray card diet against the food for the correct diet order and consistency. All staff do have access to find that information in PCC. The process for getting any meal after meal service or when a resident first gets in is, we get the diet order from the 3008 because that is signed by a doctor. Our process is the nurse will sign a diet ticket and it gets processed by the kitchen and returned with the copy of the meal ticket ordered. No tray should be made, or a tray given out without checking the resident's diet first. We should not use a room as a patient identifier when requesting a tray. I think that (Staff A's name) used a room number to identify (Resident #249's name) instead of his name. The dietary staff (Staff C's name) thought she said room [ROOM NUMBER] who had been asking for additional food, so she made the tray after verifying that diet. The reason this occurred is staff used the room number to identify the resident instead of their names. The CNA should have verified the diet before she called the kitchen for the tray and should have had the nurse verify the diet before she brought him the tray. She gave him the tray because he asked for it. In her earlier contacts with him, he was difficult and demanding, but we still should have followed our procedures. Review of the receiving hospital medical records for Resident #249 read: History and Physical - Patient is a [AGE] year old Caucasian male with a past medical history of [REDACTED]. He was brought to the emergency department today for [MEDICAL CONDITION]. He was admitted (hospital's name) on [DATE] for GI (gastrointestinal) bleed, [MEDICAL CONDITION], aspiration pneumonia, and acute [MEDICAL CONDITION]. He was discharged to The Club yesterday. While he was in the hospital, he had a PEG (Percutaneous Endoscopic Gastrostomy) tube placed. It was reported that he was given a food tray at the facility and began choking today. He became unresponsive and CPR was initiated. It was reported that the patient was found to be in asystole (lack of a heartbeat) upon EMS arrival. He was given [MEDICATION NAME] x 4 and [MEDICATION NAME] (sodium [MEDICATION NAME]), ROSC (Return of Spontaneous Circulation) was obtained in about 20 minutes. Review of the receiving hospital's Cardiology Consult dated [DATE] read: Assessment: status [REDACTED]. Troponin x 4 done, no significant change on EKG, no evidence of ischemia, no evidence of cardiogenic shock. Patient's arrest is not likely of cardiac origin. Acute hypoxic [MEDICAL CONDITION] (not enough oxygen in your blood) secondary to apparent choking event/aspiration pneumonia. Review of the receiving hospital's discharge reveled Resident #249 was pronounced deceased on [DATE]. Review of the facility policy and procedure titled Physician and Non-physician Practitioner Orders, Policy Number 12.06.140 issued [DATE], last revision date [DATE] read: Standards: With the changing ways in communication it will be the practice of this facility to honor physicians orders in the following ways: *Telephone orders (TO), *Verbal orders, . *Electronic orders, including but not limited to direct entry into the clinical record or electronic order system . Additional guidance: *A physician must personally approve in writing and/or verbally a recommendation that an individual be admitted to the facility to ensure a minimum of dietary, medications (if necessary) and routine care to maintain or improve the residents functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan. Review of the facility policy and procedure titled Frequency of Meals Policy, Policy Number 07.07.001, issued on [DATE] and last revised on [DATE] read: Guidelines: . 6. Food transport carts are delivered to the resident care areas by the dietary staff. A system is in place to notify nursing that trays have arrived and are ready to be served. This may be with overhead paging, personally speaking to the charge nurse or another method . Dietary Staff: Unit Food Carts: 1. Tray cards updated and correct with residents' diet including likes and dislikes. 2. Kitchen manager or designee checks all trays before they leave the tray line . Nursing Staff: Unit Food carts: 1. When food carts are delivered to the unit the nurse assigned to tray service will open cart, observe the tray for proper diet, likes and dislikes. The tray will then be served to the resident providing set up and dining service as needed. Review of the facility's investigation dated [DATE] read: All Staff involved in the delivery of nutrition/hydration and validation of diet were interviewed, statements obtained, education provided, and one staff member removed from the schedule pending completion of the investigation. The facility conducted an immediate diet confirmation via MD (Medical Doctor) order and reconciled with tray tickets and documentation. There was no tray ticket for resident- no trays delivered as resident was NPO and in the system correctly. Review of the facility form titled Five Whys Root Cause Analysis read: Problem Statement: resident sustained [REDACTED]. Why: Resident consumed nutrition not consistent with physician orders for NPO diet. Why: Resident received access to scrambled eggs and slice of rye toast. Why: Resident alert and oriented, demanded food items from staff member. Why: Resident non-compliant with NPO order and received food items by staff member per request. Why: Staff member failed to validate current diet order prior to delivery of food item and/or notify supervisor of request outside diet order. CNA failed to adhere to facility policy to check physician orders prior to provision of nutrition/hydration in the absence of completed interdisciplinary team review, new MD order and signed waiver. Review of the facility Performance Improvement Plan read: Staff involved in the delivery of nutrition/hydration and validation of diet were interviewed, statements obtained, education provided, and 1 staff member removed from the schedule pending completion of the investigation. Immediate diet confirmation via MD order and reconciled with tray tickets and documentation: There was no tray ticket for resident-no trays delivered as resident was NPO and in the system correctly. Residents on mechanically altered diets and NPO residents were reviewed to ensure indicator dots were present on the name plates of the room. 100% full house audit and order reconciliation with nutrition management and PCC diets was completed on [DATE]. FNS (Food and Nutritional Services) staff were reeducated to review the meal tickets to meals on the tray to validate correct meal, texture, additions to trays and allergies [REDACTED]. FNS staff were reeducated on reconciliation of nutrition management/MD order and meal ticket for each tray service. Ten out of ten (100%) FNS staff completed the education on [DATE]. ST (Speech Therapy) to screen all residents to ensure appropriate diet in place. 100% of active residents were screened on [DATE], and all newly admitted residents with orders will be screened. Facility staff were reeducated to review meal tickets to meal trays to validate correct meal per MD order to include texture preferences and allergies [REDACTED]. 10 FNS staff members, 17 licensed nurses and 28 CNAs (100%) completed the education on [DATE]. Facility staff were reeducated on how to identify level of assistance/supervision during meals and outside of mealtimes via Kardex review under resident care in PCC. 17 licensed nurses and 28 CNAs (100%) completed the education on [DATE]. Facility staff were educated on process for immediate response to residents observed with s/sx (signs/symptoms) of aspiration, decline or change and/or intolerance of currently ordered diet. 17 licensed nurses and 28 CNAs (100%) completed the education on [DATE]. Monitoring: IDT (Interdisciplinary Team) to review PCC (Point Click Care) order listing on all new admissions each morning for continued compliance and reconciliation of diet orders. Daily audits of PCC order listing of all new admissions were verified as completed daily beginning on [DATE] until [DATE]. The CDM manager/designee will routinely monitor meal trays as they are set up going out to floors to validate accuracy of meals per MD orders and meal ticket, as verified by observation of meal tray line on [DATE] and [DATE]. DNS/designee will conduct quality review of 5 residents on each unit weekly (10) to ensure meal trays are delivered are matching ticket/PCC diet order, as verified by review of 20 audits completed by Kitchen/dietary staff from [DATE] through [DATE]. Quality review for appropriate orange indicator dot on doorways will be completed daily x 30 days then move to weekly monitoring. Daily audits are being completed and were reviewed beginning on [DATE] until the exit date of [DATE]. An emergency meeting was held to accept the plan and provide any further recommendations. Reviewed with Medical Director and IDT team on [DATE]. Audits and progress will be presented to QAPI (Quality Assurance and Performance Improvement) Committee to ensure compliance monthly. This plan of correction will be brought to the QAPI committee monthly and the committee will decide whether to continue the monitoring period or discontinue based on effectiveness of the plan. Review of the audits revealed 165 audits have been completed to ensure that staff are checking meal trays for accuracy at the time of meal delivery from [DATE] through [DATE]. Review of the physician orders audits revealed 45 audits were completed for diet accuracy.

Based on facility medical record review, interview, and policy and procedure review, the facility failed to ensure the prevention of neglect when providing a regular diet to a resident that had a physician's order to have nothing by mouth (NPO) for 1 of 3 residents sampled who are NPO, Resident #249. This deficient practice has the potential to affect three residents who were ordered an NPO diets and ten residents out of the 60 total residents in the facility who are ordered a mechanically altered diet. Findings include: Review of the facility medical record for Resident #249 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the sending hospital records of Agency for Health Care Administration (ACHA) Form 3008 dated [DATE] provided to the facility upon transfer, under Section O, titled Nutrition/Hydration read: Dietary Instruction: NPO (nothing by mouth), Tube Feeding: G tube (gastrostomy tube), Supplements: [MEDICATION NAME] 1.2 at 70 ml/hr (milliliters per hour). Review of the physician orders dated [DATE] at 8:14 PM read: NPO diet. At 11:23 PM [MEDICATION NAME] 1.5 via feeding tube at 70 ml/hr. Review of the computerized medical record revealed NPO texture for Resident #249. At 11:23 PM [MEDICATION NAME] 1.5 via feeding tube at 70 ml/hr was entered into the computerized medical record, Point Click Care (PCC). A review of the facility nursing progress note dated [DATE] at 10:12 AM authored by Staff E, Registered Nurse (RN) read: Notified of the resident's change of condition, SSA (Social Service Assistant) relayed that resident told SSA that he should not have eaten breakfast. Floor nurse notified of resident's comment, who verified resident's diet as NPO, and prior education being provided. Upon assessment a rapid response was initiated. During this time, the resident became unresponsive as verified by absence of pulse and respirations. Code blue was called, and CPR (Cardiopulmonary Resuscitation) was started at 10:16 AM. CPR was terminated by facility staff at 10:23 AM due to EMS (Emergency Medical Service) onsite and took control of resuscitative efforts. Resident was transferred to hospital. (Doctor's name) notified via telephone on [DATE] at 10:26 AM. Physician response was send resident to ER (emergency room ). (Friend's name) notified on [DATE] 10:35 AM. Review of a typed staff interview dated [DATE] at 1:00 PM conducted with Staff D, SSA, read: At approximately 10:10 AM (Staff D's name) approached the resident's room and he motioned for her with his arm to come in. (Staff D's name) states she approached the resident he was sitting in an upright angle and his feet were also elevated. He had a tray in front of him with a plate of scrambled eggs with half a slice of toast, the patient was able to speak and stated, I shouldn't have eaten. She was able to understand him but that he was making gurgling noises, in between speaking. His color appeared normal, (Staff D's name) then moved the bedside table with tray out of reach of the resident and asked him How did you get that; you're not allowed to have that. (Staff D's name) went out of the room to get the nurse who was at her med cart near room (at room [ROOM NUMBER]). She told the nurse (Staff B's name), Your patient is NPO and had food. Nurse entered the resident's room and at the time the resident was no longer able to speak. She went out of the room to get another nurse and notified (Staff E's name) who immediately responded. (Staff D's name) states (Staff E's name) paged for all available nurses and a short time later paged a code blue. (Staff D's name) states she did not reenter the room but stayed nearby as staff were responding. (Staff D's name) states EMS arrived and left with resident; she was unsure of the exact time. Review of a handwritten statement authored by Staff E, Registered Nurse (RN), read: At approximately 10:12 AM on [DATE], I was walking toward polo dining area to give nurse meds (medications) for her cart. (Staff D's name) approached me stating room [ROOM NUMBER] is choking, he's eating and NPO. I went into the room, upon entering, member in bed, (Staff B's name) was to his left side trying to sit him up. I assisted her to pull him forward and put the head of the bed up. Left the room to page a rapid response (10:13 AM). On my way to get crash cart, asked (Staff F's name) to go assist (Staff B's name). (Staff H's name), (Staff G's name), (Staff F's name) were trying to clear members airway, suction was set up, visible egg contents from member's mouth and nose were removed, member became unresponsive, code blue was called by me at 10:15 AM. CPR initiated and continued until EMS arrived at 10:23 AM and took over. Review of a handwritten statement authored by Staff C, Dietary Aide, dated [DATE] read: I, (Staff C's name) arrived at work at 9:16 AM on [DATE] to assist in the morning before my scheduled shift at 10:00 AM. I clocked in and then came into the kitchen to see where they were at. Breakfast was already done being served, so I just helped with clean up and few meal preps for residents that did not receive trays. One request was made by phone call received in the kitchen. They had asked for scrambled eggs and toast for room [ROOM NUMBER]. After hanging up I checked the sheet for room [ROOM NUMBER] to verify the diet and made the plate. The CNA had actually arrived at the kitchen door where I gave her the tray for the resident. Review of the handwritten statement authored by Staff A, Certified Nursing Assistant (CNA), dated [DATE] read: After trays were passed, I went in to check on (Resident #249's name) because when I initially took his vital his O2 (oxygen) was extremely low which I notified (Staff B's name) about it and we put him on O2. He told me he was hungry, and I noticed he didn't have a tray. So I told (Staff B's name) he didn't get one and asked what his diet was, she said she'll see and to call the kitchen, so I did and when I was on the phone they just said ok so I went to go get it and the kitchen aid was already carrying it out and I asked is that for 52? She said yes and I said I got it. I was coming to get it anyway and I got his drink and brought him his food. Then I told (Staff B's name) that me and (staff's name) set him back up because he took out his oxygen and it went up to 81 and I told her I got him his tray and she said ok just put the vitals in. Then I went to pick up trays and 53 had the light on and I was cleaning him and that's when the code blue happened. There wasn't an NPO sign on his door. (Staff B's name) and the dietary staff ok'd the tray. I didn't know and I was just doing my job and trying to make sure he was comfortable and happy. Review of the handwritten statement authored by Staff B, Licensed Practical Nurse (LPN), read: During med pass I was notified by (Staff A's name) of an abnormal vital sign. Attending physician was notified upon assessing patient 3 L (liters) of oxygen was administered using nursing judgement. Patient was alert x 3 (person, place, time). Staff attempted to explain to patient his medical condition regarding abnormal vital signs (Oxygen saturation 62%). Patient did not verbalize understanding of education. At approximately 9:45 AM, I was notified by (Staff A, CNA's name) of information regarding another patient. Shortly after (Staff A's name) informed me that (Resident #249's name) did not have a breakfast tray. I stated, I will check his diet order and get back with you. At approximately 10 AM, I was notified by a staff member that (Resident #249's name) had been given a tray and he appears to be choking. I immediately entered the patient room to assess patient. Patient did not respond to verbal stimuli. Additional staff entered the room and began CPR. EMS was notified. EMS arrived at 10:19 AM. At no point did I tell any staff member to give patient food. During an interview with Staff D, Social Services Assistant, on [DATE] at 2:31 PM, she stated, I went in to complete my assessment about 10 after 10 (10:10 AM). I knocked and (Resident #249's name) motioned me to come in. He spoke to me briefly, and stated, I shouldn't be eating. I agreed and removed the tray. He was not coughing or short of breath then. I stepped out the door to get the nurse because she was giving medicine near the room. Her medication cart was right outside the room. When we got back in the room, he was coughing, choking and no longer able to speak, and I left to get another nurse to get her some help. I did not enter the room again but stayed while they called for all nurses to come to his room and then the code blue. During an interview with Staff E, RN, on [DATE] at 2:39 PM, she stated, I was told by (Staff D's name) the SSA that a nurse needs help with room [ROOM NUMBER]. When I got in the room the resident was coughing and choking. I assisted in sitting him up higher in bed and paged a rapid response all nurses assistance to room [ROOM NUMBER]. The patient became unresponsive and we checked for a pulse and called a code blue. One of the other nurses brought in the crash cart and we set up the suction. I don't remember if there were any obvious food during suctioning. We started CPR and called 911 for EMS. When they came, they took over the care of the resident and we stopped CPR and they continued it and he went to the hospital. I do understand how to check on PCC to find out a resident's diet. We have always had to check the resident's diet against the ticket on the tray. The nurse should have been shown the tray before it was delivered to the resident. During an interview with Staff B, LPN, on [DATE] at 2:46 PM, she stated, The SSA reported to me (Resident #249's name) had been eating and asked if he was NPO. I went to the room and assessed him, and he could not respond. CPR was started and EMS activated. There was nothing in his mouth, but food particles were on his shirt. Earlier his oxygen saturation was low. I reassessed him, elevated his HOB (head of bed) and increased his O2. He was alert and talking then. I called the doctor and let him know about the low oxygen level and that I had to increase his oxygen. I set up near his room to do increase reassessed, every 15 minutes. The CNA asked about his diet and I told her that I would check and print out a diet order. I did not tell the CNA to get a tray while I checked the diet. I did not know that she had gotten one. I knew that he needed a feeding at 10:00 AM and I was going to administer it after I had done some other resident's medications. I did know how to check a resident's diet. We cannot change a resident's diet to give them food if they are NPO, but we can make them NPO if we see them coughing and choking. We have a system where a nurse checks the meals before they get served. I do not remember the CNA telling me she got food for any resident. I would have asked to check it. Any resident who is NPO has an orange sticker on the door. (Resident #249's name) had a sticker on the door. I think he ate about half of his eggs and a bite or two of toast. During an interview with Staff A, CNA, on [DATE] at 3:00 PM, via telephone interview, she stated, Earlier in the morning, I had checked the resident and his oxygen saturation was in the 60's. (Staff B's name) put more oxygen on him and asked me to recheck his oxygen saturation. I went back to check his oxygen level and he was sitting up and told me he was hungry and wanted to eat. I saw he didn't get a tray, so I ordered one from the kitchen. I asked him what he wanted, and he said scrambled eggs and toast and orange juice. When I went to the kitchen, the kitchen aid was walking out, and I asked if that was the tray for room [ROOM NUMBER]. I told her I could bring the tray and that he wanted orange juice instead of milk. He was not demanding food. He was angry earlier when I wanted to put oxygen on him, and when the nurse came in, but once I checked on him again, he was fine. He was asking for other things like butter and I got it for him. He was thanking me and apologized for yelling at me earlier. I began to answer other call lights and heard the call for all nurses and code blue called. I did not check his diet or ask the nurse what his diet was. When I called into the kitchen, they okayed it, they should know the diet. After I had the tray, I told (Staff B's name). She asked me to put his new vital signs in the computer because his oxygen levels were higher. I would normally ask the nurses and they would tell me what the diet was, or I would ask the dietary aid and they would know. I was taught how to look up a resident's diet, but I don't remember how to get it myself so I would just always ask the nurse or call the kitchen. I didn't know that I wasn't supposed to give him food. I thought that the kitchen wouldn't give it to me if he couldn't have it. I should have had the nurse check the diet before I gave it to him, but I just thought that I was trying to save time for her and me. I should have told the kitchen his name instead of just saying the room number. During an interview with Staff C, Cook/Dietary Aide, on [DATE] at 12:45 PM, she stated, I came in on [DATE] early at 9:15 (AM) or so to help as a dietary aide before my shift started as the cook. I started cleaning up as it was after the tray line was completed when I received a call to have scrambled eggs, and rye toast for room [ROOM NUMBER]. So, I checked the diet orders and I had been called before for the resident in room [ROOM NUMBER] for more food so I didn't think anything about it. I was not told the resident's name, just the room number. I should have gotten the resident's name. The resident in room [ROOM NUMBER] (Resident #249's name) was ordered NPO. If I had gotten his room number or name, I would have known that he had an NPO order and I would not have given the CNA the tray. We should not have used just the room number. I should have asked for the name. It is our policy to identify a resident's diet before giving out the tray. During an interview with Staff H, LPN, Unit Manager, on [DATE] at 2:25 PM, she stated, I responded to the code blue. There were two nurses in the room at the time, (Staff E's name) and (Staff F's name). The resident was non-responsive, so I got the AED (Automated External Defibrillator) hooked up and he had no pulse, so we started CPR and continued CPR until EMS arrived. I did not see anyone do the [MEDICATION NAME]. He did not have a pulse and wasn't breathing, when we were doing CPR. We could see food bits of eggs and toast. Diets are entered into the computer after being ordered. I distinctly remember there being an orange NPO dot present on door when I went in his room. The policy was that nurses should check the tray prior to giving it to the residents. The nurse should have checked the tray prior to it getting to the resident, that was not done. The CNA just gave the resident the tray and did not follow our policies. We use at least two identifiers to identify a resident, like the name and date of birth. We should never use a room number as a resident identifier. During an interview with Staff G, LPN, on [DATE] at 2:40 PM, she stated, I responded to a page for all nurses to respond to his room. I went in and saw (Staff F's name) was there attempting back blows. We realized that the resident had no respirations and called a code blue and started CPR. There were some eggs in his mouth, but we didn't suction anything out. When we started CPR there were some eggs coming up with compressions. We do have a procedure to check residents' diets in place before this happened. We also put orange stickers on the door to quickly identify NPO residents before this happened. The CNA should have brought the tray to the nurse before she gave the tray to the resident. We use the resident's name and date of birth as identifiers. We should not use a room number as a way to identify a resident. During an interview with Staff F, LPN, on [DATE] at 3:05 PM, he stated, I was in room [ROOM NUMBER] and (Staff E's name) asked me to assist with a patient that was unresponsive. When I walked in the room, he was not responsive, and he was grey. I did an abdominal thrust and sat him up, delivered a few back blows and checked his pulse. He didn't have one and we started CPR; by then the code cart and suction were there. There were food particles of eggs when we did CPR coming out of his mouth and nose. We continued CPR until EMS arrived and they took over. We have always checked a resident's diet before they got it. The CNA should have brought the tray to the nurse to check before she gave it to him. When we check diets, we check for the right diet, texture and if liquids are thickened and any allergies [REDACTED]. When we do anything for a resident, we use two identifiers usually the name and date of birth. We should not use a room number as an identifier. During an interview with the Certified Dietary Manager (CDM) on [DATE] at 11:18 AM, she stated, The cooks serve as managers when I am not present. In order to get a diet, there must be a diet order entered into the computer. This will generate an up to date list of residents' diets. If a resident is admitted after a meal, the nurses would enter the order and it would have a paper order with a yellow slip that came to the department. We would have a paper copy even when a resident is NPO when they are admitted off hours. There must be a diet order for anyone who is admitted before a tray is delivered. Residents are identified by both name and room number. When we receive a telephone call, we must have the name of the resident and room number. This has been in place prior to this incident. We should not have delivered a tray without confirming the resident's name. During an interview with the Director of Nursing (DON) on [DATE] at 2:15 PM, she stated, It is my expectation that all staff check to make sure the right diet is getting delivered. We have always had a policy that when meal trays come out, a licensed nurse checks the tray card diet against the food for the correct diet order and consistency. All staff do have access to find that information in PCC. The process for getting any meal after meal service or when a resident first gets in is, we get the diet order from the 3008 because that is signed by a doctor. Our process is the nurse will sign a diet ticket and it gets processed by the kitchen and returned with the copy of the meal ticket ordered. No tray should be made, or a tray given out without checking the resident's diet first. We should not use a room as a patient identifier when requesting a tray. I think that (Staff A's name) used a room number to identify (Resident #249's name) instead of his name. The dietary staff (Staff C's name) thought she said room [ROOM NUMBER] who had been asking for additional food, so she made the tray after verifying that diet. The reason this occurred is staff used the room number to identify the resident instead of their names. The CNA should have verified the diet before she called the kitchen for the tray and should have had the nurse verify the diet before she brought him the tray. She gave him the tray because he asked for it. In her earlier contacts with him, he was difficult and demanding, but we still should have followed our procedures. Review of the receiving hospital medical records for Resident #249 read: History and Physical - Patient is a [AGE] year old Caucasian male with a past medical history of [REDACTED]. He was brought to the emergency department today for [MEDICAL CONDITION]. He was admitted (hospital's name) on [DATE] for GI (gastrointestinal) bleed, [MEDICAL CONDITION], aspiration pneumonia, and acute [MEDICAL CONDITION]. He was discharged to The Club yesterday. While he was in the hospital, he had a PEG (Percutaneous Endoscopic Gastrostomy) tube placed. It was reported that he was given a food tray at the facility and began choking today. He became unresponsive and CPR was initiated. It was reported that the patient was found to be in asystole (lack of a heartbeat) upon EMS arrival. He was given [MEDICATION NAME] x 4 and [MEDICATION NAME] (sodium [MEDICATION NAME]), ROSC (Return of Spontaneous Circulation) was obtained in about 20 minutes. Review of the receiving hospital's Cardiology Consult dated [DATE] read: Assessment: status [REDACTED]. Troponin x 4 done, no significant change on EKG, no evidence of ischemia, no evidence of cardiogenic shock. Patient's arrest is not likely of cardiac origin. Acute hypoxic [MEDICAL CONDITION] (not enough oxygen in your blood) secondary to apparent choking event/aspiration pneumonia. Review of the receiving hospital's discharge reveled Resident #249 was pronounced deceased on [DATE]. Review of the facility policy and procedure titled ANE (Abuse, Neglect and Exploitation) and Investigations, Policy Number 12.08.009 issued on [DATE], last revised on [DATE] read: Standards: It will be the standard of this facility to honor residents rights and address with employees the seven (7) components regarding mistreatment, abuse, neglect, sexual misconduct, injures of unknown source, involuntary seclusion, corporal punishment, misappropriation of residents property or funds or use of physical or chemical restraint not required to treat the residents symptoms in accordance with Federal law . Definitions: 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 . Guidelines: . 3. Prevention: . The facility environment will be monitored to prevent any ANE through: . * monitoring staff actions while caring for residents. Review of the facility policy and procedure titled Physician and Non-physician Practitioner Orders, Policy Number 12.06.140 issued [DATE], last revision date [DATE] read: Standards: With the changing ways in communication it will be the practice of this facility to honor physicians orders in the following ways: *Telephone orders (TO), *Verbal orders, . *Electronic orders, including but not limited to direct entry into the clinical record or electronic order system . Additional guidance: *A physician must personally approve in writing and/or verbally a recommendation that an individual be admitted to the facility to ensure a minimum of dietary, medications (if necessary) and routine care to maintain or improve the residents functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan. Review of the facility policy and procedure titled Frequency of Meals Policy, Policy Number 07.07.001, issued on [DATE] and last revised on [DATE] read: Guidelines: . 6. Food transport carts are delivered to the resident care areas by the dietary staff. A system is in place to notify nursing that trays have arrived and are ready to be served. This may be with overhead paging, personally speaking to the charge nurse or another method . Dietary Staff: Unit Food Carts: 1. Tray cards updated and correct with residents' diet including likes and dislikes. 2. Kitchen manager or designee checks all trays before they leave the tray line . Nursing Staff: Unit Food carts: 1. When food carts are delivered to the unit the nurse assigned to tray service will open cart, observe the tray for proper diet, likes and dislikes. The tray will then be served to the resident providing set up and dining service as needed. Review of the facility's investigation dated [DATE] read: All Staff involved in the delivery of nutrition/hydration and validation of diet were interviewed, statements obtained, education provided, and one staff member removed from the schedule pending completion of the investigation. The facility conducted an immediate diet confirmation via MD (Medical Doctor) order and reconciled with tray tickets and documentation. There was no tray ticket for resident- no trays delivered as resident was NPO and in the system correctly. Review of the facility form titled Five Whys Root Cause Analysis read: Problem Statement: resident sustained [REDACTED]. Why: Resident consumed nutrition not consistent with physician orders for NPO diet. Why: Resident received access to scrambled eggs and slice of rye toast. Why: Resident alert and oriented, demanded food items from staff member. Why: Resident non-compliant with NPO order and received food items by staff member per request. Why: Staff member failed to validate current diet order prior to delivery of food item and/or notify supervisor of request outside diet order. CNA failed to adhere to facility policy to check physician orders prior to provision of nutrition/hydration in the absence of completed interdisciplinary team review, new MD order and signed waiver. Review of the facility Performance Improvement Plan read: Staff involved in the delivery of nutrition/hydration and validation of diet were interviewed, statements obtained, education provided, and 1 staff member removed from the schedule pending completion of the investigation. Immediate diet confirmation via MD order and reconciled with tray tickets and documentation: There was no tray ticket for resident-no trays delivered as resident was NPO and in the system correctly. Residents on mechanically altered diets and NPO residents were reviewed to ensure indicator dots were present on the name plates of the room. 100% full house audit and order reconciliation with nutrition management and PCC diets was completed on [DATE]. FNS (Food and Nutritional Services) staff were reeducated to review the meal tickets to meals on the tray to validate correct meal, texture, additions to trays and allergies [REDACTED]. FNS staff were reeducated on reconciliation of nutrition management/MD order and meal ticket for each tray service. Ten out of ten (100%) FNS staff completed the education on [DATE]. ST (Speech Therapy) to screen all residents to ensure appropriate diet in place. 100% of active residents were screened on [DATE], and all newly admitted residents with orders will be screened. Facility staff were reeducated to review meal tickets to meal trays to validate correct meal per MD order to include texture preferences and allergies [REDACTED]. 10 FNS staff members, 17 licensed nurses and 28 CNAs (100%) completed the education on [DATE]. Facility staff were reeducated on how to identify level of assistance/supervision during meals and outside of mealtimes via Kardex review under resident care in PCC. 17 licensed nurses and 28 CNAs (100%) completed the education on [DATE]. Facility staff were educated on process for immediate response to residents observed with s/sx (signs/symptoms) of aspiration, decline or change and/or intolerance of currently ordered diet. 17 licensed nurses and 28 CNAs (100%) completed the education on [DATE]. Monitoring: IDT (Interdisciplinary Team) to review PCC (Point Click Care) order listing on all new admissions each morning for continued compliance and reconciliation of diet orders. Daily audits of PCC order listing of all new admissions were verified as completed daily beginning on [DATE] until [DATE]. The CDM manager/designee will routinely monitor meal trays as they are set up going out to floors to validate accuracy of meals per MD orders and meal ticket, as verified by observation of meal tray line on [DATE] and [DATE]. DNS/designee will conduct quality review of 5 residents on each unit weekly (10) to ensure meal trays are delivered are matching ticket/PCC diet order, as verified by review of 20 audits completed by Kitchen/dietary staff from [DATE] through [DATE]. Quality review for appropriate orange indicator dot on doorways will be completed daily x 30 days then move to weekly monitoring. Daily audits are being completed and were reviewed beginning on [DATE] until the exit date of [DATE]. An emergency meeting was held to accept the plan and provide any further recommendations. Reviewed with Medical Director and IDT team on [DATE]. Audits and progress will be presented to QAPI (Quality Assurance and Performance Improvement) Committee to ensure compliance monthly. This plan of correction will be brought to the QAPI committee monthly and the committee will decide whether to continue the monitoring period or discontinue based on effectiveness of the plan. Review of the audits revealed 165 audits have been completed to ensure that staff are checking meal trays for accuracy at the time of meal delivery from [DATE] through [DATE]. Review of the physician orders audits revealed 45 audits were completed for diet accuracy.