Every finding on record at Copper Knoll Health & Rehab LLC

Based on record review, interviews, and policy review, the facility failed to timely assess and adequately investigate falls. This affected one resident (#75) out of three residents reviewed for falls. The facility census was 70.Findings include:Review of the closed medical record for Resident #75 revealed an admission date of 05/08/26 and a discharge date of 06/18/26. Diagnoses included Alzheimer's disease with late onset, generalized anxiety disorder, major depressive disorder single episode severe with psychotic features, hypokalemia, hypertension, hyperlipidemia, and unspecified protein-calorie malnutrition.Review of the admission Minimum Data Set (MDS) assessment, dated 05/13/26, revealed this resident had severely impaired cognition. This resident was assessed to require supervision for eating, toileting, bed mobility, and transfer, substantial/maximal assistance for oral hygiene, bathing, and lower body dressing, and partial/moderate assistance for upper body dressing and personal hygiene.Review of the incident log for 05/08/26 to 06/18/26 revealed no documentation related to any falls for Resident #75 on 05/21/26 or 06/07/26.Review of the progress notes from 05/08/26 to 06/18/26 revealed no documentation related to any falls for Resident #75 on 05/21/26 or 06/07/26.Review of the hospice progress note dated 05/21/26 revealed an unknown facility nurse reported Resident #75 slid out of a wheelchair and onto the floor with no injuries noted.Review of the hospice progress notes dated 06/07/26 revealed Licensed Practical Nurse (LPN) #126 contacted the hospice provider and reported that Resident #75 had fallen. Per the notes, staff were going to assist resident to bed as she was leaned forward asleep in her chair and purposely went forward. The notes also indicated Resident #75 had an additional fall around 6:15 A.M. on 06/07/26. Resident #75 was assessed by hospice on 06/07/26 with no negative findings noted.Interview on 07/23/26 at 2:01 P.M. with Certified Nursing Assistant (CNA) #40 via telephone revealed Resident #75 had two falls on 06/07/26. CNA #40 stated Resident #75 was found wrapped up in blankets on the floor before 7:00 A.M. on 06/07/26 and then had another fall later in the day in the hallway.Interviews on 07/27/26 from 9:22 A.M. to 10:12 A.M. with the Director of Nursing (DON) revealed she was not aware of the incidents on 06/07/26. The DON reported she would have instructed the nurse to complete incident reports, and the falls would have been investigated. The DON also verified there were no assessments or neurological checks for Resident #75 related to the falls on 06/07/26.Interview on 08/18/26 at 10:05 A.M. via telephone with Physician #200 revealed Resident #75 had already experienced a significant decline prior to the undocumented falls and therefore any change in condition following the falls were attributed to disease progression.Interview on 08/18/26 at 10:29 A.M. with CNA #40 via telephone revealed she informed an unknown nurse about Resident #75's fall prior to 7:00 A.M. on 06/07/26 and was instructed to have another aide assist with helping Resident #75 from the floor prior to the nurse conducting an evaluation for injuries.Interviews on 08/18/26 from 11:24 A.M. to 1:29 P.M. with the DON revealed she was not aware of the fall on 05/21/26 and confirmed there were no assessments or neurological checks regarding the fall on 05/21/26.Review of the facility policy titled Incidents and Accidents, revised 07/10/24, revealed any injuries would be assessed by a licensed nurse, and the resident would not be moved until safe to do so. In the event of an unwitnessed fall or a blow to the head, the nurse would initiate neurological checks per protocol.Review of the facility policy titled Fall Investigation and Risk Evaluation, revised 08/2024, revealed staff would assess the resident, notify the DON, document in the medical record, and initiate a post fall investigation.This deficiency represents non-compliance investigated under Complaint Number 3047731.

Based on medical record review, interviews, and policy review, the facility failed to ensure accuracy of medical records. This affected one resident (#75) out of three residents reviewed for documentation. The facility census was 70.Findings include:Review of the closed medical record for Resident #75 revealed an admission date of 05/08/26 and a discharge date of 06/18/26. Diagnoses included Alzheimer's disease with late onset, generalized anxiety disorder, major depressive disorder single episode severe with psychotic features, hypokalemia, hypertension, hyperlipidemia, and unspecified protein-calorie malnutrition.Review of the admission Minimum Data Set (MDS) assessment, dated 05/13/26, revealed this resident had severely impaired cognition. This resident was assessed to require supervision for eating, toileting, bed mobility, and transfer, substantial/maximal assistance for oral hygiene, bathing, and lower body dressing, and partial/moderate assistance for upper body dressing and personal hygiene.Review of the progress notes from 05/08/26 to 06/18/26 revealed no documentation related to any falls for Resident #75 on 05/21/26 or 06/07/26.Review of the hospice progress note dated 05/21/26 revealed an unknown facility nurse reported Resident #75 slid out of a wheelchair and onto the floor with no injuries noted.Review of the hospice progress notes dated 06/07/26 revealed Licensed Practical Nurse (LPN) #126 contacted the hospice provider and reported that Resident #75 had fallen. Per the notes, staff were going to assist resident to bed as she was leaned forward asleep in her chair and purposely went forward. The notes also indicated Resident #75 had an additional fall around 6:15 A.M. on 06/07/26. Resident #75 was assessed by hospice on 06/07/26 with no negative findings noted.Interview on 07/27/26 at 10:12 A.M. with the Director of Nursing (DON) verified there were no progress notes for Resident #75 related to the falls on 06/07/26.Follow-up interview on 08/18/26 at 1:29 P.M. with the DON confirmed there were no progress notes regarding the fall on 05/21/26.Review of the facility policy titled Incidents and Accidents, revised 07/10/24, revealed the nurse would enter the incident information within 24 hours of occurrence and document all pertinent information, including the date, time, nature of the incident, location, initial findings, immediate interventions, notifications and orders obtained or follow-up interventions.

Based on record review and staff interview, the facility failed to ensure there was a Registered Nurse (RN) on duty for at least eight consecutive hours a day, seven days a week. This had the potential to affect all 65 residents residing in the facility. The census was 65. Findings include:Review of facility staffing schedules and posted staffing information revealed there was no RN coverage for 04/25/2026.Interview on 05/13/2026 at 1:27 P.M. with Administrator verified the facility did not have a RN on duty in the facility on 04/25/2026, as the staff who usually worked the weekend was not available that day and the gap of RN coverage was missed. This deficiency represents non-compliance investigated under Complaint Number 2983365.

Based on observation, interview and policy review, the facility failed to ensure laundry was stored to prevent the spread of infection. This had the potential to affect all 64 residents who reside in the facility. The facility census was 64.Findings Included:Based on observation, interview and policy review, the facility failed to ensure laundry was stored to prevent the spread of infection. This had the potential to affect all 64 residents who reside in the facility. The facility census was 64.Findings Included:Observation on 12/31/25 at 8:35 A.M. with the Environmental Manager (EM) #39 of the 300 hall central bath with a linen cart with four shelves filled with linens, towels, washcloths, and other miscellaneous items had a front flap that was opened up and on top of the cart, leaving all of the items on the cart exposed. The bathtub was about one foot from the cart. Interview on 12/31/25 at the time of the observation the EM #39 stated the cover was constantly up and the items were exposed when housekeeping goes in multiple times per day in all of the central bath rooms. Continued observation revealed the 200 hall central bath room with a linen cart designed the same as the 300 hall central bath with the linen cart flap open and on top with items on top of the flap. The cart was about two feet from the bathtub. Continued observation of the 100 hall central bath with a linen cart the same design as the 200 and 300 hall central baths with the flap open with items on the top of the flap. The EM #39 verified the flaps were all up and not covering the items on the cart and could be exposed to bacteria from the bathtub. Review of the policy titled, Handling Clean Linen, dated 11/01/23 clean linen shall be delivered to resident care units on covered linen carts with covers down. Nothing shall be kept on top of linen carts. Only rolls of bags used for linen transport may be kept on the carts, in the designated pockets only.

Based on observation, interview, review of the safety data sheets, and policy review, the facility failed to ensure the resident environment was free of accident hazards. This affected four (#01, #16, #26 and #54) out of four residents reviewed and had the potential to affect all seven (#01, #16, #26, #33, #51, #54 and #64) independently mobile residents who reside in the memory care unit. The facility census was 64.Findings include-Based on observation, interview, review of the safety data sheets, and policy review, the facility failed to ensure the resident environment was free of accident hazards. This affected four (#01, #16, #26 and #54) out of four residents reviewed and had the potential to affect all seven (#01, #16, #26, #33, #51, #54 and #64) independently mobile residents who reside in the memory care unit. The facility census was 64.Findings Include:1. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included anxiety disorder, dementia in other diseases classified elsewhere, severe with other behavioral disturbance, major depressive disorder, attention-deficit hyperactivity disorder, hallucinations, and post-traumatic stress disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 had severe cognitive impairment, supervision with eating, substantial assistance with toileting, dependent with bathing, and partial assistance with personal hygiene. 2. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE]. Diagnoses included Alzheimer ' s disease with late onset, dementia, anxiety disorder, and adult failure to thrive. Review of the most recent MDS 3.0 assessment revealed Resident #16 had severe cognitive impairment, supervision with eating, dependent with toileting, dependent with bathing, and supervision with personal hygiene. 3. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia, vascular dementia, depression, amnesia, and cerebral infarction. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #26 had moderately impaired cognition, supervision with eating, independent with toileting, supervision with bathing, and independent with personal hygiene. 4. Review of the medical record Resident #54 was admitted to the facility on [DATE]. Diagnosis included Alzheimer ' s disease, unspecified dementia, other symptoms and signs involving cognitive functions and awareness, and personal history of other diseases of the nervous system and sense organs. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #54 had severe cognitive impairment, supervision with eating, independent with toileting, dependent with bathing, and supervision with personal hygiene. Observation and interview on 12/31/25 at 10:30 A.M. the State Tested Nurse Aide (STNA) #50 verified the central bathing door was unlocked with one large jug of soap with no lid and five razors sitting on the table directly inside the door. The STNA #50 verified the door was unlocked due to being broken and the medication room unlocked as well. Interview on 12/31/25 at 10:35 A.M. Licensed Practical Nurse (LPN) #36 verified the medication room door was unlocked with items in the cabinets included the following:Five insulin syringes with needlesFive razorsOne tub of Clorox wipes 75 countAcetaminophen (pain reliever) 325 milligrams (mg) two full bottles One bottle of vitamin D3 50 micrograms (mcg) 250 tabletsOne bottle of cimetidine (acid reducer) 200 mg 60 tab bottle Six bottles of acetic acid irrigation 500 milliliters (ml) in eachTwo jugs of drug busterTwo bottles of hand sanitizer LPN #36 verified the medication room door had been unlocked for about one hour. Review of the safety data sheet (SDS) for drug buster dated 10/10/14 identifies the hazard of eye damage/irritation, skin sensitization, skin corrosion/irritation. Review of the SDS for Clorox commercial solutions dated 06/02/20 states handle in accordance with good industrial hygiene and safety practice. Review of the SDS for germ-x hand sanitizer dated 01/16/15 identifies the hazard of flammable liquid and vapor. Review of the SDS for Lysol dated 07/30/21 identifies the hazard flammable aerosol, causes eye irritation. Review of the SDS for body wash dated 01/07/15 identifies storage as keep out of reach of children, store in a dry, well-ventilated place away from incompatible materials. Review of the SDS for Refresh tears dated 11/07/23 states handle in accordance with good industrial hygiene and safety practice. Review of the SDS for Ear Wax Remover dated 07/28/14 identifies the hazard causes serious eye irritation. Review of the policy titled, Medication Storage, dated 11/01/23 all drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. Review of the policy titled, Dementia Care, dated 11/01/23 care and services will be person-centered and reflect each resident ' s individual goals while maximizing the resident ' s dignity, autonomy, privacy, socialization, independence, choice, and safety.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure privacy of the electronic medical record. This affected two (#53 and #62) of six residents reviewed for privacy. The facility census was 64.Findings include-Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure privacy of the electronic medical record. This affected two (#53 and #62) of six residents reviewed for privacy. The facility census was 64.Findings Include:1. Review of the medical record revealed Resident #62 was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus, end stage renal disease, major depressive disorder, and hypertension.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #62 had moderately impaired cognition, required supervision with eating, supervision with toileting, and partial assistance with personal hygiene.Observation and interview on 12/29/2025 at 9:59 AM the Licensed Practical Nurse (LPN) #49 verified the medication cart laptop sat on top of the cart open to Resident #62's medication list in the Electronic Medical Record (EMR) on the screen while LPN #49 was away.2. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE]. Diagnoses included depression, Parkinson's disease without dyskinesia, cervical disc disorder, and chronic kidney disease.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #53 had moderately impaired cognition, required supervision with eating, dependent for bathing and toileting.Observation and interview on 12/30/25 at 10:29 A.M. the EMR was open to Resident #53's medications and no staff were around at the time. The Medication Aide (MA) #02 verified the laptop was open to Resident #53 where the medications were listed on the screen. The MA #2 verified she was away and obtaining supplies for a resident and left the EMR open.Review of the policy titled, Resident admission Agreement, dated 05/25 documented the facility will maintain residents' records in a confidential manner.

Based on medical record review, interview, and policy review, the facility failed to adequately monitor the administration of warfarin. This affected one (#56) of five residents reviewed for unnecessary medications. The facility census was 64.Findings include-Based on medical record review, interview, and policy review, the facility failed to adequately monitor the administration of warfarin. This affected one (#56) of five residents reviewed for unnecessary medications. The facility census was 64.Findings Include:Review of the medical record revealed Resident #56 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease late onset, epilepsy, major depressive disorder, peripheral vascular disease, chronic embolism and thrombosis of unspecified vein, and essential hypertension.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #56 had severely impaired cognition, required supervision with eating, dependent with toileting, and dependent with bathing.Review of Resident #56 provider order dated 04/14/25 revealed warfarin (a blood thinning medication) sodium oral tablet five milligrams (mg) give one tablet by mouth in the evening related to chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity. Collect a prothrombin time/international normalized ratio (PT/INR) weekly on Monday.Review of Resident #56's laboratory results for PT/INR were 11/17/25 PT 24.4 and INR 2.3 with progress note Nurse Practitioner (NP) aware, orders for this visit, please continue coumadin five mg daily and repeat INR in one week.Review of Resident #56 lab results for PT/INR were 12/03/25 PT 24.2 and INR 2.3. Review of Resident #56 lab results for PT/INR were 12/19/25 PT 36.8 and INR 3.5 with progress note, orders for this visit, hold coumadin dose tonight times one and repeat PT/INR tomorrow and notify of results.Review of Resident #56 lab results for PT/INR were 12/23/25 PT 14.7 and INR 1.4.Review of Resident #56 lab results for PT/INR were 12/29/25 PT 23.2 and INR 2.2.Review of Resident #56 medical record revealed no PT/INR for 11/24/25, 12/01/25, 12/08/25, 12/15/25, 12/20/25 and 12/22/25.Review of Resident #56 progress note dated 12/26/25 revealed the patient was seen for an acute care visit for decreased INR. The patient was on long-term Coumadin therapy for chronic embolism and thrombosis. The most recent INR was 1.4, which was below the target range. INR recheck was planned, but no new results were available yet. Please keep Coumadin at five mg daily and check if the INR lab was actually done. Weekly Monday INR checks were needed for safe monitoring.Review of Resident #56 care plan dated 07/22/24 revealed currently prescribed an anticoagulation medication therapy with the intervention of will monitor PT/INR. Interview on 12/30/25 at 7:55 A.M. with the Director of Nursing (DON) verified no PT/INR for Resident #56 was completed on the following dates: 11/24/25, 12/01/25, 12/08/25, 12/15/25, 12/20/25 and 12/22/25 and was unsure as to why the labs were missed, the nurses should not administer the dose of warfarin with no PT/INR lab results.Interview on 12/30/25 at 8:26 A.M. with the Nurse Practitioner (NP) #80 verified the PT/INR for Resident #56 was missed a few times in the last month and she was currently working with the DON to come up with a resolution as the PT/INR was important to have drawn to monitor for a therapeutic level of warfarin. The NP #80 additionally verified she stressed to the DON that Resident #56 needed the PT/INR drawn every Monday.Review of the policy titled, High Risk Medications Anticoagulants, dated 02/05/25 reads routine labs, including baseline and subsequent labs, shall be ordered for each resident requiring anticoagulant medication. Results shall be communicated to the physician in a timely manner. Review of the policy titled, Coumadin Monitoring, dated 06/22 it reads Coumadin will be administered in the evening to ensure lab results are received and reported prior to administering the dose on the date of the lab draws. Review of the policy titled, Laboratory Services and Reporting, dated 11/29/23, reads the facility must provide or obtain laboratory services to meet the needs of its residents.

Based on record review, facility staff interview and facility policy review, the facility failed to ensure allegations of abuse were reported in a timely manner. This had the potential to affect 62 of 62 residents. Findings included:Review of a self-reported incident (SRI) dated 03/31/25 revealed on 03/29/25 at about 11:30 A.M., a visitor to the facility was heard speaking loudly to Resident #13 and #32, telling them they could not sit at the table they were at and it belonged to her mother and her friends. The visitor told Residents #13 and #32 no one likely them and they had been told before not to sit at this table. Licensed Practical Nurse (LPN) #101 immediately intervened and addressed the visitor who immediately reported the incident to the weekend manager and called the Administrator. After documentation from the weekend was reviewed, it was determined the incident was more than a visitor being rude. Review of a statement by Resident #1 dated 03/31/25 revealed she was sitting at a table when a family member came in and in a loud voice said, we're going to put the tables together and I think you should move. Resident #1 said she couldn't remember if anything else was said but acknowledged this was not the first time that person told her to move. Resident #1 stated she was upset and didn't want to go back to the dining room, and wondered how that person would feel if someone treated their mother like that. Resident #1 was teary-eyed during the interview. Review of a statement by Resident #2 dated 03/31/25 revealed a family member yelled at her and Resident #1 wanting them to move from a table. Resident #2 stated she was mad and didn't like the drama. Review of a witness statement dated 04/01/25 by Activities Staff (AS) #110 revealed she witnessed a family member tell Resident #1 she could not sit at the table she had already been sitting at. AS #110 stated it was very loud and upset Resident #1 who stated she felt bullied. Review of a statement dated 04/01/25 by Staff #113 revealed she walked into the dining room to help residents get set up for lunch, Resident #1 was sitting at a table and a family member started yelling at her and saying, you can't sit here, other people are sitting here, and you don't belong here. The family kept repeating those sentences. A nurse intervened and the family denied saying anything wrong. Review of a statement dated 04/01/25 by Registered Nurse (RN) #132 revealed a family member brings in treats for certain residents to the dining room and once told a resident who didn't eat her treat she could not get one next time. Review of a statement dated 04/01/25 by Certified Nursing Assistant (CNA) #121 revealed a family member brings in food for residents who sit at the same table, some get the food and some do not get the food, leaving some residents feeling left out. The family tried to tell residents where they could or could not sit and has made residents move, has been rude, and has made residents not want to eat in the dining room. Review of a statement dated 04/01/25 by CNA #125 revealed a family member tells residents where they can and can't sit while in the dining area, has been asked not to move the tables together and continues to do so. Residents were beginning to refuse to come to the dining room due to the family member being present. Review of a statement dated 04/03/25 at 12:08 P.M. by CNA #120 revealed she was walking to the dining room to speak to the nurse, and she was behind a resident and her family. The family member began walking fast to go get a table and approached the table Resident #1 was at and screamed to her saying she could not sit at the table. The family member pointed her finger in Resident #1's face while yelling and did not realized staff were in the area. LPN #101 walked to the family member, who changed her whole attitude, and said the resident didn't need to move tables, but needed to move temporarily to push tables together. Interview on 08/08/25 at 2:50 P.M. with Administrator confirmed the allegation of verbal abuse was not reported in the required timeframe. Review of a policy titled Abuse, Neglect, and Exploitation dated 11/01/23 revealed reporting of all alleged violations to the Administrator, adult protective services, state agency, and all other required agencies will be completed immediately, but no later than two hours after the initial allegation is made if the allegation involves abuse or serious bodily injury, no later than 24 hours if the allegations do not include abuse or result in serious bodily injury.

Based on observation, staff interview, review of signage on the resident unit refrigerators, and policy review, the facility failed to ensure foods were safely stored. This had the potential to affect all 52 residents who received food from the kitchen. The facility census was 52. Findings include: Observation on [DATE] at 9:00 A.M. revealed the following kitchen sanitation issues: - In the milk cooler, twenty five eight ounce individual serving cartons of chocolate milk with an expiration date of [DATE]. - In the walk in refrigerator, there was no internal thermometer. There were eight glasses of orange fluid undated and unlabeled, two pitchers of fluid unlabeled and undated and four containers, labeled as pudding, undated. Observation on [DATE] at 8:07 A.M., revealed the following Unit 300 resident refrigerator sanitation issues: - There was no thermometer in the resident refrigerator. - There was an insulated lunchbag, undated and unlabeled. - There was two containers of unidentifiable food unlabeled and undated. Observation on [DATE] at 8:10 A.M., revealed the following Unit 100 resident refrigerator sanitation issuess: - There was no thermometer in the freezer - There was one unopened expired milk carton dated [DATE]. - There was one opened container labeled as fruit dip with no open date and an expired date of [DATE]. - There was one bowl of identified dry cereal undated and unlabeled. Interview on [DATE] at 9:15 A.M., Cook #11 verified the sanitation conditions in the walk in refrigerator. Cook #11 verified the expired foods should have been discarded and all foods should be labeled, dated, and marked with an open date. Interview on [DATE] at 8:10 A.M, the Assistant Director of Nursing (ADON) #17 verified the Unit 100 and the Unit 300 resident refrigerators were designated for resident food storage and for staff food items. The ADON #17 said the expired foods should have been discarded and all foods should have been labeled and dated. Review of a sign attached to the front of the Unit 100 and the Unit 300 resident refrigerators revealed the refrigerator shoulde be cleaned out every Tuesday. All foods must be marked with name, date and the date the item was opened. Staff must put their name on their items. Review of the policy titled Food Storage, undated revealed all food shall be covered, labeled, and dated. Every refrigerator must be equipped with an internal thermometer. Refrigerators on the nursing floors will be monitored by nursing.

Based on medical record review, observation and staff and resident interview, the facility failed to ensure the resident environment was sanitary. This affected eight residents (#01, #04, #12, #16, #44, #45, #46 and #103) of 52 residents' room environment observed. In addition, the facility failed to ensure the floors were in good repair. This had the potential to affect 31 of 31 residents who could independently ambulate. The facility identified 21 residents (#01, #09, #07, #22, #20, #14, #23, #47, #08, #41, #02, #36, #15, #19, #39, #06, #07, #09, #35, #11 and #38) who were unable to independently ambulate in the facility. The facility census was 52. Findings Include: 1. Review of the medical record revealed Resident #04 revealed the resident was admitted to the facility on [DATE]. Diagnoses included heart failure, diabetes, chronic pain, and psychotic disturbance. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed Resident #04 had moderately impaired cognition. The resident was non ambulatory and required assistance for locomotion in wheelchair. Observation on 06/05/23 at 1:33 P.M. revealed Resident #04 lying in bed facing a wall with several deep gouged exposed areas measuring from one inch to eight inches long, four inches by two inches, and one inch by six inches. The areas exposed drywall. There was also eight inches of baseboard missing at the bottom of the wall with debris. Interview 06/05/23 at 1:33 P.M., Resident #04 revealed the areas had been exposed and had not been repaired since she had been at the facility. She did not like looking at the areas from her bed. 2. Observation on 06/05/23 at 9:00 A.M. through 06/7/23 at 1:20 P. M revealed Resident #16, #44, #45, and #46's rooms had two inch by 12 inch strips of exposed drywall on both sides of the wall near the hallway door frame. The areas were a non-cleanable surfaces. Interview on 06/07/23 at 8:40 A.M., the Maintenance Director (MD) #73 verified Resident #04's baseboard was missing and collected debris. He stated the wall gouges had not been repaired for three weeks and the repair would take about a week. The MD #17 verified the rooms of Residents' #16, #44, #45, and #46 had exposed drywall near the doorframes. He stated there had been attached signage removed from those resident rooms walls about three weeks ago and the exposed walls were a non-cleanable surface. 4. Observation on 06/05/23 at 9:00 A.M. through 06/07/23 at 1:20 P.M. revealed the floor surrounding the 100, the 200 and the 300 nurses' stations had linoleum flooring with exposed subflooring and jagged edges. The areas of disrepair ranged from two inches by 12 feet, one inch by two feet and one inch by six feet. There was noted debris along the jagged edges of the linoleum. Observations on 06/05/23 through 06/07/23 at varied times revealed residents ambulating on the exposed flooring at the 100, the 200 and the 300 unit nursing station areas. Interview on 06/07/23 at 8:40 A.M., the MD #73 verified the linoleum flooring surrounding the 100, the 200 and the 300 nurses' stations was in disrepair, making it difficult to clean, and had debris in the jagged edging. He stated the floor was separating at the seams of the linoleum and needed repaired. 31404 5. Observation on 06/08/23 at 1:17 P.M. revealed Resident #01 and #12's room had gouges, missing drywall and paint by wall by Resident #01's bed. The room also had gouges and missing paint on the wall by the bathroom. Interview with Registered Nurse #72 on 06/08/23 at 1:17 P.M. verified the observation in Resident #01 and #12's room. Observation on 06/08/23 at 1:19 P.M. revealed Resident #103's room had scuffs and missing drywall around the baseboard in the bathroom. Interview with Registered Nurse #72 on 06/08/23 at 1:19 P.M. verified the observation in Resident #103's room.

Based on medical record review, staff interview, review of the minimum data set log, and review of the resident assessment instrument (RAI) manual, the facility failed to ensure resident assessments were completed quarterly. This affected three residents (#05, #20 and #32) of four residents reviewed for timely assessments. The facility census was 52. Findings Include: 1. Review of the medical record revealed Resident #05 was admitted to the facility on [DATE]. Diagnoses included dementia, diabetes, and depressive disorder. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had impaired cognition. Review of the MDS log revealed Resident #05 should have had a quarterly MDS completed on 08/02/22 and it was completed on 09/06/22. The previous quarterly MDS was completed on 05/23/22. This was greater than 90 days between MDS completion dates. 2. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, dementia, and hypertension. Review of the MDS comprehensive assessment dated [DATE] revealed the resident had impaired cognition. Review of the MDS log revealed Resident #20 should have had a quarterly MDS assessment completed on 04/12/23 and it was completed on 05/19/23. The previous quarterly MDS was completed on 01/10/23. This was greater than 92 days between MDS completion dates. 3. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, hypertension, and acute respiratory failure. Review of the MDS comprehensive assessment dated [DATE] revealed the resident had impaired cognition. Review of the MDS log revealed Resident #32 should have had a quarterly MDS assessment completed on 04/28/23 and it was completed on 06/05/23. The previous MDS assessment was completed upon admission completed on 01/27/23. This was greater than 92 days between MDS completion dates. Interview on 06/08/23 at 2:55 P.M., the Assistant Director of Nursing (ADON) #17 verified the MDS assessments for Resident #05, #09, #20 and #32 had been completed greater than 90 days from the previous MDS completion. Review of the RAI manual revealed a quarterly assessment would need to be completed no more than 92 days after the most recent Omnibus Budget Reconciliation Act (OBRA) assessment.

Based on review of the facilities records and policy, review of the facility's Self-Reported Incidents, medical record review, and family and staff interviews, the facility failed to report allegations of resident abuse to the State Survey Agency. This affected four (Residents #36, #40, 64, and #75) of five residents reviewed for abuse. The facility census was 56. Findings include: 1. Review of the medical record for Resident #36 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had mildly impaired cognition and required total assistance with mobility and activities of daily living. Review of the facility's Self-Reported Incidents (SRI) from 06/07/22 to 06/21/22 revealed there were no SRIs filed regarding Resident #36. Interview on 06/22/22 at 3:20 P.M. with the Activities Director #14 stated she attended a plan of care conference for Resident #36 on 06/07/22. During the conference, Resident #36 had complained an unidentified state tested nursing aide (STNA) had slammed her in the bed. Activities Director #14 stated she went to find the Director of Nursing (DON) immediately who then attended the conference to address the allegation with Resident #14. Interview with the DON and Assistant Director of Nursing (ADON) #67 on 06/22/22 at 4:10 P.M. verified they were aware of Resident #36's complaint on 06/07/22. The DON stated she did go to the care conference on 06/07/22 and spoke with Resident #36. The DON stated Resident #36 was having a bad day and always says 'crazy things'. The DON stated Resident #36 admitted no one was rough with her but stated STNA #45 had slammed her in the bed. The DON stated STNA #45 was not on the schedule that day. The DON and ADON #67 verified the facility did not submit an SRI to the State Survey Agency involving Resident #36. The DON and ADON #67 both stated they don't have to report allegations of abuse, only actual abuse and the complaint by Resident #36 was not abuse. Interview on 06/22/22 at 4:30 P.M. with the Administrator stated she was working as an aide the day of Resident #36's complaint and had taken care of her. The Administrator stated she has never had anyone complain about her care and that it was impossible for Resident #36 to be slammed in the bed because she requires a Hoyer lift for bed mobility. The Administrator further stated there was no need to report anything because no abuse occurred. 2. Review of the medical record for Resident #40 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 had intact cognition and required limited to extensive assistance from staff with mobility and activities of daily living. Review of the medical record for Resident #75 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #75 had severely impaired cognition. Review of the resident council minutes dated 02/18/22 revealed Resident #40 and Resident #75 had been documented as having reported an unidentified night shift state tested nursing aide (STNA) with concerning bedside manner. Resident #40 had been recorded in the minutes as stating she did not want the same unidentified STNA in her room because she was 'yanking her roommate (Resident #75) like a rag doll'. Review of the facility's response to the resident council minutes signed by the Director of Nursing (DON) on 03/07/22 revealed she had interviewed Resident #40. The DON stated in the response that Resident #40 denied allegation of abuse and admitted she cannot see the roommate but felt like it did happen or may happen. The DON further documented the unidentified STNA denied any allegations of abuse but was counseled on her bedside manner. The DON also stated Resident #40 was ok with the unidentified STNA taking care of her. Review of the facility's Self-Reported Incidents (SRI) from 02/18/22 to 02/30/22 revealed there were no SRIs filed regarding Residents #40 and #75. Interview on 06/22/22 at 3:20 P.M. with Activities Director #14 stated her assistant had recorded the minutes for the resident council meeting on 02/18/22 but she was in attendance and signed off on them the same day before presenting them to the appropriate department manager. Activities Director #14 stated she gave the complaints from Resident #40 and Resident #75 to the DON. Activities Director #14 stated it sometimes takes a while to get the resident council department head sheets back. Interview on 06/22/22 at 4:10 P.M. with the DON and Assistant Director of Nursing (ADON) #67 verified they were aware of Resident #40 and Resident #75's allegation on 02/18/22. The DON stated she was not the DON at the time she received the allegation. The DON stated Resident #40 was blind, and Resident #75 was deaf and yells all the time, so she knew nothing happened. The DON and ADON #67 verified the facility did not submit an SRI to the State Survey Agency. The DON and ADON #67 both stated they don't have to report allegations of abuse, only actual abuse. 3. Review of the medical record for Resident #64 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 had severe cognition and required full assistance from staff with mobility and activities of daily living. Review of the facility's Self-Reported incidents (SRI) from 04/14/22 to 06/21/22 revealed there were no SRIs filed regarding Resident #64. Interview on 06/22/22 at 10:19 A.M. with a family member for Resident #64 revealed she had concerns about potential abuse that had not been addressed. The family member for Resident #64 stated about a week before incident, she noticed Resident #64 having a sudden change that included being fearful, making negative statements about being scared, and was making motions indicating he wanted to avoid being cared for by Temporary Nurses Aide (TNA) #35. Resident #64's family member stated she decided to keep an eye on it at first because she couldn't prove anything and wasn't sure if something else was wrong with him. The family member for Resident #64 stated on 04/14/22, STNA #61 had asked if she had heard the scream coming from the bathroom, that she had heard it and had discovered TNA #35 was in there with Resident #64 who appeared scared. The family member decided to have him discharged immediately. The family member stated ADON #67 asked her if she would keep Resident #64 at the facility if she moved TNA #35 to a different unit. The family member for Resident #64 stated the following week after the move, she had sent a letter to the Administrator with concerns about Resident #64 but did not receive a response. Review of the letter written by the family member for Resident #64 dated 04/17/22 revealed she was filing a complaint about the care provided to Resident #64. The family member for Resident #64 described in the letter the concerns of retaliation by TNA #35 for prior incidents and her complaint about TNA #35 allegedly screaming at Resident #64 on 04/14/22. Interview on 06/22/22 at 10:00 A.M. with TNA #35 stated she recently was the subject of an abuse complaint about Resident #64. TNA #35 stated on 04/14/22 she was assisting Resident #64 in the bathroom when he suddenly became combative. TNA #35 stated she did shout at him to sit down because Resident #64 had swung at her. TNA #35 stated she did shout because he was hard of hearing but was not being mean to him. TNA #35 stated she knows STNA #61 told Resident #64's family member that she had screamed at him, but it wasn't true. TNA #35 further stated she spoke with the family member for Resident #64 who denied hearing any screaming but had taken him out of the facility that day. TNA #35 stated in the days after, she was told by multiple people she was being reported to the State Survey Agency. TNA #35 stated DON and ADON #67 talked to her about the incident but the DON and ADON #67 stated to not worry about it because she didn't do anything wrong. Interview with the DON and Assistant Director of Nursing (ADON) #67 on 06/22/22 at 4:10 P.M. verified they were aware of the incident with Resident #64 on 04/14/22. The DON stated the family member for Resident #64 never reported any issues and did not know why she wanted to discharge him that day. ADON #67 stated she was aware of TNA #35 being accused of screaming at Resident #64 but there was no allegation of abuse and the family member for Resident #64 denied hearing any screaming or physical abuse. The DON and ADON #67 both stated they don't have to report allegations of abuse and the situation with Resident #64 had no allegation of abuse in their opinion. The DON and ADON #67 verified the facility did not submit an SRI to the State Survey Agency. Interview on 06/22/22 at 4:30 P.M. with the Administrator confirmed the family member for Resident #64 had texted her on 04/14/22 stating she was taking Resident #64 to another facility because she was upset with TNA #35 for yelling at her husband. The Administrator acknowledged she had received a letter from the family member of Resident #64 but did not provide information about what she did with the information and stated the other facility was behind all of it. The Administrator further stated there was no need to report anything because no abuse occurred. Review of the facility's undated abuse policy revealed the facility maintains a zero tolerance regarding abuse and in the event of suspected or alleged abuse, neglect, or misappropriation, a prompt investigation will be completed and shall be reported to the Administrator. The policy further states the facility will forward investigation results to the state agency within 24 hours and no later than five days. This deficiency substantiates Complaint Number OH 268.

Based on review of the facilities records and policy, medical record review, family and staff interviews, the facility failed to complete a thorough investigation when abuse allegations were made by residents and/or family members. This affected four (Residents #36, #40, #64, and #75) of five residents reviewed for abuse. The facility census was 56. Findings include: 1. Review of the medical record for Resident #36 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had mildly impaired cognition and required total assistance with mobility and activities of daily living. Interview on 06/22/22 at 3:20 P.M. with the Activities Director #14 stated she attended a plan of care conference for Resident #36 on 06/07/22. During the conference, Resident #36 had complained an unidentified state tested nursing aide (STNA) had slammed her in the bed. Activities Director #14 stated she went to find the Director of Nursing (DON) immediately who then attended the conference to address the allegation with Resident #14. Interview with the DON and Assistant Director of Nursing (ADON) #67 on 06/22/22 at 4:10 P.M. verified they were aware of Resident #36's complaint on 06/07/22. The DON stated she did go to the care conference on 06/07/22 and spoke with Resident #36. The DON stated Resident #36 was having a bad day and always says 'crazy things'. The DON stated Resident #36 admitted no one was rough with her but stated STNA #45 had slammed her in the bed. The DON stated STNA #45 was not on the schedule that day. The DON verified she could not provide an investigation and an assessment of Resident #36 for any injuries. The DON and ADON #67 both stated they don't have to investigate allegations of abuse, only actual abuse and the complaint by Resident #36 was not abuse. Interview on 06/22/22 at 4:30 P.M. with the Administrator stated she was working as an aide the day of Resident #36's complaint and had taken care of her. The Administrator stated she has never had anyone complain about her care and that it was impossible for Resident #36 to be slammed in the bed because she requires a Hoyer lift for bed mobility. The Administrator further stated there was no need to complete an investigation because no abuse occurred. 2. Review of the medical record for Resident #40 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 had intact cognition and required limited to extensive assistance from staff with mobility and activities of daily living. Review of the medical record for Resident #75 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #75 had severely impaired cognition. Review of the resident council minutes dated 02/18/22 revealed Resident #40 and Resident #75 had been documented as having reported an unidentified night shift state tested nursing aide (STNA) with concerning bedside manner. Resident #40 had been recorded in the minutes as stating she did not want the same unidentified STNA in her room because she was 'yanking her roommate (Resident #75) like a rag doll'. Review of the facility's response to the resident council minutes signed by the Director of Nursing (DON) on 03/07/22 revealed she had interviewed Resident #40. The DON stated in the response that Resident #40 denied allegation of abuse and admitted she cannot see the roommate but felt like it did happen or may happen. The DON further documented the unidentified STNA denied any allegations of abuse but was counseled on her bedside manner. The DON also stated Resident #40 was ok with the unidentified STNA taking care of her. Interview on 06/22/22 at 3:20 P.M. with Activities Director #14 stated her assistant had recorded the minutes for the resident council meeting on 02/18/22 but she was in attendance and signed off on them the same day before presenting them to the appropriate department manager. Activities Director #14 stated she gave the complaints from Resident #40 and Resident #75 to the DON. Activities Director #14 stated it sometimes takes a while to get the resident council department head sheets back. Interview on 06/22/22 at 4:10 P.M. with the DON and Assistant Director of Nursing (ADON) #67 verified they were aware of Resident #40 and Resident #75's allegation on 02/18/22. The DON stated Resident #40 was blind, and Resident #75 was deaf and yells all the time, so she knew nothing happened. The DON and ADON #67 verified the facility did not complete an investigation and had documentation to support an investigation was completed. The DON verified she only wrote the resident council response. The DON and ADON #67 both stated they don't have to report allegations of abuse, only actual abuse. The DON and ADON #67 could not disclose the identity of the STNA that was counseled for concerning bedside manner and denied Resident #75 was assessed for any injuries. 3. Review of the medical record for Resident #64 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 had severe cognition and required full assistance from staff with mobility and activities of daily living. Interview on 06/22/22 at 10:19 A.M. with a family member for Resident #64 revealed she had concerns about potential abuse that had not been addressed. The family member for Resident #64 stated about a week before incident, she noticed Resident #64 having a sudden change that included being fearful, making negative statements about being scared, and was making motions indicating he wanted to avoid being cared for by Temporary Nurses Aide (TNA) #35. Resident #64's family member stated she decided to keep an eye on it at first because she couldn't prove anything and wasn't sure if something else was wrong with him. The family member for Resident #64 stated on 04/14/22, STNA #61 had asked if she had heard the scream coming from the bathroom, that she had heard it and had discovered TNA #35 was in there with Resident #64 who appeared scared. The family member decided to have him discharged immediately. The family member stated ADON #67 asked her if she would keep Resident #64 at the facility if she moved TNA #35 to a different unit. The family member for Resident #64 stated the following week after the move, she had sent a letter to the Administrator with concerns about Resident #64 but did not receive a response. Review of the letter written by the family member for Resident #64 dated 04/17/22 revealed she was filing a complaint about the care provided to Resident #64. The family member for Resident #64 described in the letter the concerns of retaliation by TNA #35 for prior incidents and her complaint about TNA #35 allegedly screaming at Resident #64 on 04/14/22. Interview on 06/22/22 at 10:00 A.M. with TNA #35 stated she recently was the subject of an abuse complaint about Resident #64. TNA #35 stated on 04/14/22 she was assisting Resident #64 in the bathroom when he suddenly became combative. TNA #35 stated she did shout at him to sit down because Resident #64 had swung at her. TNA #35 stated she did shout because he was hard of hearing but was not being mean to him. TNA #35 stated she knows STNA #61 told Resident #64's family member that she had screamed at him, but it wasn't true. TNA #35 further stated she spoke with the family member for Resident #64 who denied hearing any screaming but had taken him out of the facility that day. TNA #35 stated in the days after, she was told by multiple people she was being reported to the State Survey Agency. TNA #35 stated DON and ADON #67 talked to her about the incident but the DON and ADON #67 stated to not worry about it because she didn't do anything wrong. Interview with the DON and Assistant Director of Nursing (ADON) #67 on 06/22/22 at 4:10 P.M. verified they were aware of the incident with Resident #64 on 04/14/22. The DON stated the family member for Resident #64 never reported any issues and did not know why she wanted to discharge him that day. ADON #67 stated she was aware of TNA #35 being accused of screaming at Resident #64 but there was no allegation of abuse and the family member for Resident #64 denied hearing any screaming or physical abuse. The DON and ADON #67 both stated they don't have to report allegations of abuse and the situation with Resident #64 had no allegation of abuse in their opinion. The DON and ADON #67 verified the facility did not complete an investigation regarding Resident #64. Interview on 06/22/22 at 4:30 P.M. with the Administrator confirmed the family member for Resident #64 had texted her on 04/14/22 stating she was taking Resident #64 to another facility because she was upset with TNA #35 for yelling at her husband. The Administrator acknowledged she had received a letter from the family member of Resident #64 but did not provide information about what she did with the information and stated the other facility was behind all of it. The Administrator further stated there was no need to report anything because no abuse occurred. Review of the facility's undated abuse policy revealed the facility maintains a zero tolerance regarding abuse and in the event of suspected or alleged abuse, neglect, or misappropriation, a prompt investigation will be completed and shall be reported to the Administrator. The abuse policy also includes guidelines that state a documented assessment would be placed in the resident record. This deficiency substantiates Complaint Number OH 268.

Based on observation, staff interview, record review, and review of the facility's policy, the facility failed to ensure resident foods in the unit refrigerators were dated and/or labeled and thickened water was not expired. This had the potential to affect 39 of 40 residents who receive food from the kitchen (Resident #26 received nothing by mouth). Findings include: 1. Observation of the 200 hall unit refrigerator on [DATE] at 2:21 P.M. revealed two eggs in a bag in the refrigerator with no name or date. Interview with Minimum Data Set (MDS) Nurse #3 on [DATE] at 2:21 P.M. verified the two eggs had no name or date. 2. Observation of the Fall hall unit refrigerator on [DATE] at 2:25 P.M. revealed four white castle sandwiches with no name or date and a partially used container of lemon flavored nectar consistency water with an open date of [DATE]. Observation of the lemon flavored nectar consistency water packaging revealed the product was to be used within seven days of opening. Interview with MDS Nurse #3 on [DATE] at 2:25 P.M. verified Fall hall unit refrigerator had four white castle sandwiches with no name or date and verified the lemon flavored nectar consistency water was partially opened, had an open date of [DATE], and was to be used within seven days of opening. Review of the facility's list of residents and their diets revealed Resident #26 was on a nothing by mouth diet and the only resident who didn't receive food from the kitchen. Review of the facility's policy titled Resident Food Storage and Handling, last revised [DATE], revealed the resident food will be kept for five days from the label date and then discarded except: condiment-type foods will be kept for two months/60 days, and non-perishable drinks and frozen foods will be kept for one month/30 days. Any food or beverage that is not labeled with resident name and dated will be discarded immediately.

Based on record review, observation, review of the facility's policy and staff interviews, the facility failed to ensure activities were provided to meet the needs of Resident #25. This affected one (Resident #25) of three residents reviewed for activities. This had the potential to affect all seven residents (Resident #1, #3, #8, #11, #25, #32, and #33) residing on the memory care unit. The facility census was 40. Findings include: Review of the medical record for Resident #25 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the five-day Minimum Data Set (MDS) assessment, dated 02/22/21, revealed Resident #25 was unable to complete the interview for the brief interview for mental status assessment. Review of the annual MDS assessment dated [DATE] revealed it was very important for Resident #25 to have books, newspapers, and magazines to read, listen to music she likes, do things with groups of people, do her favorite activities, go outside when the weather was nice, and participate in religious services/practices. It was somewhat important for Resident #25 to keep up with the news. Review of Resident #25's comprehensive care plan revealed a problem of Resident #25 spends most of the time alone or watching television and had little or no involvement in activity programs with interventions including to introduce to other residents with similar interests/disabilities/limitations, invite to scheduled activities, offer a variety of activity types and locations, offer to assist/escort resident to activity functions, remind resident that they may leave activities at any time and are not required to stay for the entire activity, and resident likes to have her hair brushed due to it calming her. Review of the Resident #25's activity attendance records dated April 2020, revealed she was not marked as attending or refusing any activities on 04/01/21, 04/05/21, 04/06/21, 04/11/21, 04/14/21, 04/16/21, 04/17/21, 04/18/21, 04/20/21, 04/21/21, and 04/26/21. Review of the facility's April 2021 activity calendar revealed no structured activities were scheduled on 04/01/21 through 04/11/21 as well as on 04/17/21, 04/18/21, and 04/25/21. Observations of Resident #25 on 04/26/21 at 11:10 A.M., 12:16 P.M., 3:00 P.M., and 3:51 P.M., all revealed Resident #25 was in her room laying in her bed. On 04/27/21 at 3:35 P.M. and 4:16 P.M., she was laying in bed with the television on. On 04/28/21 at 9:43 A.M., she was laying in bed in her room. On 04/28/21 at 1:37 P.M., she was seated in her wheelchair in the common area with the television on. On 04/28/21 at 2:55 P.M., Resident #25 was in her wheelchair in the common area and the television was on. On 04/28/21 at 4:00 P.M., Resident #25 was in her wheelchair in the corner of the common area. The television was observed to be on however Resident #25 was not observed to be able to see the television from where she was seated. Interview with State tested Nurse Aide (STNA) #54 on 04/28/21 at 5:26 P.M. revealed the STNAs were currently responsible for activities on the memory care unit. She stated there has been minimal structured activities on the memory care unit since the activities staff resigned several months ago. STNA #54 stated she tries to complete activities with residents however it was hard to complete structured activities when there was no activities staff. The quality and quantity of activities on the memory care unit has declined over the past several months since the activities staff resigned. STNA #54 stated she tries to give residents coloring books or puzzles as well as do their nails for activities. She stated [NAME] day was scheduled for 04/28/21 however Resident #25 did not attend [NAME] day due to staff only being able to take a few of the residents from the memory care unit. The STNAs were unable to complete all of the activities with the residents on the memory care unit due to having to provide care to them. The residents on the memory care unit used to participate in more activities when the facility had designated activities staff. Interview with Physical Therapy Assistant #75 on 04/29/21 at 2:40 P.M. revealed she has been assisting with activities on the memory care unit. She verified there were no structured activities on the memory care unit due to residents with different cognition levels. Prior to the COVID-19 pandemic when there was more activities staff, there were more structured activities on the memory care unit. She stated Resident #25 enjoyed playing with the knob board and fake cat, as well as having her nails/hair done. Review of the facility's census and room number roster revealed Resident #1, #3, #8, #11, #25, #32, and #33 resided on the memory care unit. Review of the facility's undated policy titled Activity Policy and Procedure revealed the activity department will be responsible for planning, implementation, and scheduling of activity programs, encouraging and stimulating residents to have a fuller and richer life, plan programs based on resident needs, interests and abilities, and offer in-room self directed activities as well as one to one visits to residents that choose not to attend group activities.

Based on record review and resident and staff interviews, the facility failed to hold initial care planning conferences for new admissions to the facility. This affected one (#27) of one resident sampled for care planning conferences. The facility census was 40 residents. Findings include: Record review for Resident #27 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment, dated 03/03/21 revealed Resident #27 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] The record was silent for an initial care planning conference. Interview on 04/26/21 at 1:50 P.M., with Resident #27 revealed the facility had not invited the resident to attend care conference after admission to the facility. Interview on 04/29/21 at 9:44 A.M. with Social Service (SS) #50 revealed an understanding that care conferences were done every three months after admission and confirmed a care conference was not completed upon admission for Resident #27. SS #50 stated she does an admission note but not a care conference and was not instructed to complete an admission care conference on new residents.

Based on observation, review of manufacturer's recommendations and staff interview, the facility failed to dispose of outdated insulin and failed to date open vials of insulin with the date when opened. This affected one (#11) of eight residents identified by the facility who receive insulin. The facility census was 40 residents. Findings include: On 04/29/21 at 10:09 A.M., an observation in the Fall unit medication cart with Licensed Practical Nurse (LPN) #56 revealed an open vial of [MEDICATION(S)] insulin with a date when opened of 03/08/21, and two open vials of [MEDICATION(S)] insulin with no date when opened for Resident #11. On 04/29/21 at 10:09 A.M., an interview with LPN #56 confirmed the findings and verified the open vials of [MEDICATION(S)] insulin should be disposed of after 28 days after opened and all opened vials of insulin should have the date when opened noted on the vial. Review of the manufacturers's recommendations for [MEDICATION(S)] insulin revealed the [MEDICATION(S)] insulin must be discarded 28 days after opened.

Based on record review, review of the facility's policy, and staff interview, the facility failed to accurately document resident supplements and administration of a resident's narcotics. This affected two (Resident #3 and #22) of four residents reviewed for nutrition and one (Resident #27) of five residents for unnecessary medications. The facility census was 40. Findings Include: 1. Review of the medical record for Resident #3 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the active physician orders revealed an order dated 08/15/19 for a magic cup (high calorie nutritional supplement) twice a day with lunch and dinner. Review of the April 2021 medication administration records (MAR) revealed Resident #3 received a magic cup with lunch and dinner until 04/23/21 when it was crossed out and marked as discontinued. There was no documentation of Resident #3 receiving the magic cup twice a day after it was crossed out and marked discontinued on 04/23/21. Review of the physician orders revealed an order dated 01/15/21 for Two Cal supplement (high calorie nutritional supplement) 240 milliliters three times a day. Review of the physician orders revealed an order dated 04/22/21 for Two Cal 240 milliliters to be increased to four times a day. Review of the April 2021 MAR revealed Resident #3 was ordered Two Cal 240 milliliters four times a day however there were only three slots available each day for documentation of administration of the Two Cal and Resident #3 was only documented as having received it three times a day from 04/23/21 through 04/28/21. Interview with Registered Dietitian (RD) #76 on 04/29/21 at 1:05 P.M. revealed Resident #3 received Magic Cup twice daily with lunch and dinner and it was never discontinued. She verified Resident #3 was ordered Two Cal 240 milliliters four times a day and received it four times a day. RD #76 stated she does not know why the fourth slot for the Two Cal 240 milliliters was not added to the MAR on 04/23/21 when it was increased. Interview with the Director of Nursing (DON) on 04/29/21 at 1:58 P.M. revealed Resident #3 received Two Cal 240 milliliters four times a day since it was increased on 04/23/21. The staff forgot to add the fourth slot in order to document the administration of the additional 240 milliliters of Two Cal. The DON verified Resident #3 has been receiving magic cup twice daily with lunch and dinner despite it having been marked discontinued on 04/23/21. 2. Review of the medical record for Resident #22 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the February 2021 physician orders revealed Resident #22 was ordered Magic Cup twice a day and Mighty Shakes (high calorie nutritional supplement) two shakes with each meal. The physician orders for March 2021 revealed no order for Magic Cup twice a day or Mighty Shake two shakes with each meal. The physician orders for April 2021 revealed an order dated 04/14/21 for Magic Cup twice a day and there was no order for Mighty Shake two shakes with each meal. There were no physician orders to discontinue the Magic Cup or Mighty Shakes despite they were not on the MAR for March 2021 and during part of April 2021. There was no documentation of Resident #22 having been ordered or received Magic Cup twice a day or Mighty shake two shakes with each meal for March 2021 MAR. There was no documentation of Resident #22 having been ordered or received Mighty shake two shakes with each meal for April 2021 MAR. Resident #22 was re-ordered Magic Cup twice a day on 04/14/21 and was documented as receiving it twice a day from 04/15/21 through 04/27/21. Interview with RD #76 on 04/29/21 at 1:05 P.M. revealed Resident #22 was receiving Mighty Shakes two shakes with each meal and Magic Cup twice a day due to weight loss. Resident #22 received the supplements despite them not being ordered in the physician orders or documented on the March 2021 MAR or April 2021 MAR prior to 04/14/21. Interview with the DON on 04/29/21 at 1:58 P.M. revealed Resident #22 received Mighty Shakes two shakes with each meal and Magic Cup twice a day between 03/01/21 and 04/14/21. The DON verified Resident #22's Mighty Shakes and Magic Cups were not documented on the MAR between 03/01/21 and 04/14/21 and his physician orders list between 03/01/21 and 04/14/21 do not include the orders for Mighty shake two shakes with each meal and Magic Cup twice a day despite Resident #22 having received both. The DON further verified the April 2021 MAR still does not document Resident #22 having received his Mighty Shake two shakes with each meal despite having received them. Review of the facility's undated policy titled Nursing Standards of Practice revealed documentation guidelines pertinent to good clinical record practice will be followed by all individuals who document in the patient's/resident's record. A complete health picture of the patient/resident must be available to all disciplines contributing to patient/resident care. 3. Record review for Resident #27 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment, dated 03/03/21 revealed the resident was cognitively intact and was on a scheduled pain regimen and was in constant pain. Review of the physician order sheet, dated 03/2021 and 04/2021, revealed an order, dated 02/24/21, for [MEDICATION(S)] IR (immediate release) (narcotic used to treat moderate to severe pain) 15 milligrams (mg.) one tablet every twelve hours as needed for moderate pain. Review of the resident's narcotic sign out sheet and the resident's medication administration record (MAR) revealed they did not correspond on the following dates and times: · On 03/10/21, the narcotic sign out sheet revealed two doses were signed out on 03/10/21 at 6:30 A.M. and 6:30 P.M. but the MAR were not marked as administered on 03/10/21. · On 04/02/21, the [MEDICATION(S)] [MEDICATION(S)] IR was signed out at 1:00 P.M., but the MAR record was silent for the 1:00 P.M. dose marked as given. · On 04/03/21, the narcotic sign out sheet revealed two doses of [MEDICATION(S)] IR 15 mg. were signed out at 1:00 A.M. and at 2:30 P.M., but the MAR revealed three doses were marked as administered on 04/03/21 at 1:00 A.M., at 1:00 P.M. and at 2:30 P.M. · On 04/07/21 the [MEDICATION(S)] [MEDICATION(S)] IR was signed out at 4:30 A.M. on the narcotic sign out sheet, but the MAR record was silent for the 4:30 A.M. dose marked as administered. · On 04/08/21, the [MEDICATION(S)] [MEDICATION(S)] IR was signed out at 10:00 P.M. on the narcotic sign out sheet, but the MAR record was silent for the 10:00 P.M. dose marked as administered. · On 04/09/21, the narcotic sign out sheet revealed two doses were signed out at 10:00 A.M. and at 10:00 P.M., but the MAR had three doses marked as administered at 10:00 A.M., 10:00 P.M., and at 2:00 P.M. · On 04/012/21, the [MEDICATION(S)] [MEDICATION(S)] IR was signed out at 3:30 A.M. on the narcotic sign out sheet, but the MAR record was silent for the 3:30 A.M. dose marked as administered. · On 04/17/21, the [MEDICATION(S)] [MEDICATION(S)] IR was signed out at 6:45 P.M. on the narcotic sign out sheet, but the MAR record was silent for the 6:45 P.M. dose marked as administered. · On 04/24/21, the [MEDICATION(S)] [MEDICATION(S)] IR was signed out at 3:00 A.M. on the narcotic sign out sheet, but the MAR record was silent for the 3:00 A.M. dose marked as administered. Interview on 04/29/21 at 9:01 A.M. with the Director of Nursing (DON) revealed the facility did a quality assurance performance improvement (QAPI) plan on signing out narcotics three or four months ago. The DON confirmed Resident #27's signed out narcotics where not documented accurately on the MAR as administered.

Based on resident and staff interviews, and review of the facility's policy, the failed to ensure the resident's mail was delivered on Saturdays. This had the potential to affect all 40 residents residing in the facility. Findings include: Interview with Resident #12, Resident #24, Resident #30, and Resident #35 on 04/27/21 at 2:42 P.M., revealed the resident's mail was not delivered to residents on Saturdays. Interview with Marketing #50 on 04/27/21 at 4:26 P.M. revealed she was the only staff member who delivers resident mail and she does not work on Saturday. She stated Saturday's mail was delivered to the residents on Monday. Review of the facility's undated policy titled Activity Policy and Procedure revealed the activity department will be responsible to pass mail daily (six days a week).

Based on medical record review, review of the Emergency Medical Squad (EMS) run report, review of hospital records, review of facility maintenance work orders, review of in-servicing and sign-in sheets, review of facility invoices for call light repairs, review of the Minimum Data Set Resident Assessment Instrument manual, review of facility policies for meal service in the resident rooms and call lights and staff interviews, the facility failed to provide adequate supervision with eating and maintain an assistive device in a fully operational manner to allow a resident to summon for assistance in the event of an emergency while eating alone in her room. This resulted in Immediate Jeopardy and serious life-threatening consequences when Resident #01 began choking while eating supper in her bed, unattended in her room. Upon receiving a phone call from the resident's Family Member #150, Registered Nurse (RN) #800 went to Resident #01's room and found her choking. RN #800 removed Resident #01's dentures, did a finger sweep, removed food, suctioned the resident and called 911. The resident was intubated by emergency medical personnel and admitted to the hospital with [REDACTED]. This affected one (#01) of three residents reviewed for supervision of diets and utilizing assistive devices. The facility census was 54. On 07/22/20 at 4:45 P.M., the facility Administrator was notified Immediate Jeopardy began on 07/10/20 at approximately 4:40 P.M., when Resident #01 experienced a choking incident while eating supper, in her bed, unattended in her room. Resident #01 pressed her call light which activated a flashing light outside of the resident's room. The audible signal for the call light, which was supposed to sound at the nurses ' station was not working. Resident #01's Family Member #150 had called Resident #01's cell phone on 07/10/20 at 4:46 P.M. when the resident was eating and learned the resident was gasping for air and no one was coming to help her. Family Member #150 called the facility telephone and requested staff check on the resident immediately because of the choking concerns. RN #800 entered Resident #01's room at approximately 4:46 P.M. on 07/10/20. The nurse verified the call light was flashing with a visual signal but there was no audible signal, because the call light was not functioning properly. The nurse did a finger sweep and removed a large piece of food from Resident #01's mouth and called 911. The resident was assessed by the nurse as being cyanotic, unresponsive, with irregular breathing and wet/gurgling breath sounds. The EMS personnel removed more food and intubated the resident in route to the hospital. Resident #01 was admitted to the hospital with [REDACTED]. Per interview with Family Member #150, the resident is now off the ventilator and is currently residing in another nursing facility, per the family request, and had been hospitalized at the larger hospital for a total of 15 days. The Immediate Jeopardy was removed on 07/22/20 when the facility implemented the following corrective actions: · On 07/10/20, Resident #01 received assistance for choking by RN #800. Resident #01 was provided treatment at the facility and then was taken to the hospital by emergency medical personnel. · On 07/18/20, between 9:00 P.M. and 10:00 P.M., Licensed Practical Nurse (LPN) #250 ensured the call light in Resident #01's room was functioning with light and sound properly. · On 07/20/20, the facility's outside call light vendor was onsite and worked on repairs to the call light system from 7:15 A.M. to 3:30 P.M. The work order revealed the call light system was fully functional. · On 07/20/20, between 10:30 A.M. and 12:30 P.M., the facility's outside call light vendor conducted a facility wide audit of the call lights and determined all the lights were fully functional. · On 07/21/20, the Administrator purchased additional cow bells, in case needed in the future. · On 07/22/20, beginning at 6:20 P.M. and completed by 9:00 P.M., RN #350 in-serviced all nursing staff on the call light system and notification policy if the system is not working. Review of in-service sign-in sheets confirmed all nursing staff were trained. · On 07/22/20, beginning at 6:20 P.M. and completed by 9:00 P.M., RN #350 in-serviced all nursing staff on providing a resident with assistance while eating. Review of in-service sign-in sheets verified all nursing staff had been trained. · On 07/22/20, at 7:00 P.M., Maintenance Director (MD) #700 completed a facility wide audit of the call lights and determined all the lights were fully functional. · Beginning 07/22/20, nurses will audit every resident daily for any choking, chewing, or swallowing issues to ensure correct supervision is provided with meals. · Beginning on 07/22/20, MD #700 or designee will conduct random audits of the call light system daily. The call light daily audits will continue and become permanent with the daily maintenance logs. The Quality Assurance and Performance Improvement committee will monitor the audits at their monthly meetings with the Medical Director for the next six months and then will monitor every other month thereafter. Although the Immediate Jeopardy was removed on 07/22/20, the facility remains out of compliance at Severity Level 2 (the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective actions and monitoring for effectiveness and on-going compliance. Findings include: Review of the medical record for Resident #01 revealed the resident was admitted to the facility's designated COVID-19 quarantine area for new admissions on 07/02/20 with a [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment for Resident #01, dated 07/09/20 revealed the resident was cognitively intact, required supervision and set up help for eating, was assessed as coughing or choking during meals or when swallowing medications and was totally dependent on the assistance of two staff with bed mobility and transfer. Review of the Care Area Assessments (CAA) regarding Nutritional Status revealed the resident was morbidly obese and had functional problems that affected the resident's ability to eat including functional limitation in range of motion and inability to perform activities of daily living without significant physical assistance. The CAA further revealed nutritional status would be addressed in the resident's care plan with an objective to avoid complications. Review of the CAA regarding Activities of Daily Living (ADL) functional rehabilitation potential revealed the resident needed assistance with most ADLs and would be care planned to maintain current level of ADL functioning and avoid complications. Review of the baseline care plan for Resident #01 dated 07/02/20 revealed the resident ate in her room, feeds self, wore upper dentures, was at risk for chewing and swallowing problems and was totally dependent on staff to transfer out of bed. Review of the July 2020 physician orders [REDACTED]. Review of the nurse's progress note for Resident #01 dated 07/02/20 at 2:40 P.M., revealed the resident was oriented to the use of the call light upon admission. Review of the nurse's progress note for Resident #01 dated 07/10/20, no time noted, revealed the nurse was notified at 4:46 P.M., the resident was in distress. Further review of the note revealed the resident was unable to respond, skin was bluish in color, and respirations were short, shallow, irregular and moist, and resident had a faint pulse. The note also documented the nurse removed the resident's teeth and attempted to suction her airway and called 911. The EMS arrived at 5:04 P.M., to transport resident to the hospital. Review of the EMS run report for Resident #01 dated 07/10/20, revealed the emergency personnel arrived at the facility at 5:06 P.M. The emergency personnel suctioned a small amount of food from resident's airway at 5:09 P.M. and inserted a breathing tube at 5:12 P.M. Further review of the EMS run report revealed Resident #01 was unconscious upon their arrival to the facility and the chief complaint was a foreign body obstructing the airway which caused acute respiratory distress. Review of the hospital admission record for Resident #01 dated 07/10/20, revealed the resident was admitted to the hospital with [REDACTED]. Further review of the record revealed the resident remained on a ventilator and was transferred to a larger hospital. Review of a 15-minute log dated 07/10/20 revealed signatures of staff performing 15-minute checks with the last check being completed at 4:45 P.M. Review of a nurse progress note for Resident #01 dated 07/11/20, no time noted, revealed the resident had been admitted to the intensive care unit of the hospital in critical condition but stable condition. Review of the hospital discharge note for Resident #01 dated 07/17/20, revealed the resident was sent via squad to a local hospital on [DATE] but was then transferred to a larger hospital via life flight. Review of facility maintenance work orders for the month of July 2020 revealed no reports of call lights not working, including Resident #01's call light. Review of a service log from the call system vendor dated 06/16/20 revealed multiple call lights were repaired prior to Resident #01's admission to the facility. Resident #01's room was not listed as needing repair. The report documented the boards at the nurse's station needed repaired. Review of a service log from the call system vendor dated 07/20/20 revealed several call lights were repaired or replaced and the call light system board to the nurse's station where Resident #01's room would have alerted was replaced. The service work was for eight hours from 7:15 A.M. to 3:15 P.M. Random observations of call lights on 07/20/20 from 3:37 P.M. to 4:40 P.M., throughout the facility, revealed call lights were answered in less than two minutes and were functioning with visual and audible signals at the nurses ' stations. Interview with the Administrator on 07/20/20 at 4:02 P.M., verified all the call lights in the facility were currently functioning properly and there had been some problems with a few lights recently, but she did not recall which rooms were affected and she would e-mail the information later on 07/20/20. Interview on 07/21/20 at 10:08 A.M. with Family Member (FM) #150 verified she spoke to Resident #01 by phone on 07/10/20 at 4:46 P.M., and the resident complained she couldn't breathe. FM #150 further verified she called the facility and spoke to RN #800 and asked her to check on the resident immediately. FM #150 verified the resident remained in the hospital but was no longer on a ventilator. Interview on 07/21/20 at 4:29 P.M. with RN #800, verified Resident #01's call light was not fully functional all day on 07/10/20 and did not produce an audible signal. RN #800 further verified the facility staff checked on Resident #01 approximately every 15 minutes but did not have written or electronic documentation of the checks. RN #800 stated the facility did not provide the resident with a tap bell to summon staff in the event of an emergency. RN #800 verified she was alerted to go to Resident #01's room on 07/10/20, at approximately 4:46 P.M., when FM #150 called the facility and requested RN #800 check on the resident. RN #800 verified she enter Resident #01's room on 07/10/20, at approximately 4:46 P.M., and found the resident was in bed and appeared to be choking. RN #800 verified the resident's call light was in reach and the visual signal portion of the call light was functioning and flashing, but the call light did not emit an audible signal. RN #800 verified she removed Resident #01's dentures and performed a finger sweep which produced a bolus of undigested food and she attempted to suction for more food and called 911 for assistance. Interview on 07/22/20 at 8:03 A.M. with MD #700 verified he was not aware of any problems with Resident #01's call light. MD #700 further verified the facility has work order books at each nurses' station and no work orders had been filled out regarding the resident's call light nor had anyone told him the call light was not fully functional. Interview on 07/22/20 at 8:27 A.M. with Certified Nursing Assistant (CNA) # 400 verified Resident #01's call light had not been fully functional for approximately one week prior to 07/10/20. CNA #400 verified the light portion of the call light worked but the audible signal which was supposed to ring in the nurses' station was not working. CNA #400 further verified the resident did not have a tap bell to summon staff in the event of an emergency. CNA #400 stated the staff checked on the resident approximately every 15 minutes but did not have written or electronic documentation of the checks. CNA #400 verified she delivered a supper tray which included a pulled pork sandwich to Resident #01 who was eating supper in bed. CNA #400 further verified Resident #01 was able to feed herself with set up but could not get out of bed without the use of a mechanical lift and the assistance of two staff. CNA #400 verified on 07/10/20 at approximately 4:46 P.M., she had left Resident #01's room and was assisting another resident when RN #800 called her name and asked her to come and assist. CNA #400 verified the visual signal to Resident #01's light was flashing but no audible signal was emitted. CNA #400 verified she brought the crash cart to Resident #01's room and resident appeared to be unresponsive. CNA #400 verified she witnessed RN #800 perform a finger sweep of Resident #01's mouth and removed a piece of what appeared to be undigested pork. Interview 07/22/20 at 11:30 A.M. with Physical Therapy Assistant (PTA) #900, verified Resident #01's call light had not been working properly for about a week prior to 07/10/20. PTA #900 verified the lights were supposed to emit an audible signal at the nurses ' station to alert the staff, but Resident #01's light did not produce a sound. PTA #900 verified she had asked facility staff if staff were going to provide the resident with a bell or similar device since the call light was not working, but she did not think the resident had been provided with one. Interview on 07/22/20 at 4:40 P.M. with the Administrator, verified the facility had completed hand-written every 15-minute checks for Resident #01 on 07/10/20 and was not sure why staff had said they did not complete them. Review of the written statement by RN #800, provided by the facility dated 07/22/20, no time noted, revealed the nurse was aware Resident #01's call light was not sounding at the nurses' station to alert the staff. The written statement indicated that is why the resident was placed on 15-minute checks. Further review of the statement revealed the nurse went to check on Resident #01 on 07/10/20 at 4:46 P.M. after the resident's family member had called on the phone to say she thought the resident was choking. Interview on 07/27/20 at 10:13 A.M. with FM #150 verified on 07/10/20 at approximately 4:46 P.M., she called Resident #01 on her cell phone, and the resident was gasping for air and when asked if she was okay, Resident #01 replied, No, choking, they won't come. FM #150 verified the phone call to the resident's cell phone lasted approximately five seconds. FM #150 stated she then called the facility and told a female who answered the phone to get to Resident #01's room immediately because she was not okay. FM #150 verified the female told her they would check on her immediately and this phone call lasted only approximately five seconds. FM #150 stated Resident #01 was currently residing in another nursing facility and had been hospitalized at the larger hospital for a total of 15 days. Review of the undated facility policy titled Meal Service in the Resident Room revealed the facility will take measures to promote meal satisfaction for residents who eat in their rooms which included leaving the room for the resident to eat his/her meal after ensuring adequate assistance had been provided and ensuring the resident's call light was in reach. Review of facility document titled Open Discussion: Call Lights undated revealed call lights were to be placed within resident reach and should be maintained in working order. Further review revealed if a call light was not functioning properly the resident should be placed on every 15-minute checks or provided with a tap bell. Review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.17.1 dated 10/2019, chapter three, page G-1, defines supervision as requiring oversight, encouragement, or cuing during the activity of eating. Page G-10 revealed staff were to code supervision for residents who receive individual supervision with eating. Page K-1 revealed the ability to swallow safely can be affected by many disease processes and functional decline and alterations in the ability to swallow can result in choking and aspiration. The resident's care planning should include provisions for monitoring the resident during mealtimes and during functions/activities that include the consumption of food and liquids. The resident should be evaluated by the physician, speech language pathologist and/or occupational therapist to assess for any need for swallowing therapy and/or to provide recommendations regarding the consistency of food and liquids. Staff should assess for signs and symptoms that suggest a swallowing disorder that has not been successfully treated or managed with diet modifications or other interventions and represents a functional problem for the resident. The care plan should be developed to assist the resident to maintain safe and effective swallowing using compensatory techniques, alteration in diet consistency, and positioning during and following meal. This deficiency substantiates Complaint Number OH 166.