Every finding on record at Decatur County Healthcare

Based on policy review, medical record review, observation, and interview, the facility failed to document oxygen administration and failed to follow physician's orders for oxygen administration for 3 of 3 (Resident #28, Resident #29 and Resident #45) sampled residents reviewed for respiratory care. The findings include: 1. Review of the facility policy titled, PRN [As Needed] Medication Administration, dated 9/2022, revealed .It is the policy of this facility that medications shall be administered as prescribed by the attending physician.Medications must be administered in accordance with the written orders of the attending physician.When PRN medications are administered, the nurse must record.The date and time administered.Any results achieved from administering the drug and the time such results were observed. Review of the facility policy titled, Oxygen Administration, dated 12/2025, revealed .It is the policy of this facility that oxygen therapy is administered, as ordered by the physician. 2. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE], with diagnoses including Atrial Fibrillation, Depression, Anemia, and Hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #28 scored 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was cognitively intact. Review of the Physician's Orders dated 12/1/2025, revealed .PRN [as needed] OXYGEN AT 2L/MIN [Liters per minute] VIA [by way of] NASAL CANNULA/MASK. Review of the Treatment Administration Record (TAR) dated 12/2025, revealed staff failed to document the administration of PRN Oxygen to Resident #28 on 12/8/2025 and 12/9/2025. Observation in Resident #28's room on 12/8/2025 at 3:55 PM, and on 12/9/2025 at 9:22 AM, revealed Resident #28 was sitting in the recliner receiving Oxygen therapy at 2L/min via Nasal Cannula (NC). 3. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Dementia, Diabetes, Morbid Obesity, and Muscle Weakness. Review of the quarterly MDS assessment dated [DATE], revealed Resident #29 scored an 11 on the BIMS assessment, which indicated she was moderately cognitively impaired. Review of the Physician's Orders dated 12/18/2024, revealed .Oxygen at 2 L [Liters] per min BNC [By nasal cannula] as needed for SOB [Shortness of Breath]. Review of the TAR dated 12/2025, revealed staff failed to document the administration of PRN Oxygen to Resident #29 on 12/8/2025 and 12/9/2025. Observation in Resident #29's room on 12/8/2025 at 9:01 AM and 12/8/2025 at 9:56 AM, revealed Resident #29 was lying in bed receiving Oxygen therapy at 3 L/min via BNC. Observation in Resident #29's room on 12/9/2025 at 9:28 AM, revealed Resident #29 was lying in bed receiving Oxygen therapy at 2.5-3 L/min via BNC. During an interview on 12/9/2025 at 9:50 AM, Licensed Practical Nurse (LPN) C was asked what the physicians order for Resident #29's oxygen was. LPN C stated, It should be at 2L/min. During an observation and interview in Resident #29's room on 12/9/2025 at 9:52 AM, revealed LPN C verified that oxygen was being administered at 3 L/min. During an interview on 12/9/2025 at 9:55 AM, the Director of Nursing (DON) was asked do you expect oxygen to be administered as ordered by the physician. The DON stated, .Yes, I would expect it to be. 4. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease and Heart Failure. Review of the quarterly MDS assessment dated [DATE], revealed Resident #45 scored a 3 on the BIMS assessment, which indicated he was severely cognitively impaired. Resident #45 was not assessed for oxygen therapy. Review of the Physician's Orders dated 11/19/2024, revealed .Oxygen at 2 L per min BNC as needed . Review of the TAR dated 12/2025, revealed staff failed to document the administration of PRN Oxygen to Resident #45 on 12/10/2025. Observation in Resident #45's room on 12/10/2025 at 8:04 AM, revealed Resident #45 was lying in bed receiving Oxygen therapy per BNC at 2 liters. During an observation and interview in Resident #45's room on 12/10/2025 at 8:05 AM, LPN B was asked what Resident #45's oxygen was set on. LPN B stated, A little over 2 liters. LPN B was asked if oxygen was administered should it be signed out on the TAR. LPN B stated, Yes. During an interview on 12/10/2025 at 8:21 AM, the DON was asked to explain the process for PRN medications or treatments. The DON stated, They should be signing out the order, and the system should trigger a follow up to see if it was effective . The DON was asked should PRN medications or treatments be documented on the TAR. The DON replied, Yes.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored when expired medications were found in 1 of 7 (400 Hall Medication Cart) medication storage areas. The findings included: 1. Review of the facility policy titled, Medication Administration: Medication, Controlled and Biological Storage, Night/Emergency Box and Backup Pharmacy, dated 4/25/2025, revealed .Whenever a seal of a multidose vial is broken it must be initialed and dated by the Nurse with an open date and expiration date. These shall expire 28 days after opening unless otherwise specified by the manufacturer. Review of the facility policy titled, Medication Administration, dated 4/25/2025, revealed .Check the expiration date of each medication. 2.During an observation and interview at the 400 Hall Medication Cart on 12/9/2025 at 8:59 AM, revealed 1 opened vial of multidose Lispro insulin (used to treat diabetes) with an open date of 10/25/2025, and an expiration/discard date of 11/22/2025, and 1 bottle of Folic Acid (vitamin supplement) 100 mg [milligrams] capsules with an expiration date of 11/2025. Registered Nurse (RN) A acknowledged expired medication should not be stored in the medication cart. During an interview on 12/10/2025 at 9:16 AM, the Director of Nursing (DON) was asked if expired medication should be on the medication cart. The DON stated, No, it should not be.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when the ice machine was found with black slimy residue on the inside trim of the ice machine and white residue running down the inside of the door. The facility had a census of 74 residents with 74 of those residents receiving a tray from the kitchen. The findings include: Review of the facility policy titled, Dietary: Ice Storage, dated 11/30/2022, revealed .Ice is to be maintained and served to patients in a sanitary manner . Review of the Named Company's invoice dated 4/15/2024, revealed the last time the ice machine was clean/sanitized was on 4/15/2024. Observation in the Clean Utility Room on the 300 Hall on 10/30/2024 at 8:09 AM, revealed a black, slimy substance on the inside trim and inside edge of the ice machine and white residue running down the inside of the door. During an interview on 10/30/2024 at 8:13 AM, the Dietary Supervisor (DS) stated that Maintenance is responsible for cleaning the ice machine. The DS confirmed there should not have been any black slimy substance or white residue on the ice machine. During an interview on 10/30/2024 at 8:21 AM, the Maintenance Director (MD) was asked how often the ice machine should be cleaned. The MD stated, .should be cleaned monthly through a contractor . The MD was asked should there be black slimy and white residue on the ice machine. The MD stated, .Probably not.

Based on policy review, observation, and interview, the facility failed to ensure appropriate infection control prevention and practices during medication administration when 1 of 2 nurses Registered Nurse (RN) C observed failed to perform hand hygiene between changing gloves during medication pass, and 1 of 1 Certified Nurses Assistant (CNA) B failed to properly handle and transport a soiled brief. The findings include: 1. Review of the facility policy titled, Infection Control, dated 11/20/2023, revealed . It is a policy of this facility to establish and maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary .environment .to help prevent the development and transmission of communicable diseases and infections .direct care staff shall handle, store, process, and transport linens so as to prevent spread of infection .All staff shall demonstrate competence in relevant infection control practices . Review of the facility policy titled, Hand Hygiene, dated 3/28/2024, revealed .Staff involved in direct resident contact shall perform proper hand hygiene procedures to prevent the spread of infection .the use of gloves does not replace hand hygiene. Perform hand hygiene after removing gloves .before applying and after removing personal protective equipment .including gloves . 2. During an observation on 10/30/2024 at 7:35 AM, revealed RN C entered Resident #29 ' s room to administer medications, sanitized, donned gloves, administered eye drops, removed gloves, did not perform hand hygiene, and donned another pair of gloves to administer oral medications. Upon completion of administering oral medications, RN C removed her gloves, did not perform hand hygiene, donned another pair of gloves to administer the second ordered eyedrops. 3. During an observation on 10/30/2024 at 8:04 AM, RN C entered Resident #227 ' s room to administer medications and performed hand hygiene before donning gloves. RN C helped the resident unbutton his shirt to gain access to the Peripherally inserted central catheter (PICC) (a thin flexible tube inserted into a vein in the arm and threaded into a large vein in the chest) line, removed her gloves, and did not perform hand hygiene before donning a new pair of gloves. RN C failed to perform hand hygiene after removing gloves during medication administration. 4. A random observation and interview on the 400 Hall on 10/30/2024 at 9:23 AM, revealed CNA B walked out of a resident ' s room with a dirty brief in her bare hand, walked to the other side of the hallway and placed the brief in a trash barrel. CNA B confirmed it was a dirty brief in her hand. CNA B confirmed the dirty brief should have been in a plastic bag before she walked out of the room. 5. During an interview on 10/30/2024 at 9:37 AM, the Director of Nursing (DON) was asked how should staff handle dirty briefs when exiting a resident ' s room. The DON stated, Put it in a bag and then it goes into a barrel in the hallway. During an interview on 10/31/24 at 7:15 AM, the DON confirmed that hand sanitization should always be performed after removing gloves. 47835

Based on policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored and secured for 1 of 1 sampled residents (Resident #277) when medications were found unattended and unsecured in the Resident's room. The findings include: Review of the facility policy titled, Medication Administration: Medication, Controlled and Biological Storage, Night/ Emergency Box and Backup Pharmacy Storage, dated 9/25/2024, revealed .It is the policy of this facility to ensure all medications housed on our premises will be stored .in locked compartments .medications must be under the direct observation of the person administering medications of locked in the medication storage area/cart . Review of the medical record revealed Resident #277 was admitted to the facility on [DATE], with diagnoses including Osteomyelitis, Diabetes, and Anemia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #277 was cognitively intact and assessed for special treatments that included intravenous (IV) medications. Observation in Resident #277's room on 10/28/2024 at 9:35 AM, revealed 2 syringes filled with Heparin (a medication used to keep IV catheters open and prevent blood clots) on the chair next to the bed, unsecured and unattended. During an interview on 10/28/2024 at 9:46 AM, RN A confirmed that the medications should not be left at bedside unattended. During an interview on 10/30/2024 at 5:02 PM, the Director of Nursing confirmed that Heparin should not be left at the Resident's bedside unattended.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when expired, opened, and undated food items were found in the dry food storage area. The facility had a census of 70, with 68 of those residents receiving a meal tray from the Kitchen. The findings include: Review of the facility's policy titled, Dietary: Food Storage, dated [DATE], revealed .Product will be used or discarded within the appropriate time frame .spices should be dated with the delivery date and discarded after one year . Observation in the Kitchen on [DATE] beginning at 8:52 AM, revealed the following: a. a 16 ounce (oz) plastic container of ground mustard seasoning opened and dated [DATE] b. a 18 oz plastic container of paprika seasoning opened and dated [DATE] c. a 16 oz plastic container of salt free seasoning opened, undated, and no visible use by date During an interview on [DATE] at 9:49 AM, the Dietary Manager confirmed that all food and spices should have an open date and spices should be discarded after 1 year.

Based on medical record review, observation, and interview, the facility failed to accurately assess residents for antipsychotic medication use and [CONDITION(S)] for 5 of 21 sampled residents (Resident #3, #9, #21, #33, and #64) reviewed for accuracy of Minimum Data Set (MDS) assessments. The findings include: Review of the facility's policy titled, [CONDITION(S)], dated 10/18/21, revealed .Residents who have [CONDITION(S)] ([CONDITION(S)]) and receive [CONDITION(S)] will be .identified in assessments . Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #3 was assessed as having received Antipsychotic medications on a routine basis. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #3 was assessed as having received Antipsychotic medications on a routine basis. Review of the medical record, revealed Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #9 was assessed as having received Antipsychotic medications on a routine basis. During an interview on 8/17/2022 at 4:44 PM, MDS Coordinator #1 stated she coded Resident #9 as receiving Antipsychotic medications because she was receiving some type of [CONDITION(S)] medication. Review of the medical record, revealed Resident #21 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Treatment/Order Update/Change in Condition sheet dated 12/15/2021, revealed .Verbal Order Begin Date 12/15/2021 .3 Times Weekly .[CONDITION(S)] on M [Monday]-W [Wednesday]-F [Friday] . Review of the Treatment Sheet dated 6/2022, revealed Resident #21 received [CONDITION(S)] on 6/13/2022, 6/15/2022, and 6/17/2022. Review of the quarterly MDS assessment dated [DATE], revealed Resident #21 was assessed as having a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #21 was not coded as receiving [CONDITION(S)] services. During an interview on 8/17/2022 at 7:43 PM, MDS Coordinator #1 confirmed Resident #21 received [CONDITION(S)] and should have been assessed for [CONDITION(S)] services on the 6/19/2022 quarterly MDS assessment. Review of the medical record, revealed Resident #33 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #33 was assessed as having received Antipsychotic medications on a routine basis. Review of the medical record, revealed Resident #64 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS dated [DATE], revealed Resident #64 was assessed as having received Antipsychotic medications on a routine basis. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #64 was assessed as having received Antipsychotic medications on a routine basis. During an interview on 8/17/2022 at 5:21 PM, MDS Coordinator #1 and MDS Coordinator #2 confirmed the MDS assessments were coded incorrectly for receiving Antipsychotic medications.

Based on policy review, review of the facility's APPROVED DIET MANUAL .Menu Guide, medical record review, review of the Emergency Medical Services (EMS) report, review of the hospital record, and interview, the facility failed to follow the care plan interventions for a therapeutic diet for 1 of 16 (Resident #24) sampled residents of the 33 residents included in the stage 2 review. The failure of the facility to follow the care plan interventions for a therapeutic diet resulted in an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) when Resident #24, a dependent diner (unable to feed herself) who was at risk of choking, was served a food that was specifically excluded from her therapeutic diet resulting in a life-threatening choking event. Resident #24 sustained a fracture to her sternum as a direct result of the life-saving interventions required to prevent her death from choking. The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy on 10/11/17 at 3:05 PM in the conference room. The facility was cited an Immediate Jeopardy at F282-J. An extended survey was conducted on 10/12/17 and 10/13/17. An acceptable allegation of compliance (A(NAME)) which removed the immediacy of the jeopardy, was received on 10/13/17 at 10:46 AM, and the corrective actions were validated onsite by the surveyors on 10/13/17. The corrective actions were validated on site through review of facility documents, auditing tools, in-service training record, medical record review, observation, and staff interview by the surveyors on 10/13/17. The Immediate Jeopardy was effective 10/9/17. The immediacy was removed 10/13/17. The noncompliance continues at F282-E for monitoring of effectiveness of the corrective actions to ensure sustained compliance. The findings included: 1. The facility's Care Plans policy documented, Care planning is an essential part of healthcare providing a road map of sorts, to guide all who are involved with patient's care .The care plan must describe the services that are to be furnished to attain and maintain the patient's highest practical, physical, mental and psychosocial wellbeing . 2. The facility's APPROVED DIET MANUAL .Menu Guide, documented, .Level 2: Mechanically Altered (diet) is a transition from the pureed diet and requires the ability to chew and tolerate mixed textures. Foods are soft and moist .Considerations for specific food items .Pineapple - restricted from all three levels of the NCM (Nutrition Care Manual) Dysphagia Diet . 3. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] and the quarterly MDS assessment dated [DATE] revealed Resident #24 had a Brief Interview of Mental Status (BIMS) score of 1 out of 15, indicating she was severely cognitively impaired, and was dependent on staff for eating. Resident #24's care plan dated 5/1/17, and revised on 8/2/17, documented, .receives a therapeutic diet .Has teeth missing from extraction 8/2/17 Diet changed to CC (Controlled Carbohydrate) mech (mechanical) ground d/t (due to) choking .Interventions .Monitor for episodes of choking Has some teeth missing .Diet changed to mech (mechanical) ground .Diet as ordered . The physician's orders [REDACTED].Diet - CCHO (Controlled Carbohydrate) Mechanical Ground (L (level) 2) . Review of a clinical note dated 10/9/17 revealed the charge nurse was called to Resident #24's room during lunch and found Resident #24 in acute respiratory distress after choking while being fed her noon meal. Resident #24 required life-saving interventions. EMS removed a piece of pineapple, a food restricted from the level 2 mechanically ground diet, from Resident #24's airway. Resident #24 was transferred from the facility to the hospital. 4. The EMS report dated 10/9/17 documented, .Respiratory Distress .choking on piece of fruit .Pt (patient) presents cyanotic from mid-abdomen up to her face and pt is gasping for air and no longer able to cough .used the laryngoscope (a lighted instrument used to visualize a person's airway) and Magill Forceps (an instrument used to remove a foreign object from a person's airway) to retrieve .a chunk of pineapple, from the pt's trachea successfully . 5. The hospital records dated 10/9/17 documented, .ER (emergency room ) NOTE .Chief Complaint Description choking .Impression .Closed fracture of body of sternum .Mechanism of Injury: choking incident on pineapple . 6. Interview with Certified Nursing Assistant (CNA) #1 on 10/10/17 at 2:30 PM, in the 300 hall dining room, CNA #1 was asked if Resident #24 required a special diet. CNA #1 stated, She was on a chopped or mechanical soft because her meat was ground up . CNA #1 was asked to describe what happened during lunch on 10/9/17. CNA #1 stated, I was in there (Resident #24's room) assisting her with her meal .she had eaten everything and her fruit was the last thing I was helping her with. I was getting up and she asked me for another drink. I noticed when I gave her the drink she sounded a little strangled and she didn't sound right. I hollered for the nurse to come in and check her out, and then she went into full blown choking and started turning colors .(Named Licensed Practical Nurse (LPN) #1) came in .started doing [MEDICATION NAME] (an action to remove what is blocking the airway) on her with no results. We called for more help .paged (Named LPN #2) to come in there. He came and they all tried with no results. (Named the Assistant Director of Nursing (ADON)) and the Family Nurse Practitioner (FNP)) .still no results with the [MEDICATION NAME] .tried suctioning, no results. 911 (EMS) came and they got it (a piece of pineapple) out with forceps .the fruit they had yesterday (10/9/17) had pineapples in it . CNA #1 was asked if the fruit was cut in a special size. CNA #1 stated, It had pineapples in it about an inch in size .I had to cut it in half because she doesn't have any teeth . Interview with LPN #1 on 10/10/17 at 2:41 PM, at the 300 hall nurse's station, LPN #1 was asked if Resident #24 required a special diet. LPN #1 stated, No, she was on just a regular diet I believe . When LPN #1 was asked about the event that occurred on 10/9/17, LPN #1 stated, (Named CNA#1) came and got me and told me the patient was choking .I tried the [MEDICATION NAME] several times and was unsuccessful .tried .suction, and kept trying the [MEDICATION NAME]. 911 came and they removed a chunk of pineapple about an inch and a half in size. Interview with the Food Service Supervisor on 10/10/17 at 4:05 PM in the conference room, the Food Service Supervisor was asked what was included in a mechanical L2 diet. The Food Service Supervisor stated, Most of the time, it's going to be meats run through the chopper .sometimes fried vegetables may have to be steamed . The Food Service Supervisor was asked if pineapple was allowed. She stated, Um, it may have to be altered at times, I'm not sure . The Food Service Supervisor was asked how staff know what to serve on the meal trays. She stated, They go by the spreadsheets .they did a canned tropical fruit yesterday, because I didn't have seasonal fruit .it was a blend of pineapples, mangoes . The Food Service Supervisor was asked based on the Level 2: Mechanically Altered diet definition from the diet manual, should Resident #24 have been served the tropical fruit. She stated, No, not with the pineapple . Interview with the DON on 10/13/17 at 9:07 AM, in the conference room, the DON was asked if facility staff followed the physician's diet orders for Resident #24 on 10/9/17. The DON stated, No they did not, because she received the pineapple. The facility failed to follow physician ordered care plan interventions for Resident #24's therapeutic diet when they served her the pineapple that was restricted from her mechanically ground diet causing her to choke, go into respiratory distress, and sustain a sternal fracture, which resulted in Immediate Jeopardy. The Immediate Jeopardy was effective 10/9/17 through 10/13/17. An extended survey was completed on 10/12/17 and 10/13/17. An acceptable allegation of compliance (A(NAME)) which removed the immediacy of the jeopardy, was received on 10/13/17 at 10:46 AM, and the corrective actions were validated onsite by the surveyors on 10/13/17 through review of facility documents, auditing tools, in-service training record, medical record review, observation, and staff interview by the surveyors on 10/13/17. Corrective actions validated on 10/13/17 included the following: 1. Medical record review revealed Resident #24's diet was changed to a CCHO (Controlled Carbohydrate) pureed diet on 10/9/17, the care plan had been updated to reflect the diet change, and the Speech Therapy screening had been completed. Observations of Resident #24 confirmed she was receiving a pureed diet. Observations in the kitchen revealed all pineapple and products containing pineapple had been removed from the facility. 2. The facility provided documentation of dietary and nursing staff in-service training regarding therapeutic diets, allowed foods and foods that were not allowed. Interviews with facility staff verified the training had been completed and that staff were knowledgeable regarding the use of therapeutic diets. 3. The facility's diet spreadsheets were revised and included specific food items and amounts to be served for mechanically altered diets. 4. Review of the facility's Nursing Audit Tool revealed the diets were reviewed by the DON, Assistant Director of Nursing (ADON) and the Staffing Coordinator for every mechanically altered diet starting with the evening meal on 10/10/17 through 10/13/17. The facility completed audits comparing the foods served to the diet orders, diet spreadsheets, and meal tickets. The audits were conducted both in the kitchen as a first step, and then by a second administrative staff member in the dining room and on the units by checking the meal trays, meal tickets, and verifying the physician's orders [REDACTED]. The facility was cited an Immediate Jeopardy at F282-K. The noncompliance continues at F282-E for monitoring of the corrective actions to ensure sustained compliance. The facility is required to submit a plan of correction.

Based on review of the facility's APPROVED DIET MANUAL .Menu Guide, review of the facility's Diet Spreadsheet, medical record review, review of the Emergency Medical Services (EMS) report, review of the hospital record, and interview, the facility failed to provide care and services necessary to maintain the highest practicable physical, mental, and psychosocial well-being of residents when staff failed to follow physician orders [REDACTED].#24) sampled residents reviewed receiving a mechanically altered therapeutic diet with the potential to effect a total of 37 residents receiving a mechanically altered therapeutic diet. Resident #24 was in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) when staff failed to follow therapeutic diet orders for Resident #24, a dependent diner (requires staff to feed her) who was at risk for choking, was fed pineapple, a fruit that was specifically excluded from her therapeutic diet, causing Resident #24 to choke and obstruct her airway. The episode of choking required emergency medical interventions that included use of abdominal thrusts, also known as the [MEDICATION NAME] maneuver (an action to remove what is blocking the airway), airway suctioning, and physical removal of the pineapple from her airway. This choking episode and subsequent emergency interventions resulted in a fracture to Resident #24's sternum. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy on 10/11/17 at 3:05 PM in the conference room. The facility was cited an Substandard Quality of Care at F309-K. An extended survey was conducted on 10/12/17 and 10/13/17. An acceptable allegation of compliance (A(NAME)) which removed the immediacy of the jeopardy, was received on 10/13/17 at 10:46 AM, and the corrective actions were validated onsite by the surveyors on 10/13/17 through review of facility documents, auditing tools, in-service training record, medical record review, observation, and staff interview by the surveyors on 10/13/17. The Immediate Jeopardy was effective 10/9/17. The immediacy was removed 10/13/17. The noncompliance continues at F309-E for monitoring of effectiveness of the corrective actions to ensure sustained compliance. The findings included: 1. The facility's APPROVED DIET MANUAL .Menu Guide, documented, .Level 2: Mechanically Altered (diet) is a transition from the pureed diet and requires the ability to chew and tolerate mixed textures. Foods are soft and moist .Considerations for specific food items .Pineapple - restricted from all three levels of the NCM (Nutrition Care Manual) Dysphagia (difficulty swallowing) Diet . 2. The facility's Diet Spreadsheet documented, .Week 4 Day 23 (of the menu calendar) .L (level) 2/MECH (mechanically) ALT (altered) (diet) .SEASONAL FRESH FRUIT (SUMMER .1/2 EACH (1/2 cup or piece of fruit) . 3. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] and the quarterly MDS assessment dated [DATE] revealed Resident #24 had a Brief Interview of Mental Status (BIMS) score of 1 out of 15, indicating she was severely cognitively impaired, was dependent on staff for all activities of daily living (ADLs) including eating. Review of the care plan dated 7/28/17 through 10/10/17 revealed Resident #24 received a therapeutic diet, had teeth missing from extractions on 8/2/17 and her diet was changed from a Controlled Carbohydrate (CC) diet with regular consistency to a CC mechanically ground diet due to a choking episode on 8/2/17 with interventions to monitor for episodes of choking due to missing teeth and to provide diet as ordered. A clinical note dated 8/2/17 documented, .CN (Charge nurse) SUMMONED TO PT (patient) ROOM BY CNA (Certified Nursing Assistant) DURING LUNCH. CNA STATED PT HAD GOTTEN CHOKED ON A PIECE OF COUNTRY FRIED STEAK. CNA STATED PT STARTED COUGHING, FACE TURNED RED/PURPLE BUT PT WAS ABLE TO COUGH UP MEAT. PT WAS ASSESSED BY THIS CN .NO S/S (signs and symptoms) OF DISTRESS NOTED AT PRESENT, DIETARY CONSULTED, NEW ORDER TO CHANGE DIET TO MECHANICAL GROUND . A physician's telephone order dated 8/2/17 documented, .Begin date: 08/02/2017 .CCHO (Controlled Carbohydrate) Diet - Mechanical Ground (L (level) 2) . The 30 day physician's re-certification visit note dated 8/16/17 documented, .Patient had episode of choking on country fried steak on 8-2-17 and diet was changed to mechanical ground carb (carbohydrate) controlled diet. Patient tolerating well . A clinical note dated 10/9/17 documented, .CN was called to pt's room during lunch, pt noted to be cyanotic and shallow gasp or wheeze noted. Heimleich ([MEDICATION NAME]) maneuver was performed multiple times without success, pt remained conscious but lethargic. Attempts to suction unsuccessful. EMS called. Upon arrival paramedic removed chuck (chunk) of pineapple from airway and pt sent to (named hospital) via (by) EMS . A NURSE'S EVENT NOTE dated 10/9/17 documented, .CN was called to pt's room during lunch by CNA d/t (due to) pt choking. Upon CN arrival pt cyanotic (skin appeared blue due to a lack of oxygen) [MEDICATION NAME] maneuver was performed multiple time (times) without success, abdominal thrust were allowing some oxygenation, however unable to clear airway completely. EMS activated. Immediate response from EMS and were able to remove object (piece of pineapple) .Pt transferred to hospital, will complete speech therapy evaluation and change diet to puree upon return to facility . 4. The EMS report dated 10/9/17 at 12:22 PM documented, .Altered Level of Consciousness .Respiratory Distress .choking on piece of fruit .U/A (upon arrival) on scene, we were directed to the pt's room where we found several NH (nursing home) staff attempting abdominal thrusts and suctioning the pt with a suction .NH staff state, 'She is choking on a piece of fruit, Hurry! Help!' Pt presents cyanotic from mid-abdomen up to her face and pt is gasping for air and no longer able to cough. I instructed the NH staff to lay the pt back down on the bed and pull the bed out. I then used the laryngoscope and Magill Forceps to retrieve the foreign body, a chunk of pineapple, from the pt's trachea successfully. When I initially opened the pt's mouth, there were oral secretions and a small amount of bright red blood in the oropharynx prior to retrieval of the foreign object with the forceps. After removing the fruit from the pt's airway, I further assessed the pt .JVD (Jugular Venous Distention which is bulging neck veins) due to choking event/ apneic (a period without breathing) episode, lung sounds present mild rales (abnormal breath sounds) on auscultation, abd (abdomen) soft not tender and has bruising distal of her xiphoid process (area below the middle of her chest) from abdominal thrusts .Pt slowly regained consciousness . 5. The hospital records dated 10/9/17 documented, .ER (emergency room ) NOTE .Chief Complaint Description choking, .Impression .Closed fracture of body of sternum .Mechanism of Injury: choking incident on pineapple .CHEST 2 VIEWS .FINDINGS: Under aerated two views of the chest demonstrates mild .atelectasis (partial collapse of the lung) versus infiltrate (an accumulation of fluid in the lungs) .STERNUM MINIMUM 2 VIEWS .CHOKING EPISODE, S/P (status [REDACTED]. A clinical note dated 10/10/17 at 12:40 AM documented, .Returned to facility at this time via EMS .Pt c/o (complained of) pain .[MEDICATION NAME] administered .Will monitor . A clinical note dated 10/10/17 at 12:53 AM documented, .Bruising also noted to chest where [MEDICATION NAME] ([MEDICATION NAME]) maneuver was performed earlier in the day . 6. Interview with CNA #1 on 10/10/17 at 2:30 PM in the 300 hall dining room, CNA #1 was asked to describe what happened during lunch on 10/9/17. CNA #1 stated, I was in there (Resident #24's room) assisting her with her meal .she had eaten everything and her fruit was the last thing I was helping her with. I was getting up and she asked me for another drink. I noticed when I gave her the drink she sounded a little strangled and she didn't sound right. I hollered for the nurse to come in and check her out, and then she went into full blown choking and started turning colors. (Named licensed practical nurse (LPN) #1) came in and started helping me get her up in bed and started doing the [MEDICATION NAME] on her with no results. We called for more help .paged named LPN #2 to come in there. He came and they all tried with no results. (Named the Assistant Director of Nursing (ADON) and the Family Nurse Practitioner (FNP)) .still no results with the [MEDICATION NAME] ([MEDICATION NAME]) .tried suctioning, no results. 911 (EMS) came and they got it (the pineapple) out with forceps .the fruit they had yesterday (10/9/17) had pineapples in it .she may have pocketed (held between her gums and cheek) it because she didn't choke while I was feeding her .she was still talking when (named LPN #1) got in there . CNA #1 was asked if Resident #24 required a special diet. CNA #1 stated, She was on a chopped or mechanical soft because her meat was ground up . CNA #1 was asked if the fruit was cut in a special size. CNA #1 stated, It had pineapples in it about an inch in size .I had to cut it in half because she doesn't have any teeth .I've had her for about 5 years and she's gotten strangled before but nothing like this . Interview with LPN #1 on 10/10/17 at 2:41 PM at the 300 hall nurse's station, LPN #1 was asked to describe what happened during lunch on 10/9/17. LPN #1 stated, (Named CNA#1) came and got me and told me the patient was choking. When I got in there she was turning gray. I tried the [MEDICATION NAME] several times and was unsuccessful .they went and got help, we tried to see if we could suction it (the object in her throat) and kept trying the [MEDICATION NAME]. 911 came and they were able to get it out with forceps and removed a chunk of pineapple about an inch and a half in size. LPN #1 was asked if Resident #24 required a special diet. LPN #1 stated, No, she was on just a regular diet I believe . LPN #1 was asked if Resident #24 had a history of [REDACTED].#1 stated, Not that I'm aware of; I haven't heard anything since I've been here . Interview with the Food Service Supervisor on 10/10/17 at 4:05 PM in the conference room, the Food Service Supervisor was asked what was included in a mechanical L2 diet. The Food Service Supervisor stated, Most of the time, it's going to be meats run through the chopper .sometimes fried vegetables may have to be steamed . The Food Service Supervisor was asked what fruits were allowed. She stated, Pretty much anything .may have soft fruit instead of hard fruit. The Food Service Supervisor was asked if pineapple was allowed. She stated, Um, it may have to be altered at times, I'm not sure . The Food Service Supervisor was asked how staff know what to serve on the meal trays. She stated, They go by the spreadsheets .They did a canned tropical fruit yesterday, I didn't have seasonal fruit .it was a blend of pineapples, mangoes, and I can't tell you what else was in it . The Food Service Supervisor was asked if the facility used the APPROVED DIET MANUAL .Menu Guide she provided to this surveyor earlier for the Level 2: Mechanically Altered diet. She stated, (Named the food service company) sends us the manual so I assume that it is. The Food Service Supervisor was asked based on the Level 2: Mechanically Altered diet definition from the diet manual, should Resident #24 have been served the tropical fruit. She stated, No, not with the pineapple . Telephone interview the Regional Registered Dietitian (RD) on 10/10/17 at 4:25 PM, the Regional RD was asked what was included in a mechanical L2 diet. She stated, Typically chopped meats, foods that are easy to chew .gravy on meats, softer foods .we have spreadsheets that specify for the mechanically altered diet and what would be different from the regular diet. The Regional RD was asked what type of fruit was allowed. She stated, .I wouldn't be able to tell you without looking . The surveyor read the definition of the level 2 mechanically altered diet from the facility's diet manual and then asked her if Resident #24 should have been served pineapple. The Regional RD stated, No. Interview with the FNP on 10/11/17 at 3:15 PM in the conference room, the FNP was asked to describe what happened during lunch on 10/9/17. The FNP stated, Well, I got called to the room and they were in there doing the [MEDICATION NAME]. EMS had already been called. She (Resident #24) was cyanotic .you could tell they were moving something when they were doing the [MEDICATION NAME] because she would pinken up and then she would suck it right back .we tried to suction but couldn't get anything up that way .EMS came in .got the Magill Forceps and got a piece of pineapple up and she immediately pinked up . The FNP was asked if Resident #24 had ever choked before this incident. The FNP stated, Yes, she got strangled on a piece of meat and she was able to get that up .we changed her to a mechanical soft .ground meat diet . The FNP was asked what was included in a mechanical soft diet. The FNP stated, Ground meat .the other food items should be soft .mashed potatoes .soft food . The FNP was asked how large was the piece of pineapple. The FNP stated, .about the size of the end of my thumb . The FNP was shown the facility's diet manual containing the definition of the level 2 mechanically altered diet and was asked if Resident #24 should have been served the pineapple. The FNP stated, No. The FNP was asked if she ordered a specific diet, would she expect the facility to follow that order. The FNP stated, Yes. The FNP was asked if the sternal fracture was a direct result of the [MEDICATION NAME] maneuver and abdominal thrusts. The FNP stated, Yes. The FNP was asked if the fracture would have occurred if Resident #24 had not choked on the pineapple. The FNP stated, No, she had bruising immediately after the [MEDICATION NAME] . Interview with the Speech Language Pathologist (SLP) on 10/11/17 at 3:31 PM in the conference room, the SLP was asked if she had ever evaluated or treated Resident #24 prior to 10/9/17. The SLP stated, No .Not that I can remember . The SLP was asked what was included in the level 2 mechanically altered diet. The SLP stated, It's typically just softer vegetables, meat being chopped up about 1/4 an inch, just mechanically chopped up, no raw vegetables, fruits with seeds in them like black berries or raspberries need to be avoided for sure .no fruits with skins/peelings .pineapple is one to avoid . The SLP was asked if Resident #24 should have been served the pineapple. The SLP stated, No . Interview with the DON on 10/13/17 at 9:07 AM in the conference room, the DON was asked if facility staff followed the physician's diet orders for Resident #24 on 10/9/17. The DON stated, No they did not, because she received the pineapple. Interview with the Assistant Director of Nursing (ADON) on 10/13/17 at 10:00 AM in the conference room, the ADON was asked to describe what happened during lunch on 10/9/17. The ADON stated, I was coming by the 300 nurse's station and was told I was needed in (named Resident #24's room) .I confirmed with the folks in the room that she was choking. (Named LPN #2) was standing behind her with his arms around her doing abdominal thrusts .she was very pale. I could still hear intermittent air moving .there was some air getting around intermittently throughout the process until the ambulance service arrived. I relieved (named LPN #2) to perform abdominal thrusts .when I did thrusts, she would get some good air, then she would suck it back in, and we would have to do thrusts again .the Nurse Practitioner came in behind me and observed and over saw what we were doing .she didn't do any thrusts because she felt like we were doing what she needed. The ambulance service got here pretty quickly, positioned her flat on the bed. The paramedic got from head of bed, put scope in and plucked it right out . The ADON was asked what the paramedic removed. She stated, It was something between the forceps . The ADON was asked at what point she was made aware Resident #24 had been served the wrong diet. The ADON stated, When somebody came down here and met with you; maybe when (named the Administrator) or (named the DON) came down .I don't know . The ADON was asked if the CNA was aware that pineapple was not allowed. The ADON stated, No . Interview with LPN #2 on 10/13/17 at 10:20 AM in the conference room, LPN #2 was asked to describe what happened during lunch on 10/9/17. LPN #2 stated, They paged me in there and when I got in there she (Resident #24) was in distress. (Named LPN #1) had said she had choked on something, she wasn't having any luck, she had checked her and she wasn't getting any air in .we told her to go get the crash cart and department head .I stepped behind her (Resident #24) somebody called 911, I started the [MEDICATION NAME] .did several thrusts .she was still breathing, shallow, had a wheeze and you could tell there was some obstruction .did that for a while, and at some point (Named the ADON) came and she relieved me. While she was doing it we were setting up the suction machine, then I took back over, stopped for a second, and they tried suctioning her, and then shortly thereafter EMS arrived. We put her flat in the bed, the paramedic was at the head of the bed and used forceps and removed what appeared to be a piece of pineapple. We set her back up, she coughed, and cleared some, and her color improved . LPN #2 was asked when he was made aware that she received a food that was restricted from her diet. LPN #2 stated, 2 days later, I was off on Tuesday (10/10/17) and I was informed when I came back on Wednesday (10/11/17). LPN #2 was asked what he was told about the pineapple. LPN #2 stated, They just said that on her level of diet, that it wasn't supposed to be on there but they weren't aware of it at the time. LPN #2 was asked who told him that information. LPN #2 stated, Probably about 5 or 6 people. Telephone interview with the Medical Director on 10/13/17 at 2:25 PM, the Medical Director was asked if the facility's staff had a history of [REDACTED]. The Medical Director was asked how he was notified about Resident #24's choking incident. The Medical Director stated, The Administrator called me, I believe, yesterday morning . The Medical Director was asked if the Administrator informed him that Resident #24 had been served the wrong diet. The Medical Director stated, Yes, he did, he was pretty clear about it and said she was not to have pineapple and how that came about .he told me the lady preparing the meals said the menu said seasonal fruit, but instead a can of mixed fruit that had pineapple in it was served and shouldn't have been . The Medical Director was asked if it was common for a sternal fracture to occur as a result of the [MEDICATION NAME] maneuver. The Medical Director stated, Common .no .It is definitely possible . The Medical Director was asked if Resident #24 had not choked, would she have sustained the sternal fracture. The Medical Director stated, No. The Medical Director was asked if he was informed that the facility's staff was unaware Resident #24 had received the wrong diet until it was brought to their attention by the survey team. The Medical Director stated, Yes, he (the Administrator) told me that. The Medical Director was asked if he felt the facility's staff should have identified that Resident #24 was served the wrong diet. The Medical Director stated, Yes. Interview with the Administrator on 10/13/17 at 4:07 PM in the business office, the Administrator was asked what the procedure was when an unusual event occurred in the facility. The Administrator stated, An investigation would be started to see if we could determine the cause of the incident and to identify any process problems. The Administrator was asked when he was notified about Resident #24's choking episode. The Administrator stated, I was made aware the day it happened (10/9/17) that we had not followed the orders. I was made aware that a resident had a choking episode at our facility and that she had been transported from our facility . The Administrator was asked when he was informed that physician's orders [REDACTED]. The Administrator stated, To the best of my knowledge, I believe I was made aware the next day (10/10/17) that we had not followed the orders .I'm going to say the Food Service Supervisor .I was made aware by several individuals in a short amount of time. The Administrator was asked if he knew who identified the fact that the orders had not been followed. The Administrator stated, I know we had started investigating it (10/9/17) but I don't think we had identified it until the surveyor came to the Food Service Supervisor when she was shown where the pineapple wasn't allowed . The Administrator was asked if he felt the facility had completed a thorough investigation. The Administrator stated, I feel like we had done a good job up until that point to determine the root cause of what had happened. I feel like at some point, we would have identified this as the root cause. The facility failed to ensure Resident #24 received the proper therapeutic diet when Resident #24 was served pineapple that caused her to choke, go into severe respiratory distress, and sustained a fracture to her sternum, when life saving procedures were performed resulted in an Immediate Jeopardy. The Immediate Jeopardy was effective 10/9/17 through 10/13/17. An extended survey was completed on 10/12/17 and 10/13/17. An acceptable allegation of compliance (A(NAME)) which removed the immediacy of the jeopardy, was received on 10/13/17 at 10:46 AM, and the corrective actions were validated onsite by the surveyors on 10/13/17 through review of facility documents, auditing tools, in-service training record, medical record review, observation, and staff interview by the surveyors on 10/13/17. Corrective actions validated on 10/13/17 included the following: 1. Medical record review revealed Resident #24's diet was changed to a Controlled Carbohydrate (CCHO) pureed diet on 10/9/17, the care plan had been updated to reflect the diet change, and the Speech Therapy screening had been completed. Observations of Resident #24 confirmed she was receiving a pureed diet. Observations in the kitchen revealed all pineapple and products containing pineapple had been removed from the facility. 2. The facility provided documentation of dietary and nursing staff in-service training regarding therapeutic diets, allowed foods and foods that were not allowed. Interviews with facility staff verified the training had been completed and that staff were knowledgeable regarding the use of therapeutic diets. 3. The facility's diet spreadsheets were revised and included specific food items and amounts to be served for mechanically altered diets. 4. Review of the facility's Nursing Audit Tool revealed the diets were reviewed by the DON, ADON and the Staffing Coordinator for every mechanically altered diet starting with the evening meal on 10/10/17 through 10/13/17. The facility completed audits comparing the foods served to the diet orders, diet spreadsheets, and meal tickets. The audits were conducted both in the kitchen as a first step, and then by a second administrative staff member in the dining room and on the units by checking the meal trays, meal tickets, and verifying the physician's orders [REDACTED]. The facility was cited an Immediate Jeopardy at F309-K. The noncompliance continues at F309-E for monitoring of the corrective actions to ensure sustained compliance. The facility is required to submit a plan of correction.

Based on policy review, job description review, review of the facility's APPROVED DIET MANUAL .Menu Guide, review of the facility's Diet Spreadsheet, medical record review, and interview, 1 of 1 (Regional) Registered Dietitian (RD) failed to provide oversight to ensure dietary staff prepared and served therapeutic diets as ordered by the physician and failed to provide education to dietary managers. The Regional RD's failure to provide oversight and education to dietary managers resulted in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirement of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) when the incorrect diet was served to Resident #24. Resident #24 subsequently choked on a food item excluded from the mechanically altered diet and sustained a sternal fracture when life-saving procedures were performed. Serving excluded food items to a resident on a mechanically altered diet had the potential to effect a total of 37 residents receiving a mechanically altered therapeutic diet. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy on 10/11/17 at 3:05 PM in the conference room. The facility was cited an Immediate Jeopardy at F361-K. An extended survey was conducted on 10/12/17 and 10/13/17. An acceptable allegation of compliance (A(NAME)) which removed the immediacy of the jeopardy, was received on 10/13/17 at 10:46 AM, and the corrective actions were validated onsite by the surveyors on 10/13/17. The corrective actions were validated on site through review of facility documents, auditing tools, in-service training record, medical record review, observation, and staff interview by the surveyors on 10/13/17. The Immediate Jeopardy was effective 10/9/17. The immediacy was removed 10/13/17. The noncompliance continues at F361-E for monitoring of effectiveness of the corrective actions to ensure sustained compliance. The findings included: 1. The facility's Nutritional Services policy documented, .A qualified dietitian oversees the clinical nutritional dietary services in the facility .The facility has available .the services of a qualified registered dietitian who is responsible for the development and implementation of a nutrition care process to meet the needs of patients for health maintenance, disease prevention and .medical nutrition therapy to treat an illness, injury or condition . 2. The facility's JOB DESCRIPTION Regional Registered Dietitian documented, .Responsible for providing clinical expertise through assessment of patients utilizing Medical Nutrition therapy, providing education to Dietary Managers relating to new strategies or implementation of new policies and procedures .to provide the best patient outcomes. ESSENTIAL DUTIES AND RESPONSIBILITIES .Assess individual patients regarding appropriate nutritional care in compliance with state and federal regulations and company policies and procedures. Provide clinical expertise in long term care and be a facilitator in the identification and development of quality patient care and delivery. Collaborate with the Director of Nutrition Services to coordinate and implement nutrition guidelines, clinical program initiatives and processes, and monitor outcomes .Be a resource and mentor to Dietary Managers. Provide education, training, and in-service opportunities to Dietary Managers and dietary staff regarding patient care, clinical findings, survey preparedness and areas of concern in each facility dietary department .SUPERVISORY RESPONSIBILITY: Assists in providing training, work direction and/or problem solving for other workers . 3. The facility's APPROVED DIET MANUAL .Menu Guide, documented, .Level 2: Mechanically Altered (diet) is a transition from the pureed diet and requires the ability to chew and tolerate mixed textures. Foods are soft and moist .Considerations for specific food items .Pineapple - restricted from all three levels of the NCM (Nutrition Care Manual) Dysphagia (difficulty swallowing) Diet . 4. The facility's Diet Spreadsheet documented, .Week 4 Day 23 (menu calendar) .L (level) 2/MECH (mechanically) ALT(altered) (foods that are moist, soft-textured and easily formed and easy to swallow) (diet) .SEASONAL FRESH FRUIT (SUMMER .1/2 EACH (1/2 cup or piece of fruit) . 5. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] and the quarterly MDS assessment dated [DATE] revealed Resident #24 had a Brief Interview of Mental Status (BIMS) score of 1 out of 15, indicating she was severely cognitively impaired, was dependent on staff for all activities of daily living (ADLs) including eating. A physician's telephone order dated 8/2/17 documented, .Begin date: 08/02/2017 .CCHO (Controlled Carbohydrate) Diet - Mechanical Ground (L2) . Medical record review revealed Resident #24 was served pineapple (a food restricted from her diet) for lunch on 10/9/17 causing her to choke and require life-saving interventions that resulted in a sternal fracture. 6. Interview with Certified Nursing Assistant (CNA) #1 on 10/10/17 at 2:30 PM in the 300 hall dining room, CNA #1 stated, I was in there (Resident #24's room) assisting her with her meal .she had eaten everything and her fruit was the last thing I was helping her with .It had pineapples in it about an inch in size .I had to cut it in half because she doesn't have any teeth . Interview with the Food Service Supervisor on 10/10/17 at 4:05 PM in the conference room, the Food Service Supervisor was asked what was included in a mechanical L2 diet. The Food Service Supervisor stated, Most of the time, it's going to be meats run through the chopper .sometimes fried vegetables may have to be steamed . The Food Service Supervisor was asked if pineapple was allowed. She stated, Um, it may have to be altered at times, I'm not sure . The Food Service Supervisor was asked how staff know what to serve on the meal trays. She stated, They go by the spreadsheets. The Food Service Supervisor looked at the spreadsheet for the lunch meal that was served on 10/9/17 and stated, They did a canned tropical fruit yesterday, I didn't have seasonal fruit .it was a blend of pineapples, mangoes, and I can't tell you what else was in it . The Food Service Supervisor was asked if the facility used the APPROVED DIET MANUAL .Menu Guide that she provided to this surveyor earlier for the Level 2: Mechanically Altered diet. She stated, (Named the food service company) sends us the manual so I assume that it is. The Food Service Supervisor was asked based on the Level 2: Mechanically Altered diet definition from the diet manual, should Resident #24 have been served the tropical fruit. She stated, No, not with the pineapple . Telephone interview with the Regional Registered Dietician (RD) on 10/10/17 at 4:25 PM, the Regional RD was asked what was included in a mechanical L2 diet. She stated, Typically chopped meats, foods that are easy to chew .gravy on meats, softer foods .we have spreadsheets that specify for the mechanically altered what would be different from the regular diet. The Regional RD was asked what type of fruit was allowed. She stated, .I wouldn't be able to tell you without looking . The surveyor read the definition of the level 2 mechanically altered diet from the facility's diet manual and then asked her if Resident #24 should have been served pineapple. The Regional RD stated, No. Interview with Cook #1 on 10/10/17 at 6:18 PM in the conference room, Cook #1 was asked what foods were included in the Level 2 mechanically altered diet. Cook #1 stated, Anything chopped or cooked food, something we would consider more soft . Cook #1 was asked what type of training she had received for her job. Cook #1 stated, The menu, how to read the different diets .that was the hardest part of my training because you're dealing with a lot of different special people with different needs . Cook #1 was asked what type of fruit was included in the level 2 mechanically ground diet. She stated, Usually I go by whatever is on the menu, usually something more soft, not like a raw fruit .I go by that as much as I can. Cook #1 was asked if she had ever been told that persons on a mechanical diet level 1, 2 or 3 could not have pineapple. Cook #1 stated, No. Interview with the Kitchen Supervisor on 10/10/17 at 6:23 PM in the conference room, the Kitchen Supervisor was asked what foods were included in the Level 2 mechanically altered diet. The Kitchen Supervisor stated, That is a dysphagia (diet) .it is between a pureed and regular chopped, it would probably have soft foods .I would have to look at my menu . The Kitchen Supervisor was asked what type of fruit was included in the level 2 mechanically altered diet. The Kitchen Supervisor stated, Without looking at menu .typically canned fruit .I would have to look at the menus . The Kitchen Supervisor was asked if she had ever been told that persons on a mechanically altered diet level 1, 2 or 3 could not have pineapple. The Kitchen Supervisor I'm going to say no .we refer to our menu .I would go with canned fruit that it's ok to give them canned fruit . Interview with the Regional RD on 10/11/17 at 4:02 PM in the conference room, the Regional RD was asked what services she provided in the facility. The Regional RD stated, I am a Regional RD, I come monthly to assess high risk patients, chart on them .wounds, [MEDICAL TREATMENT], diabetics, weight loss, and anybody else they want me to look at; do a sanitation walk through .I'm available if anything comes up when I'm not here. The Regional RD was asked if she did any in-services with the dietary staff. She stated, I have not done any .if I see something that might need to be addressed, I talk with the dietary manager so she can address it with her staff . The Regional RD was asked who trained the kitchen staff to know what to put on the trays. She stated, The Dietary Manager. The Regional RD was asked if she ever provided oversite of the dietary staff to see if the right diet was served. She stated, Yes, I check it when I'm here . The Regional RD's failure to provide oversight to ensure dietary staff prepared and served the therapeutic diet as ordered by the physician and failure to provide education to dietary managers resulted in Immediate Jeopardy when the incorrect diet with excluded food was served to Resident #24. Resident #24 subsequently choked and sustained a sternal fracture when life-saving procedures were performed. The Immediate Jeopardy was effective 10/9/17 through 10/13/17. An extended survey was completed on 10/12/17 and 10/13/17. An acceptable allegation of compliance (A(NAME)) which removed the immediacy of the jeopardy, was received on 10/13/17 at 10:46 AM, and the corrective actions were validated onsite by the surveyors on 10/13/17 through review of facility documents, auditing tools, in-service training record, medical record review, observation, and staff interview by the surveyors on 10/13/17. Corrective actions validated on 10/13/17 included the following: 1. Medical record review revealed Resident #24's diet was changed to a Controlled Carbohydrate (CCHO) pureed diet on 10/9/17, the care plan had been updated to reflect the diet change, and the Speech Therapy screening had been completed. Observations of Resident #24 confirmed she was receiving a pureed diet. Observations in the kitchen revealed all pineapple and products containing pineapple had been removed from the facility. 2. The facility provided documentation of dietary and nursing staff in-service training regarding therapeutic diets, allowed foods and foods that were not allowed. Interviews with facility staff verified the training had been completed and that staff were knowledgeable regarding the use of therapeutic diets. 3. The facility's diet spreadsheets were revised and included specific food items and amounts to be served for mechanically altered diets. 4. Review of the facility's Nursing Audit Tool revealed the diets were reviewed by the DON, Assistant Director of Nursing (ADON) and the Staffing Coordinator for every mechanically altered diet starting with the evening meal on 10/10/17 through 10/13/17. The facility completed audits comparing the foods served to the diet orders, diet spreadsheets, and meal tickets. The audits were conducted both in the kitchen as a first step, and then by a second administrative staff member in the dining room and on the units by checking the meal trays, meal tickets, and verifying the physician's orders [REDACTED]. The facility was cited an Immediate Jeopardy at F361-K. The noncompliance continues at F361-E for monitoring of the corrective actions to ensure sustained compliance. The facility is required to submit a plan of correction.

Based on job description review, review of the facility's APPROVED DIET MANUAL .Menu Guide, review of the facility's Diet Spreadsheet, hospital records, medical record review, and interview, the facility failed to ensure dietary staff members were sufficiently trained to provide the correct mechanically altered therapeutic diet for 1 of 1 (Resident #24) sampled residents reviewed with the potential to effect all 37 residents prescribed mechanically altered diets. The facility's failure to ensure dietary staff members were properly trained to competently perform their job duties resulted in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirement of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) when food not included on the mechanically altered therapeutic diet was put on a tray and served to Resident #24 who choked and sustained a sternal fracture when life-saving interventions were performed to remove a piece of food lodged in her throat. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy on 10/11/17 at 3:05 PM in the conference room. The facility was cited an Immediate Jeopardy at F362-K. An extended survey was conducted on 10/12/17 and 10/13/17. An acceptable allegation of compliance (A(NAME)) which removed the immediacy of the jeopardy, was received on 10/13/17 at 10:46 AM, and the corrective actions were validated onsite by the surveyors on 10/13/17. The corrective actions were validated on site through review of facility documents, auditing tools, in-service training record, medical record review, observation, and staff interview by the surveyors on 10/13/17. The Immediate Jeopardy was effective 10/9/17. The immediacy was removed 10/13/17. The noncompliance continues at F362-E for monitoring of effectiveness of the corrective actions to ensure sustained compliance. The findings included: 1. The facility's JOB DESCRIPTION FOOD SERVICES SUPERVISOR documented, The purpose of this position is to provide direct nutrition services to patients and to prepare food in accordance with current applicable state and federal regulations .Assist and observe tray line .Monitor meals .Instruct and assist cook as needed .Review menus prior to preparation of food .assist in planning .special diet menus .inspect special diet trays to ensure accuracy . 2. The facility's APPROVED DIET MANUAL .Menu Guide, documented, .Level 2: Mechanically Altered (diet) is a transition from the pureed diet and requires the ability to chew and tolerate mixed textures. Foods are soft and moist .Considerations for specific food item .Pineapple-restricted from all three levels of the NCM (Nutrition Care Manual) Dysphagia Diet . 3. The facility's Diet Spreadsheet documented, .Week 4 Day 23 (menu calendar) .L (level) 2/MECH (mechanically) ALT(altered) (foods that are moist, soft-textured and easily formed and easy to swallow) (diet) .SEASONAL FRESH FRUIT (SUMMER .1/2 EACH (1/2 cup or piece of fruit) . 4. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A clinical note dated 8/2/17 documented, .CN (Charge nurse) SUMMONED TO PT (patient) ROOM BY CNA (Certified Nursing Assistant) DURING LUNCH. CNA STATED PT HAD GOTTEN CHOKED ON A PIECE OF COUNTRY FRIED STEAK. CNA STATED PT STARTED COUGHING .BUT PT WAS ABLE TO COUGH UP MEAT. PT WAS ASSESSED BY THIS CN .NO S/S (signs and symptoms) OF DISTRESS NOTED AT PRESENT, DIETARY CONSULTED, NEW ORDER TO CHANGE DIET TO MECHANICAL GROUND . A physician's telephone order dated 8/2/17 documented, . Begin date: 08/02/2017 .CCHO (Controlled Carbohydrate) Diet- Mechanical Ground (L 2)(diet) . A clinical note dated 10/9/17 documented, CN was called to pt's room during lunch, pt noted to be cyanotic and shallow gasp or wheeze noted. Heimleich ([MEDICATION NAME]) (an action to remove what is blocking the airway) maneuver was performed multiple times without success, pt remained conscious but lethargic. Attempts to suction unsuccessful. EMS (Emergency Medical Service) called .paramedic removed chuck (chunk) of pineapple from airway and pt sent to (named hospital) via (by) EMS . A NURSE'S EVENT NOTE dated 10/9/17 documented, .CN was called to pt's room during lunch by CNA d/t (due to) pt choking. Upon CN arrival pt cyanotic, [MEDICATION NAME] maneuver was performed multiple time without success, abdominal thrust were allowing some oxygenation, however unable to clear airway completely. EMS activated. Immediate response from EMS and were able to remove object (piece of pineapple) .Pt transferred to hospital . 5. The hospital record dated 10/9/17 revealed, .ER (emergency room ) NOTE .Chief Complaint .choking .Closed fracture of body of sternum .Mechanism of Injury: choking incident on pineapple .RADIOLOGICAL CONSULTATION REPORT .CHEST 2 VIEWS .CHOKING EPISODE, S/P (status [REDACTED].sternal fracture . 6. Interview with Certified Nursing Assistant (CNA) #1 on 10/10/17 at 2:30 PM in the 300 hall dining room, CNA #1 was asked about the incident the day before with Resident #24 . CNA #1 stated, .she (Resident #24) had eaten everything .Her fruit was the last thing I was helping her with .She asked me for another drink .She sounded a little strangled and she didn't sound right .she went into full blown choking and started turning colors. (Named Licensed Practical Nurse (LPN) #1) came and started doing [MEDICATION NAME] on her .no results .they all tried with no results .with [MEDICATION NAME] .tried suctioning .no results .911 came and they got it out with forceps. It was a piece of fruit . CNA #1 was asked if Resident #24 was on a special diet. CNA #1 stated, She was on a chopped or mechanical soft because her meat was ground up .it had pineapples in it about an inch in size .she's gotten strangled before but nothing like this . Interview with the Food Service Supervisor on 10/10/17 at 4:05 PM in the conference room, the Food Service Supervisor was asked what fruit was on a mechanical L2 diet. The Food Service Supervisor stated, Pretty much anything .may have soft fruit instead of hard fruit .it may have to be altered at times, I'm not sure . The Food Service Supervisor was asked how the dietary staff know what to put on the food trays. The Food Service Supervisor stated, They go by the spreadsheets .they did a canned tropical fruit yesterday. I didn't have seasonal fruit . The Food Service Supervisor was asked what was in the tropical fruit. The Food Service Supervisor stated, It was a blend of pineapple, mangoes, and I can't tell you what else was in it . The Food Service Supervisor was asked if the facility used the Level 2 Mechanically Altered diet definition she provided to the surveyor. The Food Service Supervisor stated, (Named food service company) sends us the manual so I assume that is it. The Food Service Supervisor was asked, based on the Level 2 Mechanically Altered diet definition, should Resident #24 have been given the tropical fruit. The Food Service Supervisor stated, No, not with the pineapple . The Food Service Supervisor was asked if the dietary staff were aware that the pineapple was not allowed in the Level 2 mechanical diet. The Food Service Supervisor stated, I can't say .when we in-service we give out handouts, but they don't have that specific sheet (the Level 2 Mechanically Altered diet definition) in front of them when they are fixing the trays . Telephone interview with the Regional Registered Dietician (RD) on 10/10/17 at 4:25 PM, the Regional RD was asked if Resident #24 should have been served pineapple on the mechanically altered L2 diet. The Regional RD stated, No. Interview with Cook #1 on 10/10/17 at 6:18 PM in the conference room, Cook #1 was asked what training she had received. Cook #1 stated, The menu, how to read the different diets .that was the hardest part of my training because you're dealing with a lot of different special people with different needs . Cook #1 was asked what kind of fruit can they have. Cook #1 stated, Usually I go by whatever is on the menu. Usually something more soft, not like a raw fruit .I go by that as much as I can. Cook #1 was asked if she had ever been instructed that persons on a mechanical diet either Level 1, 2, or 3 could not have pineapple. Cook #1 stated, No. Interview with the Kitchen Supervisor on 10/10/17 at 6:23 PM in the conference room, the Kitchen Supervisor was asked what was a Level 2 mechanical diet. The Kitchen Supervisor stated, .it is between a pureed and regular chopped, it would probably have soft foods .I would have to look at my menus . The Kitchen Supervisor was asked what training she had received. The Kitchen Supervisor stated, We do monthly in-services and basically it is on the job training . The Kitchen Supervisor was asked what kind of fruit was allowed on the L2 mechanical diet. The Kitchen Supervisor stated, .we refer to our menus .I would go with canned fruit . The facility's failure to ensure dietary staff members were properly trained to competently perform their job duties resulted in Immediate Jeopardy when food not included on the mechanically altered therapeutic diet was put on a tray and served to Resident #24 who choked and sustained a sternal fracture when life-saving interventions were performed to remove a piece of food lodged in her throat. The Immediate Jeopardy was effective 10/9/17 through 10/13/17. An extended survey was completed on 10/12/17 and 10/13/17. An acceptable allegation of compliance (A(NAME)) which removed the immediacy of the jeopardy, was received on 10/13/17 at 10:46 AM, and the corrective actions were validated onsite by the surveyors on 10/13/17 through review of facility documents, auditing tools, in-service training record, medical record review, observation, and staff interview by the surveyors on 10/13/17. Corrective actions validated on 10/13/17 included the following: 1. Medical record review revealed Resident #24's diet was changed to a Controlled Carbohydrate (CCHO) pureed diet on 10/9/17, the care plan had been updated to reflect the diet change, and the Speech Therapy screening had been completed. Observations of Resident #24 confirmed she was receiving a pureed diet. Observations in the kitchen revealed all pineapple and products containing pineapple had been removed from the facility. 2. The facility provided documentation of dietary and nursing staff in-service training regarding therapeutic diets, allowed foods and foods that were not allowed. Interviews with facility staff verified the training had been completed and that staff were knowledgeable regarding the use of therapeutic diets. 3. The facility's diet spreadsheets were revised and included specific food items and amounts to be served for mechanically altered diets. 4. Review of the facility's Nursing Audit Tool revealed the diets were reviewed by the DON, Assistant Director of Nursing (ADON) and the Staffing Coordinator for every mechanically altered diet starting with the evening meal on 10/10/17 through 10/13/17. The facility completed audits comparing the foods served to the diet orders, diet spreadsheets, and meal tickets. The audits were conducted both in the kitchen as a first step, and then by a second administrative staff member in the dining room and on the units by checking the meal trays, meal tickets, and verifying the physician's orders [REDACTED]. The facility was cited an Immediate Jeopardy at F362-K. The noncompliance continues at F362-E for monitoring of the corrective actions to ensure sustained compliance. The facility is required to submit a plan of correction.

Based on review of the Administrator's job description, review of the Director of Nursing's (DON) job description, medical record review, observations, and interview, the Administrator failed to administer the facility in a manner that enabled it to use it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of the residents, when they failed to ensure staff implemented care plan interventions for a therapeutic diet; failed to ensure staff followed physician's orders for therapeutic diets; failed to ensure the Regional Registered Dietitian (RD) provided oversight to ensure dietary staff prepared and served therapeutic diet as ordered by the physician; failed to provide education to dietary managers; failed to ensure dietary staff members were sufficiently trained to competently perform their job duties; and failed to investigate to determine the root cause of a choking incident. The facility's failure placed Resident #24 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) when Resident #24 was served pineapple, a food restricted from a mechanically altered diet, causing her to choke and sustain a sternal fracture when life-saving interventions were performed to prevent her death on [DATE]. Serving foods that are restricted from a mechanically altered diet has the potential to effect a total of 37 residents receiving a mechanically altered diet. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 3:05 PM in the conference room. The facility was cited an Immediate Jeopardy at F490-K. An extended survey was conducted on [DATE] and [DATE]. An acceptable allegation of compliance (A(NAME)) which removed the immediacy of the jeopardy, was received on [DATE] at 10:46 AM, and the corrective actions were validated through review of facility documents, auditing tools, in-service training record, medical record review, observation, and staff interview by the surveyors on [DATE]. The Immediate Jeopardy was effective [DATE]. The immediacy was removed [DATE]. The noncompliance continues at F490-E for monitoring of effectiveness of the corrective actions to ensure sustained compliance. The findings included: 1. The Administrator's job description documented, .The purpose of this position is to establish and direct the facility's overall day-to-day operation .and coordinate these operations in accordance with current existing federal, state and local standards .to maximize high standards of care to patients .ESSENTIAL DUTIES AND RESPONSIBILITIES .Select and hire appropriate personnel to supervise activities of all departments .Conduct in-service and supervisory training meetings .Meet with personnel as required and scheduled to assist in identifying and correcting issues, and/or the improvement of services . The DON's job description documented, .The purpose of this position is to manage the nursing department and administer the nursing programs in compliance with state and federal regulations as well as company policy and procedures. ESSENTIAL DUTIES AND RESPONSIBILITIES .Plan, develop, organize, implement, evaluate and direct the Nursing Services Department, as well as related programs and activities .Includes .Licensed staff, Nursing assistants and orderlies, Print-outs of physicians' orders .In-services .Utilization review .Recognize and respond to changes in patients; conditions and document observations, interventions and outcomes .Facilitate the coordination of nursing services and other departments to maintain quality care for patients .Participate in various committees of the facility; such as care plans, infection control, pharmaceutical, budget, quality assessment and assurance .and those assigned by Administrator . 2. Interview with the Administrator on [DATE] at 4:07 PM in the business office, the Administrator was asked about his responsibilities as the Administrator. The Administrator stated, .Oversee the overall operations of the facility . The Administrator was asked what the process was when there was an unusual occurrence in the facility. The Administrator stated, An investigation would be started to see if we could determine the cause of the incident and to identify any process problems. The Administrator was asked if there had been any prior history or report of failing to follow physician's orders. The Administrator stated, No, I'm not even aware of any episode of not following orders . The Administrator was asked when he was notified of the choking incident. The Administrator stated, The day it happened ([DATE]) .I was made aware that a resident had a choking episode at our facility and that she had been transported from our facility. The Administrator was asked at what point he was made aware that the physician's orders had not been followed for her diet. The Administrator stated, To the best of my knowledge, I believe I was made aware the next day ([DATE]) that we had not followed the orders. The Administrator was asked who identified the fact that the orders had not been followed. The Administrator stated, I know we had started investigating it, but I don't think we had identified it until the surveyor came to the Food Service Supervisor, when she was shown where the pineapple wasn't allowed. The Administrator was asked if he felt like the facility had done a thorough investigation of the incident. The Administrator stated, I feel like we had done a good job up until that point to determine the root cause of what had happened. I feel like at some point we would have identified this as the root cause. The Administrator confirmed facility staff had not determined the root cause of the choking incident until surveyors identified Resident #24 had been served the wrong diet. 3. Administration failed to ensure the care plan interventions for mechanically altered therapeutic diets were followed, which resulted in Immediate Jeopardy for Resident #24. Refer to F282. 4. Administration failed to ensure physician's orders were followed for mechanically altered therapeutic diets, which resulted in Immediate Jeopardy to Resident #24. Refer to F309. 5. Administration failed to ensure the Regional Registered Dietitian provided oversight to ensure dietary staff prepared and served therapeutic diets as ordered by the physician, and failed to ensure the Regional Registered Dietitian provided education to dietary managers, which resulted in Immediate Jeopardy for Resident #24. Refer to F361. 6. Administration failed to ensure dietary staff members were properly trained to competently prepare and serve mechanically altered therapeutic diets as ordered by the physician, which resulted in Immediate Jeopardy for Resident #24. Refer to F362. The Immediate Jeopardy was effective [DATE] through [DATE]. An extended survey was completed on [DATE] and [DATE]. An acceptable allegation of compliance (A(NAME)) which removed the immediacy of the jeopardy, was received on [DATE] at 10:46 AM, and the corrective actions were validated onsite by the surveyors on [DATE] through review of facility documents, auditing tools, in-service training record, medical record review, observation, and staff interview by the surveyors on [DATE]. Corrective actions validated on [DATE] included the following: 1. Medical record review revealed Resident #24's diet was changed to a Controlled Carbohydrate (CCHO) pureed diet on [DATE], the care plan had been updated to reflect the diet change, and the Speech Therapy screening had been completed. Observations of Resident #24 confirmed she was receiving a pureed diet. Observations in the kitchen revealed all pineapple and products containing pineapple had been removed from the facility. 2. The facility provided documentation of dietary and nursing staff in-service training regarding therapeutic diets, allowed foods and foods that were not allowed. Interviews with facility staff verified the training had been completed and that staff were knowledgeable regarding the use of therapeutic diets. 3. The facility's diet spreadsheets were revised and included specific food items and amounts to be served for mechanically altered diets. 4. Review of the facility's Nursing Audit Tool revealed the diets were reviewed by the DON, Assistant Director of Nursing (ADON) and the Staffing Coordinator for every mechanically altered diet starting with the evening meal on [DATE] through [DATE]. The facility completed audits comparing the foods served to the diet orders, diet spreadsheets, and meal tickets. The audits were conducted both in the kitchen as a first step, and then by a second administrative staff member in the dining room and on the units by checking the meal trays, meal tickets, and verifying the physician's orders. Surveyors observed facility staff completing those audits both in the kitchen and in the dining room for both the lunch and supper meals on [DATE]. The facility was cited an Immediate Jeopardy at F490-K. The noncompliance continues at F490-E for monitoring of the corrective actions to ensure sustained compliance. The facility is required to submit a plan of correction.

Based on review of the Administrator's job description, review of the Director of Nursing's (DON) job description, medical record review, observation, and interview, the governing body failed to have an effective governing body that established and implemented policies and procedures that recognized concerns with hazards to health and safety, identified the root cause of the problems, and ensured systems and processes were developed and consistently followed by staff to address quality concerns. The governing body failed to have corrective actions consistently monitored to ensure the staff followed physician orders [REDACTED].#24) sampled residents reviewed receiving a mechanically altered therapeutic diet of the 37 residents receiving a mechanically altered diets; failed to ensure the Regional Registered Dietitian (RD) provided staff oversight and training to the dietary manager; and failed to ensure the dietary staff were competent to prepare and serve therapeutic diets. The governing body failed to establish and implement an effective quality assurance program that thoroughly and systematically identified and addressed concerns and noncompliance within the facility resulting in Immediate Jeopardy for Resident #24 with the potential to effect all 37 residents receiving a mechanically altered therapeutic diet. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy on 10/11/17 at 3:05 PM in the conference room. The facility was cited an Immediate Jeopardy at F493-K. An extended survey was conducted on 10/12/17 and 10/13/17. An acceptable allegation of compliance (A(NAME)) which removed the immediacy of the jeopardy, was received on 10/13/17 at 10:46 AM, and the corrective actions were validated onsite by the surveyors on 10/13/17 through review of facility documents, auditing tools, in-service training record, medical record review, observation, and staff interview by the surveyors on 10/13/17. The Immediate Jeopardy was effective 10/9/17. The immediacy was removed 10/13/17. The noncompliance continues at F493-E for monitoring of effectiveness of the corrective actions to ensure sustained compliance. The findings included: 1. The Administrator's job description documented, .The purpose of this position is to establish and direct the facility's overall day-to-day operation, both internal and external, and coordinate these operations in accordance with current existing federal, state and local standards, as well as in accordance with the established policies and procedures of (Named Corporation) .to maximize high standards of care to patients .Select and hire appropriate personnel to supervise activities of all departments .Meet with personnel as required and scheduled to assist in identifying and correcting issues, and/or the improvement of services .Direct various committees of the facility, such as .care plan .quality assessment and assurance .Monitor procedures to ensure compliance with the state and federal guidelines, laws, regulations and facility policies. The DON's job description documented, .The purpose of this position is to manage the nursing department and administer the nursing programs in compliance with state and federal regulations as well as company policy and procedures .Recognize and respond to changes in patients' conditions and document observations, interventions and outcomes .Facilitate the coordination of nursing services and other departments to maintain quality care for patients .Participate in various committees of the facility; such as care plans .quality assessment and assurance .and those assigned by the Administrator. 2. Interview with the Administrator on 10/13/17 at 4:07 PM, in the business office, the Administrator was asked when he was made aware of the incident with Resident #24. The Administrator stated, The day it happened (10/9/17). The Administrator was asked what he was told about the incident. The Administrator stated, I was made aware that we had a resident that had a choking episode at our facility and that she had been transported from our facility. The Administrator was asked at what point he was made aware that the physician's orders [REDACTED]. The Administrator stated, To the best of my knowledge, I believe I was made aware the next day (10/10/17) that we had not followed the orders. The Administrator was asked who informed him. The Administrator stated, I'm going to say the Food Service Supervisor. I was made aware by several individuals in a short amount of time. The Administrator was asked who identified the fact that the orders had not been followed. The Administrator stated, I know we had started investigating it, but I don't think we had identified it until the surveyor came to the Food Service Supervisor, when she was shown where the pineapple wasn't allowed. The Administrator was asked if he felt like the facility had done a thorough investigation. The Administrator stated, I feel like we had done a good job up until that point to determine the root cause of what had happened. I feel like at some point we would have identified this as the root cause . Continued interview with the Administrator revealed the role of the governing body was .To ensure our compliance with state and federal regulations .they help establish through our corporate structures policies and procedures and overall management practices .I talk to them on an annual basis at an official meeting with the entire governing body, but I also communicate with some of those individuals on that governing body more frequently. The Administrator was asked if the governing body had been notified of the incident involving Resident #24. The Administrator stated, Yes, the night of our QA (Quality Assurance, a process to develop and implement appropriate plans of action to correct identified quality defeciencies) committee meeting on 10/11/17. Continued interview with the Administrator revealed the governing body expected to know what all had been done up to the point of that phone call, were the residents safe, had they fixed the problem and what the facility plans were going forward to address the situation. The Governing Body failed to ensure services were provided to attain or maintain the highest practical physical, mental, and psychosocial well-being by not following the care plan to provide a level 2 mechanically altered therapeutic diet for Resident #24, which resulted in an Immediate Jeopardy. Refer to F-282. The Governing Body failed to ensure procedures were in place to assure residents were provided the appropriate therapeutic diets. Refer to F-309. The Governing Body failed to ensure the Regional Dietitian provided oversight of the dietary staff and education to the dietary managers to ensure therapeutic diets were properly prepared and served. Refer to F-361. The Governing Body failed to ensure the facility had dietary staff that were properly trained and competent to prepare and serve therapeutic diets. Refer to F-362. The Governing Body failed to ensure Administration was responsible for the identification, development, and implementation of appropriate plans of action and ensure the effective and efficient use of its resources to maintain the highest practicable well-being of all residents with mechanically altered therapeutic diets. Refer to F-490. The Governing Body failed to ensure an effective Quality Assessment and Assurance (QA&A) Committee identified, evaluated, and addressed ongoing concerns regarding resident care policies and procedures for all resident receiving mechanically altered therapeutic diets Refer to F-520. The Immediate Jeopardy was effective 10/9/17 through 10/13/17. An extended survey was completed on 10/12/17 and 10/13/17. An acceptable allegation of compliance (A(NAME)) which removed the immediacy of the jeopardy, was received on 10/13/17 at 10:46 AM, and the corrective actions were validated onsite by the surveyors on 10/13/17 through review of facility documents, auditing tools, in-service training record, medical record review, observation, and staff interview by the surveyors on 10/13/17. Corrective actions validated on 10/13/17 included the following: 1. Medical record review revealed Resident #24's diet was changed to a Controlled Carbohydrate (CCHO) pureed diet on 10/9/17, the care plan had been updated to reflect the diet change, and the Speech Therapy screening had been completed. Observations of Resident #24 confirmed she was receiving a pureed diet. Observations in the kitchen revealed all pineapple and products containing pineapple had been removed from the facility. 2. The facility provided documentation of dietary and nursing staff in-service training regarding therapeutic diets, allowed foods and foods that were not allowed. Interviews with facility staff verified the training had been completed and that staff were knowledgeable regarding the use of therapeutic diets. 3. The facility's diet spreadsheets were revised and included specific food items and amounts to be served for mechanically altered diets. 4. Review of the facility's Nursing Audit Tool revealed the diets were reviewed by the DON, Assistant Director of Nursing (ADON) and the Staffing Coordinator for every mechanically altered diet starting with the evening meal on 10/10/17 through 10/13/17. The facility completed audits comparing the foods served to the diet orders, diet spreadsheets, and meal tickets. The audits were conducted both in the kitchen as a first step, and then by a second administrative staff member in the dining room and on the units by checking the meal trays, meal tickets, and verifying the physician's orders [REDACTED]. The facility was cited an Immediate Jeopardy at F493-K. The noncompliance continues at F493-E for monitoring of the corrective actions to ensure sustained compliance. The facility is required to submit a plan of correction.

Based on review of the Administrator's job description, review of the Director of Nursing's (DON) job description, medical record review, observation, and interview, the facility's Quality Assessment & Assurance (QA&A) committee failed to recognize and develop an effective QA&A program that recognized and developed an appropriate plan to ensure the staff followed care plans interventions and physician orders [REDACTED]. The facility's QA&A committee failed to ensure the Regional Dietitian provided oversight and education to the dietary staff and to the dietary managers to ensure therapeutic diets were properly prepared and served. The facility's QA&A committee failed to ensure the facility had dietary staff that were properly trained and competent to prepare and serve therapeutic diets. The facility's QA&A committee failed to ensure Administration was effective for the identification, development, and implementation of appropriate plans of action and ensure the effective and efficient use of its resources to maintain the highest practicable well-being of all residents with mechanically altered therapeutic diets. The facility failed to ensure the QAA committee established and implemented an effective quality assurance program that thoroughly and systematically identified and addressed concerns and noncompliance within the facility resulting in Immediate Jeopardy for Resident #24 with the potential to effect all 37 residents receiving a mechanically altered therapeutic diet. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the DON were informed of the Immediate Jeopardy on 10/11/17 at 3:05 PM in the conference room. The facility was cited an Immediate Jeopardy at F520-K. An extended survey was conducted on 10/12/17 and 10/13/17. An acceptable allegation of compliance (A(NAME)) which removed the immediacy of the jeopardy, was received on 10/13/17 at 10:46 AM, and the corrective actions were validated onsite by the surveyors on 10/13/17 through review of facility documents, auditing tools, in-service training record, medical record review, observation, and staff interview by the surveyors on 10/13/17. The Immediate Jeopardy was effective 10/9/17. The immediacy was removed 10/13/17. The noncompliance continues at F520-E for monitoring of effectiveness of the corrective actions to ensure sustained compliance. The findings included: 1. Review of the Administrator's job description documented, .The purpose of this position is to establish and direct the facility's overall day-to-day operation, both internal and external, and coordinate these operations in accordance with current existing federal, state and local standards, as well as in accordance with the established policies and procedures of (Named Corporation) .to maximize high standards of care to patients .Select and hire appropriate personnel to supervise activities of all departments .Meet with personnel as required and scheduled to assist in identifying and correcting issues, and/or the improvement of services .Direct various committees of the facility, such as .care plan .quality assessment and assurance .Monitor procedures to ensure compliance with the state and federal guidelines, laws, regulations and facility policies. Review of the DON job description documented, .The purpose of this position is to manage the nursing department and administer the nursing programs in compliance with state and federal regulations as well as company policy and procedures .Recognize and respond to changes in patients' conditions and document observations, interventions and outcomes .Facilitate the coordination of nursing services and other departments to maintain quality care for patients .Participate in various committees of the facility; such as care plans .quality assessment and assurance .and those assigned by the Administrator. 2. Interview with the Administrator on 10/13/17 at 4:07 PM, in the business office, the Administrator was asked when he was made aware of the incident with Resident #24. The Administrator stated, The day it happened. The Administrator was asked what he was told about the incident. The Administrator stated, I was made aware that we had a resident that had a choking episode at our facility and that she had been transported from our facility. The Administrator was asked at what point he was made aware that the physician's orders [REDACTED]. The Administrator stated, To the best of my knowledge, I believe I was made aware the next day that we had not followed the orders. The Administrator was asked who informed him. The Administrator stated, I'm going to say the Food Service Supervisor. I was made aware by several individuals in a short amount of time. The Administrator was asked who identified the fact that the orders had not been followed. The Administrator stated, I know we had started investigating it, but I don't think we had identified it (Resident was served food that was restricted from her diet) until the surveyor came to the Food Service Supervisor, when she was shown where the pineapple wasn't allowed. The Administrator was asked if he felt like the facility had done a thorough investigation. The Administrator stated, I feel like we had done a good job up until that point to determine the root cause of what had happened. I feel like at some point we would have identified this as the root cause .then our QA committee members met in person and utilizing phone to include those member not present, to make everyone aware of the episode that had occurred, what immediate measure that were put into place and what steps we were going to take moving forward to ensure this type of incident did not happen again . The facility's QA&A committee failed to ensure services were provided to attain or maintain the highest practical physical, mental, and psychosocial well-being by not following the care plan to provide the correct therapeutic diet for Resident #24, which resulted in an Immediate Jeopardy. Refer to F-282. The facility's QA&A committee failed to ensure policies and procedures were in place to assure residents were provided the appropriate therapeutic diets. Refer to F-309. The facility's QA&A committee failed to ensure the Regional Dietitian provided oversight of the dietary staff and education to the dietary managers to ensure therapeutic diets were properly prepared and served. Refer to F-361. The facility's QA&A committee failed to ensure the facility had dietary staff that were properly trained and competent to prepare and serve therapeutic diets. Refer to F-362. The facility's QA&A committee failed to ensure Administration was effective for the identification, development, and implementation of appropriate plans of action and ensure the effective and efficient use of its resources to maintain the highest practicable well-being of all residents with mechanically altered therapeutic diets. Refer to F-490. The Immediate Jeopardy was effective 10/9/17 through 10/13/17. An extended survey was completed on 10/12/17 and 10/13/17. An acceptable allegation of compliance (A(NAME)) which removed the immediacy of the jeopardy, was received on 10/13/17 at 10:46 AM, and the corrective actions were validated onsite by the surveyors on 10/13/17 through review of facility documents, auditing tools, in-service training record, medical record review, observation, and staff interview by the surveyors on 10/13/17. Corrective actions validated on 10/13/17 included the following: 1. Medical record review revealed Resident #24's diet was changed to a Controlled Carbohydrate (CCHO) pureed diet on 10/9/17, the care plan had been updated to reflect the diet change, and the Speech Therapy screening had been completed. Observations of Resident #24 confirmed she was receiving a pureed diet. Observations in the kitchen revealed all pineapple and products containing pineapple had been removed from the facility. 2. The facility provided documentation of dietary and nursing staff in-service training regarding therapeutic diets, allowed foods and foods that were not allowed. Interviews with facility staff verified the training had been completed and that staff were knowledgeable regarding the use of therapeutic diets. 3. The facility's diet spreadsheets were revised and included specific food items and amounts to be served for mechanically altered diets. 4. Review of the facility's Nursing Audit Tool revealed the diets were reviewed by the DON, Assistant Director of Nursing (ADON) and the Staffing Coordinator for every mechanically altered diet starting with the evening meal on 10/10/17 through 10/13/17. The facility completed audits comparing the foods served to the diet orders, diet spreadsheets, and meal tickets. The audits were conducted both in the kitchen as a first step, and then by a second administrative staff member in the dining room and on the units by checking the meal trays, meal tickets, and verifying the physician's orders [REDACTED]. The facility was cited an Immediate Jeopardy at F520-K. The noncompliance continues at F520-E for monitoring of the corrective actions to ensure sustained compliance. The facility is required to submit a plan of correction.

Based on review of the Geriatric Medication Handbook Tenth Edition, observation, and interview, the facility failed to ensure measures to prevent the spread of infections were followed by 2 of 5 (Licensed Practical Nurse (LPN) #3 and #4) nurses observed during medication administration. The findings included: 1. The Geriatric Medication Handbook Tenth Edition documented ENTERAL TUBE MEDICATION ADMINISTRATION .Once all medications have been administered .Rinse and disinfect syringe . 2. Observations in Resident #131's room on 10/10/17 at 2:09 PM, revealed LPN #3 administered medications by Percutaneous Endoscopic Gastrostomy (PEG, a feeding tube placed through the wall of the stomach) tube. After the medications were administered, LPN #3 placed the used syringe into the plastic container without rinsing or disinfecting the syringe. Observations in Resident #104's room on 10/10/17 at 3:35 PM, revealed LPN #4 gave medications by PEG tube. After the medications were administered, LPN #4 placed the used syringe into the plastic container without rinsing or disinfecting the syringe. 3. Interview with LPN #4 on 10/11/17 at 11:41 AM, at the medication cart on the 100 hall, LPN #4 was asked what should be done with the syringe after administering medications by PEG tube. LPN #4 stated, Rinse it out and dry it and place it back into the bag . Interview with the Director of Nursing (DON) on 10/12/17 at 1:20 PM in the 300 hall lobby, the DON was asked what nurses should do with the syringe after medications are administered by PEG tube. The DON stated, Rinse, dry and place it back in the bag that it comes in or dispose of that syringe and get a new one .

Based on observation and interview, the facility failed to ensure food was stored, prepared and distributed under sanitary conditions as evidenced by food with no open date, food open to air, and a mixer with dry food around the top affecting 93 meals served of 97 census. The findings included: Observations during initial kitchen tour on 7/24/16 beginning at 9:20 AM revealed the following: a. 1- box frozen beef patties with no open date and open to air. b. 1- box frozen funnel fries with no open date. c. 1- box frozen dinner rolls with no open date and open to air. d. 1 large plastic drawer full of loose corn flakes with no open date and open to air. e. 1 large baggie of 8 hamburger buns with no open date. f. One half (1/2) a bag of 9 slices of wheat bread with no open date. g. One fourth (1/4) a bag of 5 slices of white bread with no open date and open to air. h. The mixer had dried food around the top. Interview with the Dietary Manager (DM) on 7/26/16 at 5:45 PM, in the DM's office, the DM was asked if it was acceptable to store food with no open date and left open to air. The DM stated, No . The DM was asked if it was acceptable for kitchen equipment to have dried food on it, the DM stated, No .

Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 3 of 23 (Certified Nursing Assistant (CNA) #1, 2, and 3) staff did not perform proper hand hygiene during dining. The findings included: The facility's EMPLOYEE EDUCATION AND TRAINING .HANDWASHING . policy documented, .Wash all surfaces of hands and wrist with liquid soap .Rinse hands .Dry hands on clean paper towel .Turn off faucet with a SECOND clean dry paper towel . Observations in Resident #83's room on 7/24/16 beginning at 12:00 PM, revealed CNA #1 served a tray, picked up trash off the floor, washed her hands in the bathroom, and did not turn the water off with a paper towel. CNA #1 then entered Resident #73's room and served a tray. CNA #1 washed her hands in the bathroom and did not turn the water off with a paper towel. CNA #1 then served a tray to Resident #7. CNA #1 washed her hands in the bathroom and did not turn the water off with a paper towel. CNA #1 then entered Resident #91's room, touched Resident #91's clothes and served a tray. CNA #1 then washed her hands in the bathroom and did not turn the water off with a paper towel. Observations in the dining room on 7/25/16 at 5:04 PM, revealed CNA #2 served a tray, washed her hands at the sink, and did not turn the water off with a paper towel. Observations in the dining room on 7/25/16, at 5:06 PM, revealed CNA #3 served a tray, washed her hands at the sink, and did not turn the water off with a paper towel. Interview with the Director of Nursing (DON) on 7/26/16 at 5:07 PM in the conference room, the DON was asked how staff should perform hand hygiene. The DON stated, .wash hands with soap .rinse with water .dry hands with a clean paper towel .use another paper towel to turn the water off . The DON was asked if staff should turn the water off with their bare hands. The DON stated, No.

Based on observation and interview, it was determined the facility failed to ensure practices to prevent the potential spread of infection or cross contamination were maintained when 1 of 5 (Nurse #3) nurses failed to wash hands or use a different tissue between instilling eye drops or clean the stethoscope prior to checking placement of a Percutaneous Endoscopy Gastrostomy (PEG) tube. The findings included: Observations during medication administration in Resident #103's room on 2/11/14 at 11:20 AM, Nurse #3 washed her hands, put on gloves and instilled eye drops into a resident's left eye and then proceeded to instill eye drops into the resident's right eye. Nurse #3 did not wash her hands, change gloves or use a clean tissue between instillation of the eye drops from the left eye to the right eye. Observations during medication administration in Resident # 145's room on 2/11/14 at 11:35 AM, Nurse #3 washed her hands, put on gloves, removed the stethoscope from around her neck and then checked placement of the PEG tube. Nurse #3 did not sanitize the stethoscope prior to checking PEG tube placement. During an interview in the Director of Nursing's (DON) office on 1/12/14 at 9:00 AM, the DON was asked what is the procedure for administering eye drops. The DON stated, "...We would wash our hands and glove, take a tissue to the lower lid, administer drop, re-wash hands and don new gloves, obtain a new tissue and administer new drop..." The DON was asked what would she expect her staff to do with a stethoscope that has been hanging around the nurse's neck before checking PEG tube placement. The DON stated, "Stethoscope should be cleaned prior to auscultation and aspiration... we use sanitizing wipes as well as bleach wipes..."

Based on policy review, medical record review, observation and interview, it was determined the facility failed to update the care plan for 1 of 21 (Resident #145) sampled residents included in the stage 2 review. The findings included: Review of the facility "Care Plans" policy documented, "...Care planning is an essential part of healthcare providing a "road map" of sorts, to guide all who are involved with the patient's care... The care plan process must begin upon admission into the facility and be fluid and changeable representing the patient's status until the patient is discharged from the facility or is deceased ..." Medical record review for Resident #145 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. A physician order [REDACTED]. Observations in Resident #145's room on [DATE] at 10:40 AM, revealed Resident #145 receiving [MEDICATION NAME] 1.5 at 60 cc/hr. Observations in the 200 hall on [DATE] at 3:45 PM, revealed Resident #145 being pushed down the hall with the feeding pump with [MEDICATION NAME] 1.5 infusing at 60 cc/hr. During an interview in the conference room on [DATE] at 10:42 AM, the Minimum Data Set (MDS) nurse was asked where the feeding information was on the care plan. The MDS nurse stated, "...I didn't see it on there..."

Based on policy review, medical record review and interview, it was determined the facility failed to revise the comprehensive care plan to reflect the resident's current status for a diet change and a Hoyer lift for 1 of 19 (Resident #4) sampled residents. The facility failed to ensure residents were invited to participate in care planning for 8 of 8 alert residents attending the group interview. The findings included: 1. Review of the facility's "COMPREHENSIVE CARE PLAN" policy documented, "The care plan... Must be reviewed every 90 days and as needed... When there is a change in patient status... All progress notes pertaining to problems identified on the comprehensive care plan should be consistent and reflect the patient's current status... QUARTERLY REVIEWS... New problems should be added with date of review reflected on the care plan..." Medical record review for Resident #4 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of the care plan dated 12/29/11 to present documented, "...Risk for choking and needs mechanically altered diet... INTERVENTIONS... Diet as ordered with monitoring for texture tolerance... Needs to be lifted due to: weakness, will not bear weight, fear of falling... Use: hoyer lift..." During an interview at the 100 hall nurses' station on 3/7/12 at 8:30 AM, Certified Nursing Assistant (CNA) #1 was asked if they still use a Hoyer lift to get Resident #4 out of bed. CNA #1 stated, "No..." CNA #1 was asked how long it had been since they used the Hoyer lift. CNA #1 stated, "About a month..." During an interview in the Minimum Data Set (MDS) office on 3/7/12 at 9:00 AM, Nurse #1 was asked if the care plan had been revised or updated to reflect the change in the physician's orders [REDACTED].#1 was asked if she knew the staff were no longer using the Hoyer lift. Nurse #1 stated, "...I know... I just haven't changed the care plan..." 2. Review of the facility's "COMPREHENSIVE CARE PLAN" policy documented, "...An interdisciplinary team, in conjunction with the patient, patient's family, surrogate, or assessment... representative, as appropriate, should develop the care plan for the highest level of functioning the patient may be expected to attain, based on the comprehensive assessment..." During the group interview in the 200 hall dining room on 3/5/10 at 1:00 PM, 8 of 8 alert and oriented residents attending the group interview stated they had not been invited to participate in meetings to plan their care and treatment. During an interview in the Minimum Data Set office on 3/7/11 at 10:00 AM, the Minimum Data Set Coordinator stated, "Honestly we don't invite them (residents) ...we do invite families..."