Every finding on record at Faith Lutheran Home

Based on interview and record review, the facility failed to submit reportable incidents to the State Survey Agency, within 24 hours of the incident, for 7 (#s 13, 14, 15, 22, 25, 29, and 38) of 17 sampled residents. Findings include: 1. Review of a Facility-Reported Incident, dated 3/2/26, showed there was an incident involving resident #25 making derogatory statements towards resident #13. The report showed when resident #25 was asked to stop, he became angry, and threw two empty, and one partially full cup of juice, at the staff members present during the incident. The incident was submitted to the State Survey Agency via the online reporting portal on 3/5/26, three days after the incident occurred. During an interview on 5/20/26 at 2:15 p.m., staff member C stated they were the only staff member who knew how to submit a reportable incident via the online reporting portal, so if an incident occurred on a weekend, it had the potential to be reported late. Staff member C stated she did not know why the incident involving resident #13 and #25 was not submitted timely, within 24 hours, to the State Survey Agency. 2. Review of a Facility-Reported Incident, dated Saturday, 2/28/26, at 1:30 p.m., showed there was a verbal altercation between resident #29 and resident #25. The incident was submitted to the State Survey Agency on 3/5/26, five days after the incident occurred. During an interview on 5/20/26 at 2:15 p.m., staff member C stated she was the only person who had access to the online reporting portal. Staff member C stated if an incident occurred on a weekend or holiday, a report was not completed until she was back in the facility. 3. Review of a Facility-Reported Incident, dated 1/24/26 at 9:45 a.m., showed resident #22 became verbally aggressive with resident #15. Resident #22 threatened to hit resident #15 with a crossword book he had in his hand. The facility reported the incident to the State Survey Agency on 1/26/26, two days after the incident occurred. Review of a Facility-Reported Incident, dated 12/21/25 at 2:30 p.m., showed resident #14 became verbally aggressive to resident #38 in the activities room. The facility reported the incident to the State Survey Agency on 12/30/25, nine days after the incident occurred. During an interview on 5/19/26 at 3:24 p.m., staff member C stated the incidents, which occurred between resident #s 14 and 38 on 12/21/25, and resident #s 15 and 22 on 1/24/26, were not reported to the State Survey Agency within 24 hours because she was out of the facility, and reported the incidents as soon as she returned. Review of the facility's policy titled, Abuse Policies, dated November 2016, showed: . 4. (1)All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services).

Based on interview and record review, the facility failed to provide 12 hours of in-service training per year, including dementia management, for Certified Nursing Assistants. This deficient practice had the potential to affect all residents with dementia or altered cognition in the facility. Findings include:During an interview on [DATE] at 9:30 a.m., staff member G stated she routinely worked in the memory care unit and received general orientation when she started working at the facility. Staff member G stated she had not received any additional training related to the care of residents in the memory care unit or any dementia training in general. Staff member G stated she had not received any training on how to deal with residents who have displayed problematic behaviors. During an interview on [DATE] at 7:47 a.m., staff member H stated she had experience working with residents with dementia. Staff member H stated she had not received any additional dementia training since starting at the facility. During an interview on [DATE] at 7:52 a.m., staff member I stated she had been employed by the facility since the beginning of 2025. Staff member I stated she had not received any education or training related to dementia care or how to deal with resident behaviors. Staff member I stated she worked in the memory care unit at least once every two weeks. During an interview on [DATE] at 8:00 a.m., staff member C stated she thought it was the responsibility of each individual CNA to ensure they had at least 12 hours of in-service training annually. Staff member C stated all staff were required to complete annual training and dementia care had not been part of the annual online training. Staff member C stated dementia care training had been added recently and would be required of all CNAs within the next month. Review of the facility's annual online training topic list, received on [DATE], failed to show any topics related to the care of residents with dementia or how to deal with resident behaviors. Review of all in-person training provided for CNAs in the past 12 months showed the following: - [DATE], air mattress training,- [DATE], ambulating resident with a gait belt,- [DATE], CPR,- [DATE], C. difficile education, - [DATE], MDS Section GG Functional Abilities, and- [DATE], enhanced barrier precautions

Based on interview and record review, the facility failed to ensure the resident, and/or the resident's representative, were made aware of the risks and benefits associated with the use of psychotropic medications prior to the start of treatment for 2 (#s 2 and 3) of 17 sampled residents. Findings include:1. Review of resident #2's physician orders showed the following psychotropic medication was being given to the resident:- 12/30/25 to 4/30/26: alprazolam 0.25 mg tablet twice daily, as needed, for anxiety.Review of resident #2's EHR, accessed between 5/18/26 and 5/21/26, failed to show documentation the resident, or their representative, were made aware of the risks and benefits of using the above listed psychotropic medication.2. Review of resident #3's physician orders showed the following psychotropic medications were being given to the resident:- 12/30/25 to 1/2/26: lorazepam 0.5 mg tablet three times daily, as needed, for anxiety.- 1/3/26 to 5/21/26: lorazepam 0.5 mg tablet send one tablet with resident to dialysis for possible anxiety while there.- 5/6/26 to 5/21/26: lorazepam 0.5 mg once daily, as needed, after dialysis due to possible anxiety.Review of resident #3's EHR, accessed between 5/18/26 and 5/21/26, failed to show documentation the resident, or their representative, were made aware of the risks and benefits of using the above listed psychotropic medications.During an interview on 5/20/26 at 3:00 p.m., staff member E stated the facility did not require signed risks and benefits consent documentation for residents taking 'as needed' psychotropic medications.A request was made on 5/20/26 for resident #2 and #3's risks and benefits consent documentation for psychotropic medication use. No documentation was received from the facility by the end of the survey.

Based on interview and record review, the facility failed to ensure an as needed psychotropic medication was limited to 14 days, unless the rationale for continuing the medication was documented by a medical provider, for 1 (#2) of 17 sampled residents. Findings include:Review of resident #2's medication administration record, dated 1/1/26 through 4/30/26, showed an order for alprazolam 0.25 mg, take two tablets, twice daily, as needed for anxiety.Review of resident #2's medication administration record, dated 5/1/26 through 5/19/26, showed an order for alprazolam 0.5 mg one tablet daily, as needed for anxiety.Both of resident #2's psychotropic medication orders for alprazolam did not include an end or stop date, and were not limited to 14 days.During an interview on 5/26/26 at 3:30 p.m., staff member F stated as needed psychotropic medication orders were limited to 14 days. Staff member F stated the alprazolam could have been missed during the medication regimen review for resident #2.

Based on interview and record review, the facility failed to accurately complete a Quarterly Minimum Data Set (MDS) assessment for a resident receiving hypoglycemic medication for 1 (#7); and failed to accurately complete a Comprehensive MDS assessment for 1 (#5) of 17 sampled residents. Findings include: 1. Review of resident #7's electronic medical record showed the resident was diagnosed with Diabetes Mellitus and was currently prescribed Trulicity (a glucagon-like peptide-1 receptor agonist) to be given once a week subcutaneously. Review of resident #7's Quarterly MDS assessment, with an ARD of 3/14/26, showed, Section N: Mediations, Insulin, Insulin injections Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days (N0350A). The answer marked by the facility was 1. During an interview on 5/21/26 at 8:49 a.m., staff member D stated she was new to the MDS role. Staff member D stated resident #7 was prescribed Trulicity and received an injection once a week. Staff member D stated the medication was listed as an insulin, and she assumed it would be accurate, under section N of the MDS, Insulin injections, to enter 1, signifying the resident was on insulin. Staff member D stated she misunderstood the resident assessment instrument, and it was her error. 2. During an interview on 5/21/26 at 8:50 a.m., staff member D stated when a resident had a Wander Guard alarm, she coded it under Section P: Restraints and Alarms, Restraints used in bed: other (P0100D), used daily, Restraints used in chair/out of bed: other (P0100H) used daily, and Alarms, Wander/Elopement Alarm (P0200), used daily. Staff member D stated she believed if the alarm was hindering a resident's independence, it was also a restraint. Review of resident #5's Comprehensive MDS assessment, with an ARD of 4/24/26, showed Section P: Restraints and Alarms, Restraints used in bed: other (P0100D), used daily, Restraints used in chair/out of bed: other (P0100H) used daily, and Alarms, Wander/Elopement Alarm (P0200), used daily. The Wander Guard alarm for resident #5 did not meet the criteria required to be a restraint as it could be easily removed and did not restrict normal access to the resident's body. A Wander Guard is also not considered a position change alarm that would cause the potential inhibition of movement.

Based on interview and record review, the facility failed to ensure the pharmacist identified and reported an as needed psychotropic medication being used in excessive duration for 1 (#2) of 17 sampled residents. Findings include:Review of resident #2's Medication Administration Record, dated 1/1/26 to 5/21/26, showed alprazolam 0.25 mg twice a day, as needed for anxiety. This was an active prescription written on 12/31/25.Review of resident #2's Medication Regimen Reviews, dated 1/1/26 to 4/30/26, showed the following recommendations by the pharmacist:- January 2026 - Do not crush omeprazole, levothyroxine take on an empty stomach, rinse mouth after taking Symbicort.- February 2026 - Do not crush omeprazole, levothyroxine take on an empty stomach, rinse mouth after taking Symbicort, do not crush duloxetine.- March 2026 - Do not crush omeprazole, levothyroxine take on an empty stomach, rinse mouth after taking Symbicort, do not crush duloxetine.- April 2026 - no issues.The Medication Regimen Reviews showed a lack of monitoring for resident #2's as needed psychotropic medication, alprazolam.During an interview on 5/26/26 at 3:30 p.m., staff member F stated he reviewed all residents taking psychotropic medication monthly. Staff member F stated he was not sure why resident #2's prescribed alprazolam was not on the medication regimen review, and a gradual dose reduction was not recommended. Staff member F stated he could have missed the medication when completing the medication reviews.

Based on interview and record review, the facility failed to maintain documentation of the COVID-19 vaccination status (received or refused) for staff member E. Findings include:During an interview on 5/20/26 at 8:59 a.m., staff member C stated she was not aware the facility needed to offer employees education on where a COVID-19 booster vaccination could be obtained and the facility's responsibility to document in the employee's record they had been educated and given a referral on where to obtain the booster vaccination. During an interview on 5/20/26 at 2:30 p.m., staff member E stated she had received two COVID-19 vaccinations in 2021, but no additional vaccinations since. Staff member E stated she did not sign a declination form for additional booster vaccinations.Review of staff member E's COVID-19 vaccination documentation, dated 7/8/21, showed staff member E received COVID-19 vaccinations on 1/6/21 and 2/3/21.Review of the facility's policy titled, 7.91 SARS-2 Vaccine Program, dated July of 2021, showed: POLICY:Immunization of health care personnel (HCP) is recommended help prevent spreading of the disease to patients, friends, family and staff and to protect me from serious illness if I get infected.PROCEDURE:Education of HCP regarding the benefits of SAR-2 vaccination and the potential health consequences of SARS to them selves and preventing health-care-associated illness. employees are encouraged to participate the vaccination program form the county Health Department. HCP will be requested to sign a declination statement if they elect not to get the vaccine for any reason. [sic]

Based on interview and record review, the facility failed to ensure a resident was discharged in a safe condition after previously accepting admission and responsibility for the resident from out of town for 1 (#1) of 1 resident sampled for inappropriate discharge. This deficient practice was corrected on 6/4/25 and determined to be past non-compliance. Findings include: Review of a facility incident report, dated 6/3/25, showed resident #1 had been refused admission to [Facility Name]. Resident #1 had arrived from several hours away via contracted ambulance, and her local family had met her at the facility. Staff determined the family members were too intoxicated to sign admission paperwork, and the staff present would not accept resident #1. The resident left with family and staff did not contact the administrator or other management. There was no safe discharge plan in place. During an interview on 11/19/25 at 8:50 a.m., staff member A stated they had not been aware of the situation with the resident being denied admission until the very next day. Staff member A contacted the State Survey Agency for guidance. Staff member B immediately contacted the resident to ensure safety and to discuss a potential admission. The resident had been living with family before her hospitalization and had not wanted to be admitted to long-term care. She decided to stay with her family rather than be admitted . She had no immediate medical concerns [i.e. IV antibiotics or rehab orders]. Staff member A stated the employee who refused admission was suspended and later resigned. Staff education was completed, and the facility held an emergency QAPI meeting on 6/4/25, and addressed the incident with a plan of correction. No other residents have since been refused admission.

Based on interview and record review, the facility failed to ensure MDS assessments were completed, encoded, and transmitted, within the required timeframe, for 1 (#196) of 14 sampled residents, and failed to ensure the assigned staff member had the knowledge necessary to correct MDS transmission errors. The failures resulted in inaccurate and missing MDS data, which was identified during the annual recertification survey process. Findings include: 1. During an interview on [DATE] at 8:15 a.m., staff member D said she did not know how to correct or add a re-entry MDS when a resident returned from the hospital. Staff member D said resident #196 did not have a re-entry MDS and was now due for a quarterly assessment. Staff member D said she recently started completing MDS assessments and only had three days of MDS training at the facility. Review of resident #196's nurse progress note, dated [DATE], showed resident #196 was discharged to the hospital on [DATE]. Review of resident #196's nurse progress note, dated [DATE], showed resident #196 was readmitted to the facility on [DATE]. Review of a screen-shot of resident #196's MDS assessment list showed resident #196 was discharged from the facility on [DATE]. The assessment list showed the next MDS entered was for, . Nursing home: tracking (entry/expired). The assessment list did not show resident #196 as having a re-entry MDS completed. 48268 2. During an interview on [DATE] at 1:05 p.m., staff member D stated she was responsible for submitting the facility's MDS reports. Staff member D stated she had been at the facility since [DATE], and had received approximately one week of MDS training from a previous employee. Staff member D stated she was unaware of any MDS submission errors and was also unaware of how to locate error messages or how to correct them. Review of CMS report titled, CASPER Report 0004D Provider Full Profile, dated [DATE], showed no facility reporting for care-level resident characteristics. Review of the facility-specific IQIES quality reporting status report, showed multiple errors, including incorrect Medicare Beneficiary Identifier, duplicate assessments, late assessments, and resident mismatches.

Based on observation, interview, and record review, the facility failed to ensure the dietary manager completed a certification program approved by a national certifying body or had higher education in a related field. This had the potential to affect residents and their nutritional status, or meal safety for those who consumed food prepared and served by the facility. Findings include: During an observation of the kitchen, on [DATE] at 7:50 a.m., no documentation of advanced training for the dietary manager was posted or readily available. During an interview on [DATE] at 8:00 a.m., staff member E said she had come out of retirement a couple months ago when the dietary manager left. Staff member E said she would help the facility until they could advertise and find a new manager. During an interview on [DATE] at 4:01 p.m., staff member A said the interim dietary manager came out of retirement to help the facility. Staff member A said staff member E's certified dietary manager certification expired about three years ago. Staff member A said there was no certified dietary manager on staff. Concerns were identified related to the dietary department services. Refer to F812 - Food Procurement, Store/Prepare/Serve/Sanitary services for further detail.

Based on observations, interviews, and record review, the facility failed to ensure sanitary conditions were maintained throughout the kitchen and the dietary storage areas; failed to ensure kitchen staff labeled and dated food in the coolers; and failed to maintain a clean kitchen environment. The deficient practices increased the risk for the development of foodborne illnesses and unsanitary conditions, for all residents who received food from the kitchen. Findings include: During an observation of the kitchen, during the initial tour on 4/22/25 at 7:25 a.m., the following observations were made: - One pitcher full of fluid was observed in the reach-in cooler. The pitcher was unlabeled and undated. - One gallon of 2% milk, opened, and not dated. - One quart of Half and Half, opened, and not dated. - The inside of the microwave was splattered with food particles. - The meat slicer had white and brown particles of debris on the cutting surface and base. - Large containers of spices were opened, not dated. - Cinnamon and cumin spice containers appeared soiled and were sticky to touch. - Numerous cups of red jellied products were not labeled or dated in the walk-in cooler. - A bowl containing a white fluffy substance was not labeled or dated in the walk-in cooler. - A large metal pan containing a mixture of pasta and sliced meat was not labeled or dated in the walk-in cooler. - A bag of seven chicken breasts were thawed in a metal pan on the top shelf of the walk-in cooler. The chicken breasts were dated 2/25/25. During an observation and interview on 4/22/25 at 7:40 a.m., staff member F was observed with a mustache and beard. Staff member F was in the food preparation area and was not wearing a beard or mustache cover. Staff member F said he never worked with the food slicer, but he thought it got cleaned every time it was used. During an observation and interview on 4/22/25 at 8:00 a.m., staff member E said dented cans are placed on a special shelf and if dented, they are sent back for credit. During an observation, one can of pumpkin, one can of diced pears, and one can of tomato soup, all dented, were observed on the shelves where undented storage cans were stored and taken by staff or use. Staff member E said the facility has a person that comes in and does deep cleaning on Thursday and Friday every week. Staff member E said the cleaning must be behind schedule due to the Easter holiday. During an observation and interview on 4/22/25 at 12:30 p.m., staff member G was observed with a beard and mustache. Staff member G was in the food preparation area and was not wearing a mustache or beard cover. Staff member E said she knows the staff with beards should wear a bear cover. Staff member E asked staff member G to immediately put on a beard cover. During an observation on 4/23/25 at 8:07 a.m., staff member F was observed in the kitchen without a beard or mustache cover. Review of a facility temperature document, untitled, located on the reach-in refrigerator showed: - Ten days in January 2025 with no temperatures documented, - Five days in February 2025 with no temperatures documented, however temperatures were documented for February 29, 30 and 31, - Four days in April 2025 with no temperatures documented. Review of the facility document titled, DIETARY FRIDGE TEMPERATURE showed: - Three days in April 2025 with no temperatures documented. Review of facility document titled, DIETARY FREEZER TEMPERATURE log showed: - Three days in January 2025 with no temperatures documented, - Three days in April 2025 with no temperatures documented.

Based on observation, interview, and record review, the facility failed to ensure enhanced barrier precautions were followed for 1 (#22) of 14 sampled residents; and failed to to maintain an adequate infection surveillance and antibiotic stewardship program and ensure policies and procedures were reviewed and revised annually for the Infection Prevention and Control Program. The deficient practices had the potential to increase the risk of infections within the facility. Findings include: 1. During an interview on 4/22/25 at 8:49 a.m., resident #22 said she had a central IV (intravenous) catheter for dialysis. Resident #22 said the nursing staff wore gloves, but never wore gowns when providing personal care. During an observation and interview on 4/22/25 at 3:05 p.m., staff member H was observed assisting resident #22 prepare for a shower. Resident #22 had a central IV catheter in her upper right chest. The IV site was covered, but the ends of the tubing were not covered. Staff member H was wearing gloves while taping a piece of plastic over the IV insertion site and around the exposed IV catheter tubing. No gown was worn during the care observation. Staff member H said she had been trained on enhanced barrier precautions, but since the IV insertion site was covered, she said she did not need a gown. Gloves were available, but no other personal protective supplies were available in or near resident #22's room. Review of resident #22's care plan, dated 4/23/25, showed an intervention directing the staff to use enhanced barrier precautions when caring for the central IV catheter. 51111 2. During an interview on 4/23/25 at 8:07 a.m., staff member C stated the facility did not use McGeer criteria (infection surveillance tool) in the infection control program until about six months ago, which is about the time staff member C stated he started the position. During an interview on 4/23/25 at 9:02 a.m., staff member D stated she started in her current position at the end of January this year. Staff member D stated she did not know what the facility was doing specifically with the antibiotic stewardship program prior to January 2025, she could not speak to what was or was not in place. Staff member D stated there was no current enhanced barrier precautions policy in place, only guidance for staff to follow. Staff member D stated the facility's corporate QAPI board needed to approve and sign off on the enhanced barrier precautions policy before it would be utilized. During an interview on 4/23/25 at 12:43 p.m., staff member B stated she helped work on infection control items along with staff member D. Staff member B stated she started her role in September of 2024. Staff member B stated NF3 worked in the facility until the end of December of last year and oversaw the infection prevention program. Staff member B stated NF3 and herself reviewed the former antibiotic stewardship system in place. Staff member B stated she and NF3 decided it was not a complete program and started things over in September of last year. Staff member B stated the facility started using McGeer criteria in September of last year. Staff member B stated she was unaware if there was a break in services of the infection preventionist role between NF2's and NF3's employment. Review of a facility document titled, Long Term Care Facility Component-Annual Facility Survey, showed, the facility reported for survey year 2025 a total of three times in the past year a new employee had to take over the infection preventionist role. Review of a facility document titled, Monthly Infection Control Log (Line List), showed: . Reporting Period Oct. 1 to Oct. 31, 2024 . Types of infections . - UTI no cath: 4 . - URI: 1 . - Eye: 3 . - # New Cases colonized (not infected) with antibiotic resistant organisms: 8 . 1. Started McGeer Criteria 2. Started Ab Stewardship & [72 hour] stop Oct. 31 . [sic] Review of the facility's Infection Prevention and Control Program policies showed the following: - Infection Control - Antimicrobial Stewardship Policy and Procedure, Origination September 2024, last revised September 2024; - Infection Control Antibiotic Stewardship- Review and Surveillance of Antibiotic Use and Outcomes, Origination September 2024, last revised September 2024; - [Facility Name] Pneumoncoccal Immunization Policy and Procedure, [sic] last revised June 2023, next review due June 2024; and, - [Facility Name] Influenza Policy and Procedure, last revised December 2017, next review June 2024.

Based on interview and record review, the facility failed to ensure documentation for screening of medical contraindications, education, and signed consent or declination by the resident or their responsible party for the influenza vaccination for 4 (#s 3, 7, 13, and 31) of 5 sampled residents. This increased the risk of residents not being informed of risks and benefits to the vaccination and verification of resident or responsible party authorization. Findings include: During an interview on 4/23/25 at 3:10 p.m., staff member A stated staff member D looked and could not find influenza vaccine consents or declination forms for resident #s 3, 7, 13, and 31. Review of a facility document titled, 2024-2025 flu vax, [sic] showed resident #s 3, 7, 13, and 31 received the influenza vaccination on 10/18/24. Review of resident #s 3, 7, 13, and 31 vaccine records did not show a vaccine consent form provided, documented, or signed by the resident or responsible parties for the influenza vaccine. The records did not have documentation of screening for medical contraindications to the vaccine or education provided prior to administration of the vaccine explaining the risks and benefits of the influenza vaccination. A request was made to the facility on [DATE] for influenza vaccine consent or declination forms for resident #s 3, 7, 13, and 31. No documentation was received by the end of the survey. Review of a facility document titled, [Facility Name] Influenza Policy and Procedure, last approved June 2023, showed: . All residents and patients will be immunized against influenza as recommended by the Advisory Committee for Immunization Practices (ACIP). The vaccine will be provided to all residents . unless medically contraindicated, or the resident or responsible party refuses . 2. Obtain informed verbal consent before the immunization is administered and will be documented on the Resident's Vaccine Administration Record. 3. An informed verbal consent may be obtained by giving the resident, patient, or responsible party a copy of the current Vaccine Information Statement (VIS) and by providing an opportunity for their questions to be answered. 4. If the resident or patient or responsible party refuses an immunization, it should be documented in the permanent medical record. The resident or responsible party should be provided with an educations program and the immunization offered again . 5. The resident or patient will be screened for contraindications before each dose of vaccine is given. All contraindications will be recorded in the permanent record . [sic]

Based on observation, interview, and record review, the facility failed to develop, implement, and operationalize a facility policy and procedure for grievances, and insure grievance information was readily accessible, to include the name and contact information for the grievance official; failed to provide residents with readily available grievance forms, as noticed by at least 1, resident (#196), of 14 sampled; and failed to provide residents with the option to file grievances anonymously. Findings include: During an interview on 4/23/25 at 2:00 p.m., resident #196 stated the resident council met monthly. Resident #196 stated the facility provided grievance forms, which were located near the nurse's station, but there was not a way to file a grievance anonymously. Resident #196 stated if a resident wanted to file a grievance, it was required to have the resident's name on the form, so the facility could address the grievance. During an observation on 4/23/25 at 2:50 p.m., a walk-through of the facility's common areas was conducted. No grievance forms were found to be readily available to residents. No posting of the name and contact information of the grievance official was found, and no secure receptacle was identified to file an anonymous grievance. During an interview on 4/23/25 at 4:30 p.m., staff member K stated grievance forms were located at the nurse's station, and a resident would need to ask a staff member for a grievance form. Staff member K stated social services also had grievance forms and could help a resident complete the form if assistance was needed. Staff member K stated residents would give the completed grievance form to a staff member, and the form would then be given to a supervisor or social services. Staff member K stated the facility did not have a way for residents to file a grievance anonymously or have a secure receptacle for residents who wanted to file grievances anonymously. A review of the facility's policy titled, [Facility Name] Policy and Procedure February 2000 Filing Grievances/Complaints, dated November 2016, showed the following: Policy Statement Our facility assists patients/residents/clients, their representatives (sponsors), other interested family members, or advocates in filing grievances or complaints when such requests are made. Policy Interpretation and Implementation 1. Any patient/resident/client, his or her representative (sponsor), family member, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other patients, residents, staff members, theft of property, etc. without fear of threat or reprisal in any form. 2. Grievances and/or complaints may be submitted orally or in writing. Written complaints or grievances must be signed by the patient/resident/client or the person filing the grievance or complaint in behalf of the individual . [sic]

Based on interview and record review, the facility failed to revise a resident care plan to address comfort care for 1 (#31) of 14 sampled residents. This failure placed the resident at risk for not receiving appropriate comfort care measures. Findings include: During an interview on 4/23/25 at 7:30 a.m., staff member M stated resident #31 had a recent change in condition. Staff member M stated resident #31 decided at the time not to go to the hospital and instead requested comfort care. Staff member M stated resident #31 had recently changed her POLST to reflect comfort care only. Staff member M stated any treatment resident #31 may need would be provided at the facility. During an interview on 4/23/25 at 1:05 p.m., staff member D stated she was responsible for updating the resident care plans. Staff member D stated she updated care plans as needed after the facility's daily morning meeting. Review of resident #31's medical provider note, dated 3/5/25, showed resident #31 was seen by the medical provider for concerns related to not eating or drinking, since diagnosed with Influenza A, the week prior. Medical provider documentation showed: Review of Systems . Psych: Voices desire to hold any heroics in her care. Absolutely refuses any hospitalization or invasive treatments . States she is ready to go and has been for awhile. [Family member] is present in room for this discussion and agrees with [resident #31] to get comfort care only . Assessment/Plan . 2. Failure to thrive in adult Will change code status to DNR with comfort care only and no hospitalization s. Will update POLST form. Family in attendance at visit and in agreement to her decision. Review of resident #31's POLST, dated 3/5/25, showed resident #31's code status was DNR with comfort care only. Review of resident #31's dietician note, dated 3/11/25, showed resident #31 was recently treated for influenza A and pneumonia. The dietician's note also showed resident #31 reported she had no energy, a poor appetite, and had decided on comfort care only. Review of resident #31's care plan, dated 3/26/25, failed to show a focus area, goals, or interventions which addressed the resident's needs specific to comfort care.

Based on interview and record review, the facilty failed to ensure residents who received dialysis were provided services, consistent with professional standards of practice, to include physician orders for the dialysis, for 1 (#22) of 14 sampled residents. The deficient practices placed the resident at risk for pre-dialysis and post-dialysis complications. Findings include: During an interview on 4/22/25 at 8:29 a.m., resident #22 said she had been getting dialysis prior to her admission to the facility. Resident #22 said she goes to a dialysis center in another town on Monday, Wednesday, and Friday. Resident #22 said she left the facility at approximately 11:00 a.m., and the dialysis ran for three hours and fifteen minutes. Resident #22 said she returned to the facility at approximately 4:30 p.m. on dialysis days. Review of resident #22's current physician orders, dated 4/22/25, showed the resident did not have a physician order for her dialysis treatment. Review of resident #22's physician order received on 4/23/25, showed the physician ordered for hemodialysis. The physician dialysis order was dated 4/23/25. Review of resident #22's initial care plan, dated 2/27/24, showed resident #22 started dialysis in August 2023. The medical record did not show a physician had ordered resident #22 to receive dialysis until 4/23/25.

Based on interview and record review, the facility failed to adhere to the participation requirements for long-term care facilities, related to the lack of appointing a licensed Nursing Home Administrator, who has an active license for Montana. This failure did not allow the facility to maintain compliance for the Requirements of Participation, and may negatively affect all residents at the facility. Findings include: During an interview on 3/12/25 at 10:03 a.m., staff member B stated he was the current Interim Chief Executive Officer providing oversight for the facility. Staff member B stated in December of 2024 the interim Director of Nursing Services had planned to renew her contract and function in the administrator role, once her license was received from the State of Montana, but her contract negotiations fell through. Staff member B stated the Interim Director of Nursing Services' last day of employment for the facility was 12/27/24. The facility did not have a licensed Nursing Home Administrator for the State of Montana since that time. A review of the State Operations Manual, Appendix PP, F540 Requirements for Participation shows: 2) Requirements. In addition to meeting the participation requirements for long-term care facilities set forth elsewhere in this subpart, a distinct part SNF or NF must meet all of the following requirements: . (ii)The administrator of the SNF or NF reports to and is directly accountable to the management of the institution of which the SNF or NF is a distinct part. The Appendix PP,includes numerous regulatory requirements which include direct involvement of the licensed Administrator, to include (not all inclusive): F585 - The management and oversight of the grievance process F600 - Abuse, Neglect, and Misappropriation 5609 - Abuse Reporting F610 - Abuse Prevention F835 - Administration F844 - Disclosure Requirements F849 - Hospice Abuse Reporting/Handling F868 - Quality Assurance and Performance Improvement 33275 Guidance was provided by the Certification Bureau on 12/16/24 to member A and NF4 on the hourly requirements of the Nursing Home Administrator and Director of Nursing roles. At that time, they stated the facility was considering having the two of them share both required positions, or they would each fill one of the roles as both intended to attempt to obtain the current Montana Nursing Home Administrator license. The two employees stated staff member B and the governing body also mentioned having one person fulfill both Federally required positions. Per review of the Appendix PP, State Operations Manual, for F727 - Director of Nursing/RN requirements, the Director of Nursing must be full-time. Having a full time DON fulfill the licensed Nursing Home Administrator position at the same time, would require that one person to work above and beyond full-time, in order to fulfill the Nursing Home Administrator requirements also. During this call, both staff stated they did not wish to work that many hours above their already full-time employment.

Based on interview and record review, the facility's governing body failed to employ an administrator that was licensed in the State of Montana. This failure has affected all residents at the facility, due to the lack of an Administrator, and the facility not being in substantial compliance due to this. Findings include: During an interview on 3/10/25 at 2:20 p.m., staff member A stated she was the Director of Nursing and had applied to the State of Montana to become a licensed administrator. Staff member A stated the licensing board had recently requested her college transcripts to move forward with her application. Staff member A stated the facility did not have a current administrator, and the facility had not advertised for the open administrator position. During an interview on 3/12/25 at 10:03 a.m., staff member B stated he was currently the Interim Chief Executive Officer. Staff member B stated in December of 2024 the interim Director of Nursing Services had planned to renew her contract and function in the administrator role, once her license was received from the State of Montana, but her contract negotiations fell through. Staff member B stated the Interim Director of Nursing Services' last day of employment for the facility was 12/27/24. As of 12/4/24, the facility has not employed a Montana licensed Nursing Home Administrator. Review of the facility's Key Personnel Contact List, dated 3/10/25, did not include an Administrator name or contact information. Review of the facility's policy titled, Big Book Info - Policies, last revised June 2023, showed: . The facility has been administered in a manner that enables it to use its resources effectively and efficiently to assist each resident to attain or maintain his/her practicable mental, physical and psychosocial well-being. This facility is licensed under all applicable State and Local laws. The facility will operate and provide services in compliance with applicable Federal, State, and local regulations and codes and with accepted professional standards and principles. The governing body appoints [NF4], a licensed State administrator, to be responsible for management of the facility. FACILITY POLICIES: [Facility Name] will have written administrative and resident care policies in the absence of the administrator, the appointed designee is the DON . Review of the State of Montana, Department of Labor and Industries online license verification, did not show a temporary or permanent Nursing Home Administrator license for NF4, as of 12/31/22. A request was made to the facility on [DATE] for documented resources used for recruiting a new administrator. No documentation was received from the facility by the end of the survey. A review of the Appendix PP, State Operations Manual, includes numerous regulations governing Skilled Nursing Facilities/Nursing Facilities. The Administrator is a position that is not only required by the federal regulations, but included in many regulations related to processes for a facility. Refer to F540 for more detail on the individual regulatory areas noted. On 1/28/25, staff member A sent an email to the Certification Bureau providing staff member B's contact information. An email was sent to staff member B on that day, which included the following, The SNF is required to have a licensed administrator per the SNF regulations. Our office has not received a confirmation or copy of the license for the new administrator. Please have the individual appointed forward a copy of the current active MT Nursing Home Administrator's license . No reply was received from staff member B. Multiple other attempts were made (on 12/24/24, 12/27/24, 1/30/25, and 2/13/25) by the Certification Bureau to contact staff member B. These attempts included having staff member A relay the message to staff member B of the need for a return call related to the appointment of the Nursing Home Administrator. No return calls or emails were ever received from staff member B, who was reportedly providing facility oversight. The ongoing failure to employee a Montana licensed Nursing home Administrator prevented the facility from being in substantial compliance with Federal regulations.

Based on interview and record review, the facility failed to follow and uphold the plan of correction for the survey dated 12/3/2024, as the QAPI committee did not meet monthly to identify ongoing issues and concerns related to the survey or faiclity, and ensure a licensed Administrator was present, which may negatively affect any resident. Findings include: During an interview on 3/12/25 at 10:29 a.m., staff member A stated a quality assurance performance improvement meeting was not held in February 2025. Staff member A stated the meeting for February 2025 was not rescheduled. Staff member A stated the next meeting would be held the third week of March 2025. Review of the Quality Assurance and Performance Improvement Committee Minutes, dated 12/23/24 and 1/22/25, showed no documentation the committee continued to meet monthly in February 2025. Review of the facility's plan of correction, dated 1/6/25, showed: . Audits will be presented to QAPI team monthly, for discussion of results and issues to maintain compliance. After 3 months, QAPI committee/IDT will determine the need for ongoing and frequency of the audit to ensure substantial compliance . [sic] Interviews identified an administrator was not employed as of late December 2024. Due to this, the QAPI committee did not include the necessary staff, as required by the Centers for Medicare and Medicaid, to participate in the QAPI meetings. Review of the Appendix PP, State Operations Manual, for F868, shows the facility must have the following positions participate in the QAPI Committee: (i) The director of nursing services; (ii) The Medical Director or his/her designee; (iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and (iv) The infection preventionist. Refer to F837 for the facility failing to employ a licensed Nursing Home Administrator.

Based on observation and interview, the facility failed to ensure privacy during wound measurement and ointment application, for 1 (#25) of 9 sampled residents. Findings include: During an observation on 12/3/24 at 1:30 p.m., resident #25 was seated in a recliner, in the open television room, on the dementia unit. Staff member G did not ask the resident #25 to go to his room but asked if it was alright to do his treatment at that time and place. Resident #25 was in full view of two other male residents. Staff member G pulled the pant legs up and removed resident #25's socks from both legs. Staff member G laid on the floor and used a piece of white paper and traced around the wound on the back of resident #25's heel/lower leg area. Staff member #25 stood up and got a medication cup containing a white colored ointment. Staff member G applied the white ointment to resident #25's legs. After resident #25's socks were reapplied, and the pant legs were pulled back down, staff member G said she did not want to waste the ointment. Staff member G then applied the same ointment to resident #25's bilateral forearms. During an interview on 12/3/24 at 2:10 p.m., staff member C said she would not expect a nurse to complete wound care in the dining room and not in front of other residents. During an interview on 12/3/24 at 5:00 p.m. staff member G said the times for wound care should be changed as resident #25 does not always cooperate with going to his room to receive the treatment in privacy.

Based on interview and record review, the facility failed to identify a resident's elopement risk or implement interventions following an elopement for 1 (#31) of 4 residents sampled for elopement, and failed to implement, monitor, and modify fall interventions to prevent multiple falls for 1 (#50) of 6 residents sampled for falls. Findings include: 1. During an interview on 5/8/24 at 12:33 p.m., staff member A stated resident #31 had made some requests to leave the facility to visit his friend. Staff member A stated approximately two or three weeks prior to his elopement, resident #31 had gone to the door to leave, but staff stopped him from exiting. Staff member A stated no elopement assessment had been done, prior to his elopement and he was not identified as an elopement risk. The resident did not have a history of eloping and had been at the facility an extended period of time. Review of resident #31's interdisciplinary progress notes on 11/8/23, at 3:07 a.m., showed resident #31 was not in his room. The staff searched the facility and surrounding grounds from 3:00 a.m., until 3:45 a.m. After the initial search, the police, administration, and IT (information technology) were notified. At the time of the elopement, resident #31's BIMS was a 10; moderately impaired cognition. Review of resident #31's last five MDS assessments showed he had a fluctuating BIMS score, and the scores ranged from 9-14. A score of 9 is moderately impaired, and a score of 14 is intact cognition. Review of resident #31's interdisciplinary progress notes on 11/8/23 showed information technology watched the facility video and identified resident #31 leaving the facility at 12:26 a.m., through the front door of the facility. Using this new information, resident #31 was found at 7:00 a.m., in a field six blocks southwest of the facility. Resident #31 was exposed for 6 1/2 hours and transported to the hospital by an ambulance. Review of resident #31's emergency department report, on 11/8/23 at 7:14 a.m., showed resident #31 was hypothermic upon arrival. Resident #31 also had abrasions to his knees. Resident #31 was returned to the facility on [DATE] at 4:04 p.m. During an interview on 5/8/24 at 12:33 p.m., staff member A stated following the elopement a wander guard was applied to his wrist and every one-hour visual checks were done. Review of resident #31's interdisciplinary progress notes on 11/10/24 at 6:51 p.m., showed resident #31 walked out of the 200 wing west door and then re-entered via the activity room door. No changes to the care plan was noted after this elopement attempt. Review of resident #31's interdisciplinary notes on 12/1/23 at 2:39 p.m., Resident walked out of room to the activity door and alarm sounded. The maintenance workers there returned resident to the floor and a CNA assisted the resident further to help back into bed. Review of the 12/1/23 through 12/31/23 treatment records showed the staff began monitoring the placement of the wanderguard on 12/24/23. There was no documentation of the monitoring of placement or the function prior to those dates. Review of resident #31's interdisciplinary progress notes on 12/26/23 at 3:07 p.m., showed a delay in transferring resident #31 to the locked memory care unit. 48268 2. During an interview on 5/7/24 at 9:20 a.m., Staff member C reported that resident #50 scored high risk for falls on admission to the facility on [DATE]. Staff member C stated, These (falls) occurred before I came here, so I don't know anything about them. During an interview on 5/8/24 at 10:12 am, staff member A stated that all nursing and CNA staff received fall, abuse, and dementia training annually through an online platform. Review of the Care Area Assessment, completed on 5/24/23, showed resident #50 triggered for Cognitive Loss/Dementia and Falls. Closed record review showed resident #50 was admitted on [DATE] after a fall with major injury at home and fell four additional times in the facility between 5/18/23 and 7/13/23, including two with major injuries. Review of a facility document titled, Resident Fall Incident Report and Post Fall Investigation, completed on 6/16/23, and reviewed by IDT on 6/20/23, showed resident #50 sustained an unwitnessed fall with major injury on 6/16/23 at 7:00 a.m. The document showed the care plan was reviewed on 6/16/23, and showed the following additional fall interventions were implemented at that time: - 1.Get her up and toilet her at start of shift to make sure she does not try to get out of bed by herself. [sic] - 2. Keep bathroom light on her room for better visibility. [sic] The document listed the following information under the heading, Contributing Factors/Action Plan to prevent another injury: - Resident got out of bed by herself and tried to walk. Too weak to remain standing . Resident #50's care plan did not show new fall interventions as per the document above. One fall intervention was added to the care plan in June 2023 was on 6/20/23, as follows: - Assist with transfers (2 person preferred). Resident does not reliably bear weight and needs a [NAME] lift for transfers (ability varies). [sic] Review of facility document titled, Resident Fall Incident Report and Post Fall Investigation, completed on 7/13/23, and reviewed by IDT on 7/18/23, showed resident #50 sustained an unwitnessed fall with major injury on 7/13/23 at 8:00 p.m. The document did not show the care plan was reviewed, and no new care plan interventions were listed. The IDT note stated that the resident was transferred to the hospital on 7/14/23. Resident #50 returned to the facility on [DATE]. No new fall interventions were added to the care plan in July 2023 or August 2023. The document listed the following information under the heading, Contributing Factors/Action Plan to prevent another injury: - Confused. Monitor more closely. [Physician Name] notified orders rec. were to monitor res. clinically t/o night. [sic] The facility failed to implement effective and measurable fall prevention interventions, which had the potential to contribute to resident #50's repeated falls and injuries.

Based on observation, interview, and record review, the facility failed to identify and implement interventions for a resident's weight loss of 9 percent in 5 months, and a significant weight loss of 6 percent in one month for 1 (#13) of 2 sampled residents. Findings include: During an observation on 5/10/22 at 8:18 a.m., resident #13 was being assisted with his breakfast meal by staff member G. The resident was nonverbal, and not able to eat or drink independently. He refused to eat his scrambled eggs, but did eat his hot cereal. Review of resident #13's Quarterly MDS, with an ARD of 9/7/21, showed a weight of 183 pounds. Review of resident #13's Quarterly MDS, with an ARD of 2/22/22, showed a weight of 167 pounds - a nine percent weight loss in five months. Review of resident #13's Weight Trend Graph showed a weight of 166 pounds on 3/24/22, and a weight of 155 pounds on 4/21/22 - a significant weight loss of six percent in one month. Review of resident #13's nursing progress note, dated 5/10/22, showed [Resident] is assisted with meals. Tonight he took 100% of his evening meal. At times [resident] will push your hand away or the plate away. Much encouragement is required. Review of the facility Resident Weight Protocol showed any weight change of five pounds should be reported to the charge nurse or the assistant director of nurses by the dietary manager. Review of resident #13's Nutrition care plan, dated 3/1/22 showed: Problem - current weight 167 pounds.' The Goal was to 'See the dietitian review 12/28/21. Weight to become stable.' The Intervention, dated 3/1/22, showed See dietitian review 12/28/21 regarding adding 4 ounce supplement daily. During an interview on 5/11/22 at 8:11 a.m., staff member M stated the MAR did not include a supplement for resident #13. During an observation and interview on 5/11/22 at 8:12 a.m., staff member G stated the supplements were kept locked in the dining area refrigerator. The refrigerator did not contain a supplement with resident #13's name on it. Staff member B stated if the supplement was ordered, it would have the resident's name on it. During an observation and interview on 5/11/22 at 9:05 a.m., staff member G was assisting resident #13 with the breakfast meal. She stated he eats very slowly, and it takes a half hour or longer for him to eat. The breakfast meal did not include a supplement for resident #13. During an interview on 5/11/22 at 4:20 p.m., staff member F stated resident #13's weight loss should have been identified by nursing. She was not aware of the weight loss. Staff member E stated she was new to the dietary manager position, and did not know how to calculate a significant weight loss. Review of the facility Resident Weight Protocol, dated 5/2021, showed the dietary manager will review weights daily Monday through Friday, and implement the dietary changes to the care plans.

Based on observation, interview, and record review, the facility failed to maintain the highest practicable well-being for 1 (#5) of 14 sampled residents, by free-pouring unmeasured amounts of un-thickened Pepsi and orange juice into the resident's mouth which caused the resident to cough, choke, spit, gasp for air, his eyes bulged, and he communicated non-verbally this caused him to be afraid. Findings include: 1. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #5's Admission MDS, with an ARD of 2/15/17, showed the resident was non-verbal, and was not easily understood by others. Resident #5 required extensive and total assistance to perform his activities of daily living. The resident's primary mode of transportation was a Geri-wheelchair propelled by the staff. A review of resident #5's Quarterly MDS, with an ARD of 8/1/17, showed the resident was non-verbal, and was not easily understood by others. He required extensive and total assistance to perform his activities of daily living. The resident's primary mode of transportation was a Geri-wheelchair propelled by the staff. A review of resident #5's October 2017 Physician Order, initiated on 5/30/17, read, House Diet- Puree/soft texture; pudding consistency. Thicken liquids except Pepsi. A review of resident #5's Care Plan, initiated 2/21/17, read, Staff or family members need to hold beverage containers, (resident's name) will not pick them up by himself. Eats in reclining position. A review of resident #5's nurse's notes, dated 2/9/17, read, Resident's family stated he needs to be fed, is a big risk for choking and aspiration, and will some times (sic) spit food onto the floor and may eat until he reaches the point of emesis. During the initial tour of the facility on 10/22/17 at 3:46 p.m., staff member C stated the resident was non-verbal, but could communicate with his eyes. The staff member stated the facility staff had learned how to communicate with the resident. Staff member C stated the resident could be asked a question, and looking up, meant yes, looking horizontal, meant no. During an observation and interview on 10/23/17 at 7:58 a.m., resident #5 was brought into the dining room while he was reclined in a Geri-wheelchair. The foot of the chair was elevated, and the resident was lying flat in the chair. The head of the chair was elevated less than 30 degrees. The resident had a pillow under each of his legs, under each arm, and under his head. At 8:13 a.m., staff member Q sat next to resident #5. She began to assist the resident with breakfast; spoon-feeding him oatmeal and poached eggs. The resident was in a semi-reclined position, with the head of his chair elevated less than 30 degrees. The resident would open his mouth, and the staff member would free-pour an unmeasured amount of Pepsi, alternating with orange juice, into his mouth, after each mouthful of oatmeal. The resident coughed, choked, and gasped for air after each mouthful of food, followed by Pepsi and orange juice. At times, the resident even had liquids running out of both corners of his mouth. Staff member Q cleaned the drool with a clothing protector and towel after each coughing episode. At 8:17 a.m., staff member Q stated the resident was to receive thickened liquids, except for Pepsi and orange juice. The staff member stated non-thickened liquids were easier to pour into the resident's mouth, even though it caused him to cough, and gasp for air. Stridor (harsh vibrating noise) could be heard from the resident with each breath he took during the meal. Licensed staff were not observed assessing the resident's lung sounds. During an observation and interview on 10/23/17 at 9:12 a.m., staff members G and H transferred resident #5 into his bed. At 9:16 a.m., staff member H free-poured an unmeasured amount of Pepsi into the resident's mouth from a 16.9-ounce Pepsi bottle. The resident was reclined, almost lying flat in bed, when he began to cough, spit, and drooled Pepsi from the corners of his mouth. At 9:20 a.m., staff member H free-poured an unmeasured amount of Pepsi into the resident's mouth while lying reclined in the bed. The resident coughed, choked, and gasped for air, as Pepsi drooled from the corners of his mouth. Staff member H cleaned the drool with a Kleenex after each cough. At 9:23 p.m., staff members G and H stated the resident drank up to four-12 ounce cans of Pepsi each day. At 9:24 a.m., staff member H free-poured an unmeasured amount of Pepsi into the resident's mouth while he continued to lie reclined in the bed. The resident coughed, choked, and gasped for air, as Pepsi drooled from the corners of his mouth. At 9:25 a.m., staff members G and H stated the resident did not cough, choke, gasp, or drool as much when thickened liquids were offered. During an interview on 10/23/17 at 10:45 a.m., staff member A stated the facility staff were required to thicken all liquids given to the resident except for Pepsi. Staff member A stated she understood the concerns observed by the surveyors when staff administered the free-pouring of unmeasured amounts of Pepsi, and the resident coughed, choked, and gasped for air. During an observation and interview on 10/23/17 at 11:22 a.m., staff member G assisted resident #5 with lunch; spoon-feeding him pureed turkey, potatoes, and vegetables. The resident was in a semi-reclined position, with the head of his chair elevated less than 30 degrees. The resident opened his mouth, and the staff member would free-pour an unmeasured amount of Pepsi from a 6 ounce paper cup into his mouth, after each mouthful of pureed food. The resident coughed and spit food and liquids out of his mouth. Staff member G used Kleenex to clean the resident's mouth, then would free-pour unmeasured amounts of Pepsi into his mouth. The resident's eyes bulged a few times during the coughing episodes. Stridor could be heard from the resident with each breath he took during the meal. Licensed staff were not observed assessing the resident's lung sounds. During an interview on 10/24/17 at 10:25 a.m., staff member I stated resident #5 had been admitted to the facility from home. She stated the resident was given Pepsi as a reward. She stated the resident was to receive thickened liquids, except for Pepsi. She was not aware of how much liquids resident #5 should have received at any one given time. Staff member I stated she had not assessed the resident's lung sounds after receiving Pepsi, and thought it was a good idea to add to his assessments. During an observation and interview on 10/23/17 at 1:20 p.m., staff members G and H entered resident #5's room. The resident was supine in bed, the head of his bed was elevated less than 30 degrees, and he was making gurgling sounds. Staff member G stated the head of the bed was supposed to be raised when he makes those noises. After the resident was weighed, and clean pants were put on him, staff member G lowered the resident's head of the bed to less than 30 degrees. Staff member G free-poured unmeasured Pepsi into the resident's mouth while he laid supine in bed. The resident began coughing, gasping for breath, and stridor could be heard from the resident with each breath he took. Staff members G and H gathered their supplies, the scale, and exited the resident's room. During an interview on 10/23/17 at 4:20 p.m., staff member O stated the resident was at a very, very terrible risk for an aspiration pneumonia. Staff member O stated he was not aware that facility staff were free-pouring unmeasured amounts of Pepsi into the resident's mouth. The staff member stated he was not aware that resident #5 was receiving up to four-12 ounce cans of Pepsi a day while reclined less than 30 degrees, and that the resident was coughing, choking, and was gasping for air. Staff member O stated free-pouring unmeasured amounts of Pepsi into the resident's mouth, to the point of it drooling form the corners of the resident's mouth, should have been closely monitored. Staff member O stated he needed to provide some education to the staff to reduce the risk of potential aspiration pneumonia to resident #5. During an interview on 10/24/17 at 9:05 a.m., staff member K stated the resident's care plan had been updated to include elevating the head of the resident's chair and bed. A review of resident #5's Care Plan, initiated 10/23/17, read, Have head of bed and head of chair elevated 45 degrees whenever giving fluid or foods. All fluids must be thickened. May have 1 can of Pepsi per day, thickened, Nursing will provide Pepsi. 1 teaspoon of food or fluid to be given at a time when being fed. During an interview on 10/24/17 at 10:40 a.m., NF1 stated the resident was always propped up during meals at home, and if the resident's position changed, the resident would be repositioned. NF1 stated the resident had limited episodes of coughing, or choking during meal time while at home. During an interview on 10/25/17 at 7:31 a.m., resident #5 was asked if he was frightened or scared when staff poured Pepsi into his mouth, and he coughed or choked. The resident moved his eyes up and down to communicate yes. Review of the facility's Guidelines for Safe and Efficient Feeding of Patients (sic) with Oropharyngeal Dysphagia, copyright 1989, provided by staff member A, read, page 2, Causes of Swallowing Difficulties- Many medical conditions can cause a patient to have a slow, inefficient, and/or unsafe swallow .[MEDICAL CONDITION], etc .Each type of swallowing problem requires a different combination of diet, posture, and methods of feeding .Page 4. The Patient's Head and Body Position Before and During Eating- The patient's head and body position can be quite important in successful oral intake .The occupational and physical therapists may be helpful in providing supports and wheelchair modifications for a patient who has difficulty assuming the desired swallowing posture.