Every finding on record at Fordsville Nursing and Rehabilitation Center

Based on observation, interview, record review and review of facility policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (2) of fifty-five sampled residents (Residents #46, and #16). Resident #46 has a persistent rash with a diagnosis of scabies. Observation on 08/05/2023, revealed Certified Nursing Assistant #22 and Registered Nurse (RN) #2 failed to don Personal Protective Equipment (PPE) when providing direct care to Resident #16 who was on Enhanced Barrier Precautions (EBP). The findings include: Review of the facility's policy, Infection Control, revised October 2018, revealed the facility would maintain a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. The facility would prevent, detect, investigate, and control infections within the facility and establish guidelines for implementing Isolation Precautions including standard and transmission based precautions. Review of the facility's policy, Scabies Protocol dated 10/2020, revealed the facility would treat residents infected with and sensitized to Sarcoptes scabies and to prevent the spread of scabies to other residents and staff. Review of the facility's policy, Enhanced Barrier Precautions (EBP) Standard of Practice, dated July 2022, revealed EBP was an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDROs). EBP involved gown and glove use during high contact resident care activities for residents known to be colonized or infected with an MDRO's as well as those at were at an increased risk of MDRO acquisition. Continued review of the policy revealed high contact resident care areas requiring gown and glove use among residents that trigger EBP use include wound care any skin opening requiring a dressing, changing briefs or assisting with toileting, changing linens, providing hygiene, transferring, bathing or showering, and dressing. Additional review revealed signage would be posted outside the resident room identifying EBP and the type of PPE recommended. Gowns and gloves were the minimum level of PPE required for high contact resident care activities. 1. Review of the medical record revealed the facility admitted Resident #46 on 11/11/2021 with diagnoses which included Dementia, Alzheimer's Disease, and Major Depressive Disorder. Review of Resident #46's the Quarterly Minimum Data Set (MDS) Assessment, dated 06/26/2023 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of zero (0) of fifteen (15) indicating severe cognitive impairment. Review of a Wound Care Note dated 06/09/2022, revealed Resident #46 had a rash and was diagnosed as scabies. The resident was prescribed Ivermectin fifteen (15) milligrams (mg) once a week for two (2) doses. Review of a Progress Note dated 06/29/2022, revealed Resident #46 was seen by dermatology and diagnosed with post-scabetic dermatitis and was to continue Clobetasol cream until rash diminished. Review of a Progress Note dated 08/31/2022, revealed Resident #46 complained of itching and the Advanced Practitioner Registered Nurse (APRN) prescribed CeraVe (anti-itch) cream for Psoriasis. Review of a Progress note dated 09/13/2022, revealed Resident #46 was seen by dermatology, diagnosed with scabies and prescribed Elimite 5% cream. Review of a Wound Care Note dated 10/04/2022, revealed Resident #46 was seen due to a complaint of a rash, diagnosis of a new case of Scabies for fourteen (14) days and was prescribed Aquaphor to the whole body twice daily. Review of Resident #46's Progress Note, dated 12/01/2022, revealed wound care ordered a skin scraping for scabies. Review of Resident #46's Progress Note dated 12/21/2022, revealed a skin scraping completed and resident had a light red rash to palms, feet and abdomen. Review of a Progress Note dated 12/21/2022 with a late entry by the Director of Nursing (DON) on 01/24/2023, revealed skin scraping was canceled by the lab. Review of a Progress Note dated 12/27/2022, revealed Resident #46 had an irritating rash. Review of a Progress Note dated 01/23/2023, revealed Resident #46 was seen by allergist, diagnosed with scabies, and treated with Natroba 0.9% topical suspension. In an interview with Resident #46's spouse on 07/20/2023 at 12:45 PM, he stated Resident #46 had a rash for several months with no improvement. He stated Resident #46 would scratch constantly due to the intense itching. Resident #46's spouse stated he scheduled a dermatology appointment and Resident #46 was seen on 06/29/2022 and was diagnosed and treated for scabies. During a telephone interview with Resident #46's daughter on 07/19/2023 at 7:36 PM, she stated Resident #46 had a recurrent rash that lasted approximately one (1) year in 2022 and the facility would deny it could possibly be scabies when family would inquire about it. Resident #46's spouse ultimately scheduled an appointment with a dermatologist in which Resident #46 was diagnosed and treated for scabies. In an interview with Certified Nursing Assistant (CNA) #2 on 07/20/2023 at 1:30 PM, she stated she had gotten a rash that was itchy and had bumps between her fingers and on her hands. CNA #2 was seen by her family physician on 05/25/2022, and was diagnosed with scabies. She stated she was treated with Permethrin cream. During a telephone interview with CNA #5 on 07/27/2023 at 8:31 PM, she stated she cared for residents with scabies and the facility would always deny that's what it was. CNA #5 further stated she also got a rash and had to see her Primary Care Provider (PCP)on her scheduled day off 02/11/2022 and was prescribed Permethrin cream for scabies. During a telephone interview with Licensed Practical Nurse (LPN) #3 on 07/23/2023 at 5:35 PM, he stated there were several residents in the facility treated with rashes. LPN #3 stated he also had a rash, was seen by his family physician in May 2022. He stated he was treated with Permethrin cream. In an interview with the Director of Nursing (DON) on 07/24/2023 at 3:55 PM, she stated if a resident were diagnosed with scabies, staff would be expected to follow facility policy when caring for those residents. She stated if staff were to be diagnosed with Scabies they should see their physician for treatment. In an interview with the Advanced Practice Registered Nurse (APRN), on 07/24/2023 at 4:58 PM, she stated after beginning work at the facility, the Medical Director informed her there was an outbreak of scabies in the facility. APRN stated Resident #46's rash had been treated with multiple creams but would always return even after seeing dermatology and being treated for Scabies. The APRN stated she did perform a skin scraping on Resident #46 on 12/21/2022 but the specimen was lost. She stated the order was canceled and she did not repeat the testing. During a telephone interview with the Medical Director (MD), on 07/25/2023 at 8:35 PM, he stated there had been several residents with a rash that was concerning. He stated it sometimes took months for residents to see a dermatologist. The MD further stated if he thought a resident had scabies, he wouldn't want to wait, so he would treat empirically, even without a definitive diagnosis. He stated if he empirically treated with Ivermectin and the resident did not get better, he would think the resident did not have scabies. The MD expected all rashes to be followed through with, treatment to be consistent and nursing staff follow the treatment plan. In an interview with the Administrator, on 07/27/2023 at 10:40 AM, she stated she would expect the staff to track communicable diseases per facility policy. She stated if these communicable diseases were not followed other residents could become affected. 2. Review of the medical record revealed the facility admitted Resident #16 on 05/06/2021 diagnoses which included , Generalized Anxiety Disorder and Chronic Kidney Disease. Review of Resident #16's Annual Minimum Data Set (MDS) Assessment, dated 07/18/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15) indicating severe cognitive impairment. Review of Physician Orders, dated 07/30/2023, revealed Resident #16 was placed on enhanced barrier precautions. Observed signage on door of Resident #16's room indicated bed B was on Enhanced Barrier Precautions (EBP). Signage stated that when providing high contact care, that included wound care, brief changes and linen changes, a gown and gloves were required to be used. Observation on 08/05/2023 at 10:12 AM, revealed Registered Nurse (RN) #2 and Certified Nursing Assistant (CNA) #22 enter Resident #16's room. Further observation revealed RN #2 performed a skin assessment, provided wound care to Resident #16's coccyx, without donning an isolation gown. Following wound care CNA #22 assisted RN #2 with providing incontinent care to Resident #16. CNA #22 failed to don a gown prior to providing direct care. In an interview with CNA #22 on 08/05/2022 at 10:30 AM, she stated she had not donned a gown prior to assisting RN #2 in providing care to Resident #16. CNA #22 stated she was not aware that Resident #16 was on EBP even though signage was present on the door. She stated she should have put on a gown because of the precautions. In an interview with RN #2, on 08/05/2023 at 12:00 PM, she stated residents were on EBP for different reasons. She stated it was basically contact precautions and staff wore gowns and gloves when providing care tasks listed on posted signage. RN #2 stated she did not don a gown when she performed a skin assessment, provided wound care, and assisted CNA #22 with incontinent care for Resident #16. She further stated she should have because cross contamination could occur when precautions were not followed. During an interview with the Director of Nursing (DON), on 08/05/2023 at 2:26 PM, she stated she expected staff to adhere to the EBP signage posted. She stated gowns and gloves should be worn when staff provided direct care. The DON stated not following the guidance could result in cross contaminations and potential infections for other residents. In an interview with the Administrator, on 08/05/2023 at 2:39 PM, she stated her expectations were that staff would follow facility policy related to EBP. She stated if guidelines indicated a gown and gloves be worn then staff should be wearing those when providing care to a resident on EBP. 46651

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to expired medications were removed from the medication refrigerators, per the facility's policy for one (1) of two (2) medication refrigerators. Observation a medication refrigerator on 08/03/2023, revealed expired medications for Resident's #35 and #32 were stored in the refrigerator. The findings include: Review of the facility's policy, Label/Store Drugs & Biologicals Standard of Practice, dated 10/2020, revealed drugs and biologicals must be labeled in accordance with currently accepted professional principles, and include the expiration date when applicable. Further review revealed expired and/or discontinued medication shall be removed from the medication storage area for timely return to pharmacy and/or documented destruction. Review of the facility's policy, Medication Administration Standard of Practice, dated 10/2020, revealed expired/beyond use date medication should not be administered. Observation on 08/03/2023 at 10:26 AM, of the medication refrigerator on [NAME] Drive Unit, with Registered Nurse (RN) #2, revealed there were six (6) Promethagan (a medication for nausea) suppositories, 12.5 milligrams (mg) per rectum, labeled for Resident #35, marked as opened on 5/12/2023. However, the expiration date stamped on the packaging was dated 04/2023. Continued observation revealed six Promethegan suppositories, 12.5 mg, labeled for Resident #32, with a stamped expiration date of 04/2023. During an interview with Registered Nurse (RN ) #2 on 08/03/2023 at 10:31 AM, she stated management audits the medication carts and refrigerators for anything that is out of date. She further stated it was important to discard expired medications so residents do not receive ineffective treatment. During an interview with RN #3 on 08/05/2023 at 9:13 AM, she stated expired medications should be discarded and not administered because they could ineffective. During an interview with the Director of Nursing (DON), on 08/05/2023 at 2:20 PM, she stated expired medications should be removed from the refrigerators so that they aren't administered to residents. She stated expired medications could be ineffective if administered. The DON stated that either she or the Unit Manager audit the carts and the medication room about once per week to remove any expired medications. Additionally, she stated she expected the nurses to watch for expiration dates on medications as they are giving them and remove any that have expired. During an interview with the Administrator, on 08/05/2023 at 3:10 PM, she stated medications that have expired should be taken out of circulation so a resident does not receive it. She stated the medication may not be effective if it's expired. The Administrator further stated she expected nurses to observe expiration dates on medications and discard them when indicated.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to protect residents from physical abuse for four (4) of fifty-five (55) sampled residents (Residents #36, #49, #50, and #213). On 01/15/2023, staff responded to an incident of Resident #213 striking Resident #50 on the face, in the common area. On 10/02/2022, staff had reported witnessing Resident #49 touching Resident #36's chest area above his/her clothing. The findings include: Review of the facility's policy, Abuse Prohibition Standard of Practice, dated 07/2022, revealed the facility would prohibit and prevent abuse, neglect, exploitation, misappropriation or resident property and ensure reporting and investigating of alleged violations, mistreatment and involuntary seclusion in accordance with Federal and State laws. 1 (a). Review of closed record revealed the facility admitted Resident #213 on 12/09/2022 with diagnoses which included include Vascular Dementia, Altered Mental Status Unspecified, and Major Depressive Disorder. Review of Resident #213's Quarterly Minimum Data Set (MDS) Assessment, dated 03/09/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) Score of zero (0) out of fifteen (15) indicating severe cognitive impairment. (b). Review of the medical record revealed the facility admitted Resident #50 on 06/16/2022 with diagnoses which included Spastic Quadriplegic Cerebral Palsy, Other Seizures and Phobic Anxiety Disorder. Review of Resident #50's Annual MDS Assessment, dated 06/23/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) Score of nine (9) out of fifteen (15) indicating moderate cognitive impairment. Review of the Long-Term Care Facility Self-Reported Incident Form, dated 01/15/2023 and completed by the Director of Nursing (DON), revealed on 01/15/2023 at 6:45 PM, Resident #50 was watching television in the common area. Resident #213 was ambulating and stopped in front of the television. Further review of the form revealed Resident #50 yelled at Resident #213 to move away from the TV and Resident #213 walked over to Resident #50 and made contact with Resident #50's face. Per review of the form the Residents' were separated and moved from the common area. Both Residents were assessed for injury and no injuries were noted. Resident #213 was placed on one to one (1:1) observation. Review of Progress Note for Resident #50, dated 01/15/2023 at 7:46 PM, signed by Licensed Practical Nurse (LPN) #4, revealed resident was sitting in the lobby with peers when he/she asked another peer to move out in front of the TV. Resident #213 went over to peer and grazed Resident #50's face with his/her hand. Resident #50 was immediately removed from the situation no injury noted. Review of Progress Note for Resident #213, dated 01/15/2023 at 7:47 PM, signed by LPN #4, revealed Resident #213 was standing in lobby when Resident #50 told him/her to move from the front of the television. Resident #213 swatted at Resident #50. Resident #213 was placed on 1:1 with staff. In an interview with the Social Services Director (SSD), on 07/25/2023 at 3:14 PM, she stated the Administrator was the Abuse Coordinator. She stated she had no role in investigating allegations of abuse. She stated the former Administrator handled all of the facility reported incidents. In an interview with the former Administrator, on 07/26/2023 at 1:13 PM, he stated he was the facility's abuse coordinator. He stated nursing would do the clinical part of the investigation and he would typically do the resident and staff interviews. He stated skin assessments, resident and staff interviews were done for every allegation. He further stated facility staff received education on abuse when the allegations occurred. During an interview with Certified Nursing Assistant (CNA) #12 on 08/05/2023 at 9:58 AM, she stated she was working when Resident #213 and Resident #50's incident occurred. She stated Resident #213 would often try to box at the television because he/she did not like what it was saying. CNA #12 further stated she was doing rounds when she heard Resident #50 yelling out and she went to see what was going on. She stated Resident #213 had swatted at Resident #50 but she could not tell if contact was made. She stated the residents were separated and Resident #213 was redirected. CNA #12 further stated Resident #213 was placed on 1:1 observation following the incident. In an interview with Licensed Practical Nurse (LPN) #4, on 08/03/2021 at 6:08 PM, she stated she was working when Resident #50 was in the common watching television. She stated she did not witness the incident but staff reported that Resident #213 was ambulating and stopped and was standing in front of the television. LPN #4 further stated Resident #50 yelled at Resident #213 to move. Resident #213 then went towards Resident #50 and swatted at him/her. She stated the residents were separated and Resident #213 was redirected from the area. LPN #4 stated Resident #213 was very unpredictable and she was not aware of any other issues with Resident #213. She stated Resident # 213 was placed on 1:1 observation. In an interview with the Director of Nursing (DON), on 08/05/2023 at 2:26 PM, she stated the former Administrator had made her aware of the incident with Resident #50 and #213. She stated nursing did skin assessments. The DON stated Resident #213 had a history of aggressive behaviors at home. She stated Psych Services started seeing Resident #213 and medication adjustments were made after the incident. In an interview with the Administrator, on 08/05/2023 at 2:39 PM, she stated she was the Abuse Coordinator for the facility. She stated her expectations were that residents remained free from abuse. 2 (a). Review of the medical record revealed the facility admitted Resident #36 on 08/06/2020, with diagnoses which included Dementia Unspecified with Behavioral Disturbance, Mood Disorder, and Generalized Anxiety Disorder. Review of Resident #36's Quarterly Minimum Data Set (MDS) Assessment, dated 06/22/2023, revealed a Brief Interview for Mental Status (BIMS) was not completed as Resident #36 was rarely or never understood. Continued review revealed Resident #36 had severe cognitive impairment. (b). Review of the medical record revealed the facility admitted Resident #49 on 04/19/2022 with diagnoses which included Vascular Dementia with Behavioral Disturbance, Schizophrenia, and Generalized Anxiety Disorder. Review of Resident #49's Quarterly Minimum Data Set (MDS) Assessment, dated 06/15/2023 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15) indicating moderate cognitive impairment. During an interview with Resident #49, on 07/26/2023 at 10:18 AM, the resident was unable to recall incident from October 2022. He/she was unable to answers question related to the incident Review of the Long-Term Care Facility Self-Reported Incident Form, dated 10/02/2022 and signed by the former Administrator, revealed that staff had reported witnessing Resident #49 touching Resident #36's chest area above his/her clothing. Further review of the report revealed the residents were separated immediately and assessed for any physical or social effects related to the alleged incident, with no issues noted. Review of a Facility Investigation Summary, dated 10/05/2022, revealed interviews with staff who observed Resident #49 place his/her hand on the chest area of Resident #36, stated that he/she was not touching or communicating with Resident #49. Staff reported Resident #49 was easily redirected from the area and that no further incidents occurred during the shift. Further review of the report revealed the residents were assessed for any adverse effects related to the incident and none were noted. Both residents were placed on increased observation and no other incidents have occurred. Review of a witness statement, not dated or signed, from Certified Nursing Assistant (CNA) #15, revealed she reported seeing Resident #49's hand on Resident #36's chest area, while the residents were in the hall. She stated Resident #36 was not touching or communicating with Resident #49. Further review of the document revealed CNA #15 removed Resident #36 form the area and that Resident #49 was easily redirected. In an interview with CNA #15, on 08/05/2023 at 3:18 PM, she stated both residents were in the hall when Resident #36 rolled up to Resident #49. She stated Resident #49 touched the chest area of Resident #36, over his/her shirt. CNA #15 stated she separated the residents and reported the incident to the Charge Nurse. She stated Resident #49 was placed on fifteen (15) minute checks. She stated she was not aware of any other incidences with Resident #49. In an interview with the Director of Nursing (DON), on 08/05/2023 at 2:26 PM, she stated the former Administrator had made her aware of the incident with Resident #50 and #213. She stated nursing did skin assessments. The DON stated Resident #213 had a history of aggressive behaviors at home. She stated Psych Services started seeing Resident #213 and medication adjustments were made after the incident. The DON further stated she was aware of the incident bewtween Resident #36 and Resident #49. She stated Resident #49 was placed on fifteen minute checks and no other incidents with Resident #36 had occurred. In an interview with the Administrator, on 08/05/2023 at 2:39 PM, she stated she was the Abuse Coordinator for the facility. She stated her expectations were that residents remained free from abuse

Based on interview, record review, review of facility policy, and review of the Resident Assessment Instrument (RAI) Manual, it was determined the facility failed to review and revise a comprehensive person-centered care plan for one (1) of fifty-five (55) sampled residents (Resident #49). Record review revealed Resident #49's care plan was not revised after he/she exhibited inappropriate sexual behaviors on 10/02/2022, 10/25/2022, and 10/26/2022. The findings include: Review of the RAI Manual, Section 4.7 The RAI and Care Planning, dated 10/2019, revealed the care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident required. Review of the facility's policy, Comprehensive Care Plans Standard of Practice, dated 10/2020, revealed an individualized comprehensive care plan should include objectives and timetables to meet the residents medical, nursing, mental, and psychosocial needs, were to be developed for each resident. Assessments of residents were ongoing and care plans were revised as information about the resident and the residents condition change. Care plans were reviewed and updated when there was a significant change in the residents condition, when the desired outcome was not met, when a resident had been readmitted to the facility from a hospital stay and at least quarterly. Review of the medical record revealed the facility admitted Resident #49 on 04/19/2022 with diagnoses which included Vascular Dementia with Behavioral Disturbance, Schizophrenia, and Generalized Anxiety Disorder. Review of Resident #49's Quarterly Minimum Data Set (MDS) Assessment, dated 06/15/2023 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15), indicating moderate cognitive impairment. Review of Resident #49's Comprehensive Care Plan revealed, the facility established a behavior care plan for Resident #49 on 04/19/2022. Continued review revealed there we no indicators of behaviors added to the care plan until 02/17/2023, prefers companionship of female peers. Additionally, on 03/06/2023, history of grabbing other residents' wheelchairs prohibiting movement was added. Review of care plan interventions dated 05/01/2022, revealed the following interventions, allow resident time to verbalize feelings, be alert for increase signs and symptoms of depression, encourage resident to participate in programs of their choosing, and invite resident to recreation programs. Additionally, the following interventions, psychologist to visit as needed, psychiatrist to visit PRN and redirect resident during behavioral episodes were added to the care plan on 03/06/2023. Continued review of the care plan revealed there was no documented evidence Resident #49's care plan was revised after he/she displayed sexually inappropriate behaviors on 10/02/2022, 10/25/2022, and 10/26/2022. Review of the Long-Term Care Facility Self-Reported Incident Form, dated 10/02/2022 and signed by the former Administrator, revealed that staff had reported witnessing Resident #49 touching Resident #36's chest area above his/her clothing. Further review of the report revealed the residents were separated immediately and assessed for any physical or social effects related to the alleged incident, with no issues noted. Review of a Facility Investigation Summary, dated 10/05/2022, revealed interviews with staff who observed Resident #49 place his/her hand on the chest area of Resident #36, stated that he/she was not touching or communicating with Resident #49. Staff reported Resident #49 was easily redirected from the area and that no further incidents occurred during the shift. Further review of the report revealed the residents were assessed for any adverse effects related to the incident and none were noted. Both residents were placed on increased observation and no other incidents have occurred. Review of Resident #49's Progress Note, dated 10/25/2022 at 5:28 PM, completed by the former Administrator, revealed Resident #49 was witnessed in the hallway rubbing his/her crotch area while looking at a female resident. Resident #49 was immediately redirected for to his room for privacy without difficulty. Review of a Progress Note dated 10/26/2022 at 9:59 AM, completed by the Social Services Director (SSD), revealed it was brought to the writers' attention by therapy staff that it was reported by a female resident that Resident #49 made him/her feel uncomfortable due to inappropriate thought processes. Review of a Progress Note dated 10/26/2022 at 12:05 PM, completed by the former Administrator, revealed it was reported by a female resident to writer that Resident #49 made an unwelcome verbal sexual advances toward him/her while in the hallway. The female resident stated that Resident #49 asked her to go to bed. After the female resident declined to go to this residence bed twice, Resident #49 left the area. Review of a Progress Note dated 10/26/2022 at 1:51 PM, revealed the former Administrator requested the SSD speak with Resident #49 about his/her behaviors and make referral to inpatient psychiatric services due to increased sexual behaviors. Further review of the note revealed the SSD and Activity Director met with Resident #49, explained the situation, and offered services. When SSD poke to Resident #49 about inappropriate behaviors residents stated, that's silly, I don't know what you're talking about, Resident #49 was agreeable to go to inpatient treatment. Review of a Progress Note dated 10/27/2022 by the Director of Nursing (DON), revealed Resident #49's plan of care was reviewed. Resident #49 noted to be inappropriate with peers. New orders received to send for the resident for a psych evaluation. In an interview with the Minimum Data Set (MDS) Coordinator, on 08/05/2023 at 1:41 PM, she stated care plans were an interdisciplinary team approach. She stated all nurses have been trained on how to do care plans. The MDS Coordinator further stated the Social Services Director (SSD) would typically do care plans related to behaviors but it was a team effort. She stated the facility discussed behaviors daily in the clinical meeting and Resident #49's care plan should have been updated and revised with any new and increased behaviors. In an interview with the Director of Nursing (DON) on 08/05/2023 at 2:26 PM, she stated Resident #49's care plan should have been revised when the incidents occurred. She stated the facility discussed behaviors daily during morning meeting. The DON stated the SSD or the MDS nurse should have revised Resident #49's behavior care plan. In an interview with the Administrator on 08/05/2023 at 2:39 PM, she stated she expected care plans to be updated and revised to reflect changes in resident behavior.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure each resident had a safe, clean, comfortable, and homelike environment for five (5) of five (5) residents' sampled rooms. Observations on 07/31/2023 through 08/04/2023, revealed multiple resident rooms had peeling wallpaper, chipped paint, and damaged walls (Rooms 3-A, 21-A, 28-B, 31-A and 37-A). The findings include: Review of the facility's policy, Homelike Environment Standard of Practice, dated 10/2020 revealed the facility would provide residents with a safe, clean, comfortable and homelike environment. The facility should maximize, to the extent possible, characteristics of the facility to reflect a personalized, homelike setting that should include cleanliness and order. 1. Observation of room [ROOM NUMBER]-A on 07/31/23 at 10:40 AM, revealed the wallpaper was peeling from the seams. 2. Observation of room [ROOM NUMBER]-B on 08/01/23 at 8:44 AM, revealed chipped and peeling paint on the wall. Linoleum at the door threshold between the hall and the room was chipped. 3. Observation of room [ROOM NUMBER]-A on 08/01/23 at 8:54 AM, revealed a large hole in bead board on the wall along the side of the resident's bed. In an interview with Resident #14 on 08/01/2023 at 8:54 AM, the resident stated he/she didn't like the look of the wall and wished they would fix it. 4. Observation of room [ROOM NUMBER]-A on 08/01/23 at 10:15 AM, revealed paint was chipping from areas of the wall. 5. Observation of room [ROOM NUMBER]-A on 08/04/2023 at 10:02 AM, revealed a large circular area of missing wallpaper. In an interview, on 08/05/2023 at 2:30 PM with the Director of Nursing (DON), she stated the facility had painters coming and there had been no complaints from the resident families about the environment. She stated she would expect wall paper peeling, chipped paint, and holes in the walls, to be repaired timely to reflect a home like environment for the residents. In an interview, on 08/05/2023 at 3:35 PM with the Maintenance Director, he stated the facility was currently in the process of painting, removing wallpaper, and replacing some flooring. He stated he was the only person in the facility doing the work and was hard to get it all done sometimes. The Maintenance Director stated it was his expectation repairs were to be made timely to create a home like environment for the residents. In an interview with the Administrator, on 08/05/2023 at 2:39 PM, she stated the facility was working on removing peeling wallpaper and painting. She stated stated the Maintenance Director performed most of the work. The Administrator stated she expected the environment to be pleasing and homelike for residents.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure a resident who was assessed to be mentally incapacitated had his/her Advance Directive information given to and signed by his/her Resident Representative for one (1) of three (3) residents sampled for closed records (Resident #214). Closed record review revealed on 05/25/2023, Resident #211 signed his/her own Kentucky Emergency Medical Services Do Not Resuscitate (DNR) Order and Cardiopulmonary Resuscitation Consent. Further review of Resident 214's Quarterly Minimum Data Set Assessment (MDS) Assessment, dated 05/15/2023, revealed the resident had severe cognitive impairment. The findings include: Review of the facility's policy, Advance Directive Standard of Practice, dated 10/2020, revealed resident's had the right to formulate an Advance Directive and to accept or refuse medical or surgical treatment. The facility would periodically assess the resident for decision making abilities and approach the health care proxy or legal representative if the resident was determined not to have decision making capacities in regard to Advance Directives and/or treatment provision. Closed record review revealed the facility readmitted Resident #214 on 05/11/2023 with diagnoses which included Paranoid Schizophrenia and Cognitive Communication Deficit. Review of Resident #214's Quarterly Minimum Data Set Assessment (MDS) Assessment, dated 05/15/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), indicating severe cognitive impairment. Review of a Social Service's Note dated 04/11/2023 at 12:25 PM, entered by the Social Services Director (SSD) revealed she had informed Resident #214's brother of the resident's recent BIMS score and discussed options which included seeking guardianship for Resident #214. The SSD noted the Resident #214's brother/Responsible Party told her he would seek guardianship on Resident #214's behalf and she provided him with contact information to move forward in the guardianship process. Review of an email dated 04/19/2023 at 8:24 AM from the SSD to the Guardianship Field Services Office Supervisor (GFSOS), revealed she had referred Resident #214 for State Guardianship and had listed Resident #214's Responsible Party. The form stated the reason for the Guardianship Referral was that Resident #214 was unable to receive care services and recourses due to cognitive impairment. Review of an SSD note dated 04/25/2023 at 2:01 PM, revealed the SSD had completed Resident #214's referral documents and had submitted then to the State Guardianship Field Office via email and was awaiting next steps. Review of Resident #214's Cardiopulmonary Resuscitation Consent (CRC) and Kentucky Emergency Services Do Not Resuscitate Order (DNR) documents, dated 05/25/2023, revealed the documents were labeled with Resident #214's name and had been signed on 05/25/2023 with an illegible signature. The DNR document had been witnessed by the Director of Nursing and the Certified Medication Technician (CMT) #11/Ward Clerk. In a phone interview on 07/25/2023 at 2:50 PM with Resident #214's Responsible Party, he stated he was never Resident #214's guardian or power of attorney (POA). He stated he did not have a chance to get the paperwork completed before the resident had passed away. Resident #214's Responsible Party further stated the facility had not discussed the residents code status with him. He stated he would have liked to discuss that with Resident #214. In an interview with the Director of Nursing (DON), on 07/18/2023 at 4:53 PM, she stated Resident #214 had signed his/her own Do Not Resuscitate (DNR) Order and Cardiopulmonary Resuscitation Consent. In an interview with the Social Services Director (SSD), on 07/25/2023 at 3:02 PM, she stated she had been in her role at the facility since 10/13/2021. She stated the BIMS assessment is usually completed by either herself, the Activities Director or by the MDS Nurse. The SSD stated a resident with a BIMS score of three (3) would be considered as having severe cognitive impairment. She stated she would not advise a resident with a BIMS score of three to sign their own legal documents. Additionally, she stated wasn't aware Resident #214 had signed his/her own DNR paperwork and felt the resident did not have the cognitive ability to sign the paperwork. In an interview on 07/25/2023 at 3:43 PM with Certified Medication Technician (CMT) #11, she stated her role at the facility was CMT/Scheduler/Ward Clerk. She stated a BIMS score of three indicated cognitive impairment. CMT #11 stated she did not check Resident #214's BIMS score before she witnessed him/her signing the code status documents. CMT #11 stated she would rely on the Director of Nursing (DON) to make her aware of a resident's impaired cognition and could not sign a document. CMT #11 stated she felt like Resident #214 presented as cognitively intact to her the day the resident signed the documents. In an interview with the Director of Nursing (DON), on 07/25/2023 at 3:38 PM, she stated she had been the DON for the past eighteen (18) months. She stated as a clinician she knew from a resident's cognition could change from day to day. The DON stated she was not aware of Resident #214's BIMS score prior to the resident signing his/her code status documents. She stated on the day Resident #214 signed his/her code status documents, the resident was oriented to self and place and could identify the DON and CMT #11. The DON further stated it would have been a good idea for her to assess the resident's BIMS score immediately prior to having him/her sign the code DNR paperwork. In an interview with the Administrator, on 07/25/2023 at 3:25 PM, she stated she knew the DON and CMT #11 witnessed the Resident #11 sign his/her paperwork, changing his/her code status at the facility. The Administrator stated it was her expectation the DON act as a prudent nurse and do what was best for the residents. She stated she would expect the DON to assess a resident's cognitive level prior to having the resident sign an Advance Directive.

Based on observation, interview, facility policy review, and the Center for Disease Control and Prevention (CDC) guidance, it was determined the facility failed to ensure an open vial of [MEDICATION(S)] (PPD) serum used for the [MEDICATION(S)] skin test (TST) for [CONDITION(S)] (TB) screening for residents and staff was labeled with an open date. Observations revealed one (1) of three (3) vials of PPD serum was opened and undated in the Foxes Drive Hall's medication refrigerator. The findings include: Review of the facility's policy, [CONDITION(S)], Employee Screening, revised [DATE], revealed all employees were screened for latent TB infection and active TB disease using the [MEDICATION(S)] skin test (TST) and symptom screening. Review of the facility's policy, [CONDITION(S)], Screening Residents, revised [DATE], revealed the facility screened all residents for TB infection and TB disease. The resident, who may have been exposed to TB or was at increased risk for TB infections would be screened using the TST. Review of the CDC's guidance on multi-dose vials, undated, revealed if a multi-dose vial was opened and needle punctured, the vial should be dated and discarded within twenty-eight (28) days. Observation on [DATE] at 9:45 AM, revealed the medication refrigerator on the Foxes Drive Hall had three (3) boxes of PPD serum. One (1) box had a glass vial with the plastic top removed. The vial did not have an open date on the glass vial or on the box. Interview with the Registered Nurse (RN) #2, on [DATE] at 9:56 AM, revealed the nurse who opened the multi-dose medications, including the PPD serum, should document an open date on the bottle. The RN revealed this would include the PPD serum used to screen residents and staff for TB. RN #2 stated pharmacy staff audited the refrigerators once a month for expired or unlabeled medications. Further review revealed the facility's clinical management also audited the refrigerators occasionally for undated or outdated medications. She stated if it was used past the 28 days, the serum would not be effective for screening for TB. RN #2 revealed if a resident or staff had TB and an undated PPD serum was used the facility may not be aware of an active case of TB. The RN stated everyone in the facility would then be potentially exposed to TB. In addition, the facility was responsible to ensure all medications were effective. Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 9:45 AM, revealed she observed the PPD serum vial opened, and that the glass vial and box were undated. The LPN revealed staff were to label the PPD serum with an open date to ensure the PPD serum was not used after it was open for 28 days. The LPN revealed if the facility used ineffective PPD serum, the residents would not be properly screened for TB, and it could cause staff and residents to be exposed to TB. LPN #1 stated the facility educated staff upon hire to label and date all open multi-vial medications, including the PPD serum. In addition, the LPN stated all nurses knew to label medications with an open date to ensure the residents' medications, including PPD serum were effective. Interview with the Staff Development Coordinator (SDC), on [DATE] at 1:00 PM, revealed the nurse should label all multi-dose medications with the date it was opened. She stated staff were to place a date on the PPD serum upon opening because the serum was not effective after 28 days. The SDC stated the facility screened for TB to protect staff and residents. In addition, she stated all staff knew to label all bottles and vials with an open date. She further stated the facility had audited the medication refrigerators on [DATE]. Interview with the Assistant Director of Nursing (ADON), on [DATE] at 12:45 PM, revealed staff should place a date on the opened vial of PPD serum to ensure it was not used for TB screening after twenty-eight (28) days. She stated all nurses were responsible to date bottles, boxes or vials. She further stated she had not identified any issues with undated medications or with the PPD serum vials. Interview with the DON (Director of Nurses), [DATE] at 7:00 PM, revealed she expected staff to date any opened PPD serum vials. She stated if the PPD serum was undated it could be used after 28 days. She stated if staff used the PPD serum after 28 days it would not be effective for the screening of TB. Furthermore, she stated she expected staff to follow the facility's policies and procedures. Interview with the Administrator, on [DATE] at 5:19 PM, revealed he expected staff to follow guidelines the facility's policies. He stated the facility had not identified issues with multi-dose vials not properly dated.

Based on observation, interview, record review, review of the facility's policy and the ProView Assure Glucometer User's Guide, it was determined the facility failed to ensure a glucometer meter was calibrated per the manufacturer's guidelines for one (1) of two (2) hallways, the Harmony Hall. Record review revealed the Harmony Hall Glucose Quality Control (QC) Log, dated April 2022, was missing the glucose control testing results from April 11, 2022, through April 20, 2022. Furthermore, the facility did not provide the Harmony Hall QC Log for March 2022 after it was requested. The manufacture's guidelines revealed the QC testing was to be completed weekly. The findings include: Interview with the Director of Nursing (DON), on 05/05/2022 at 1:00 PM, revealed the facility did not have a policy for glucometer monitoring or calibration. The DON stated the facility used the manufacturer's guideline for testing. Review of the ProView Assure Glucometer User's Guide, undated, revealed the facility should perform QC solution tests weekly, with a new bottle of strips; and, a new meter, if the test strip bottle was left open or the meter was dropped. Observation and review of the Harmony Hall Assure Platinum Blood Glucose Monitoring System QC record, dated April 2022, revealed no documentation of glucose meter control results from 04/11/2022 through 04/20/2022. In addition, the facility did not provide a QC Record for March 2022 for the Harmony Hall. Interview with Registered Nurse (RN) #2, on 05/05/2022 at 9:56 AM, revealed the RN observed the Harmony Hall April QC Log was blank from 04/11/2022 to 04/20/2022. RN #2 revealed she could not locate the March 2022 QC Log. The RN stated the night shift was responsible for completing and documenting the QC results on the log daily. RN #2 stated staff did not routinely review the Log to ensure if the QC had been completed. Further review revealed the controls were to be done in order to make sure the glucometer was accurate. RN #2 stated if the glucometer was not accurate a resident may get too much or not enough insulin. The RN stated the wrong dose of insulin could put the resident in a critical condition. However, the RN stated she assumed the glucometer QC was completed and she should not have assumed staff completed the daily control. Interview with Licensed Practical Nurse (LPN) #1, on 05/22/2022 at 10:26 AM, revealed staff on the night shift were responsible to complete the QC for the glucometer. The LPN stated the QC was completed to ensure the glucometer readings were accurate for the resident's blood sugar. However, the LPN stated she did not know where the QC logbook was located on the unit. LPN #1 stated when staff did not complete the QC, the resident's blood sugar reading could read too high or low. Continued interview revealed if staff administered the wrong dose of insulin, the resident could go into a coma. The LPN stated all clinical staff were to ensure the QC logs were completed daily. LPN #1 stated the facility provided education on diabetic management which included staff's responsibility to complete the QC of the glucometer's. Interview with the Staff Development Coordinator (SDC), on 05/06/2022 at 1:00 PM, revealed the night shift nurses were to complete the daily QC on all glucometers. The SDC stated the nurses administered insulin based on the result of the resident's blood glucose. She stated the wrong amount of insulin could hurt the resident. Interview with the Assistant Director of Nursing (ADON), on 05/06/2022 at 12:45 PM, revealed staff were to complete daily glucometer QC on the night shift. She stated staff based insulin administration on the glucometer results and the staff could give too much or too little insulin. The ADON stated the result could be a [CONDITION(S)] which could lead the resident to die. The ADON stated she had not audited the QC logs. In addition, she expected staff to follow the facility's policy or guideline recommendations for glucometer QC for each hall. Interview with the Director of Nursing (DON), on 05/06/2022 at 5:19 PM, revealed the staff on the night shift were to complete the QC for all glucometers weekly. The DON stated staff completed the QC to ensure the resident's glucose levels were accurate. Further interview revealed if the glucose levels were not accurate, staff may administer the wrong amount of insulin to the resident. She stated if a wrong dose of insulin was given it could hurt the resident. The DON stated staff were to follow the manufacture's guideline for QC. Continued interview revealed she had not audited the QC logs for the two (2) units. Interview with the Administrator, on 05/06/2022 at 7:00 PM, revealed he expected staff to follow guidelines or policies of the facility. He stated the facility had not identified issues with residents with very high or very low blood glucose levels.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to provide supervision to ensure an environment free from accidents and hazards for one (1) of thirty-three (33) sampled residents (Resident #5). Review of Resident #5's Electronic Medical Record revealed since 05/01/2021 to 05/01/2022, the resident had twenty-six (26) falls and eighteen (18) of those falls were unwitnessed. Additionally, most of the falls occurred when the resident attempted to go to the bathroom. Resident #5 sustained an injury to his/her head on 06/19/2021 from an unwitnessed fall which resulted in a laceration of two-point four (2.4) centimeters (cm) by one-point three (1.3) cm on the back of his/her head. The facility sent Resident #5 to the Emergency Department (ED). Resident #5 sustained another fall with injury on 04/17/2022 which resulted in a fractured finger. The resident's finger was splinted. The findings include: Review of the facility's policy titled, Falls Standards of Practice, dated 07/2000, revealed the facility would ensure the residents' environment remained free from hazards and the residents would receive adequate supervision and assistant devices to prevent accidents. The policy also stated after a resident had a fall and was cared for, an incident report and investigation would be completed. Appropriate interventions would be determined and put in place after each fall. Review of the facility's policy titled, Incident & Accident Process, dated 07/2020, revealed the facility would identify hazards and/or risks, evaluate and analyze the hazard/risk, implement interventions to reduce hazards and monitor interventions for effectiveness and modify when necessary. The Interdisciplinary Team (IDT) would review trends and interventions at least weekly for falls. Record review revealed the facility admitted Resident #5 on 03/18/2021 with diagnoses which included [CONDITION(S)], [CONDITION(S)], left hip pain, [CONDITION(S)] with lower urinary tract symptoms, difficulty walking, lack of coordination, lack of expected normal physiological development in childhood and abnormal posture. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 05/09/2021, revealed the facility assessed Resident #5 as a physical assistance of one (1) staff for bed mobility, transfers, and toileting. Further review revealed the facility assessed the resident to use his/her walker to ambulate. The facility assessed Resident #5's Brief Interview for Mental Status (BIMS) score as a seven (7) out of fifteen (15) which indicated the resident was severely cognitively impaired. Review of the Annual MDS assessment, dated 10/21/2021, revealed the facility assessed Resident #5 as a physical assistance of one (1) staff for bed mobility, transfers, and toileting. The facility assessed Resident #5's BIMS' score as a six (6) out of fifteen (15) which indicated the resident was severely cognitively impaired. Review of the Quarterly MDS assessment, dated 02/07/2022, revealed Resident #5 required the physical assistance of two (2) staff for bed mobility, transfers, toileting, and personal hygiene. The facility assessed Resident #5's BIMS as a six (6) out of fifteen (15) which indicated the resident was severely cognitively impaired. Review of Resident #5's Fall Care Plan, dated 03/18/2021, revealed the resident had impaired balance with transitions, was incontinent of bladder and bowels, hearing impairment, depression, Manic Depression and [CONDITION(S)] all of which contributed to his/her fall concerns. One problem area was identified on 03/18/2021, the resident's history of falls, weakness, abnormal gait and mobility. Additionally, the facility assessed the resident to have occasional incontinence, poor safety awareness and impaired cognition and impulses. Interventions put in place on 03/18/2021, included for the resident's bed to be against the wall to enhance functionality of the room, and for Resident #5 to have a fall assessment upon admission, quarterly and with changes and/or falls. Review of Resident #5's Fall Management Events revealed from 05/10/2021 to 05/01/2022 the resident fell twenty-six (26) times. The resident fell on [DATE], 06/01/2021, 06/19/2021 (times 2), 08/10/2021, 10/08/2021, 10/15/2021, 11/09/2021, 11/18/2021, 12/2/2021, 12/09/2021 (times 2), 12/19/2021, 01/04/2022, 02/10/2022, 02/18/2022, 02/19/2022, 02/25/2022, 03/11/2022, 03/15/2022, 04/06/2022 (times 2), 04/13/2022, 04/17/2022, 04/25/2022, and 05/01/2022. Review of the facility's Fall Event Report, dated 05/10/2021 at 4:15 PM, revealed Resident #5 had a witnessed fall in his/her room (although event reported stated it was an unwitnessed fall). The report revealed the Medication Technician (MT) saw resident attempt to go to the restroom and he/she fell to the floor. The MT assisted the resident back to bed and assessed him/her. No injuries were found. It was also noted on the Event Report that the resident felt dizzy before he/she fell . The Interdisciplinary Team (IDT) determined the Root Cause (RC) to be resident's history of falls prior to admission, low cognition, impaired mobility, shuffled gait with house shoes on his/her feet. However, the staff instructed the resident to use the call light when he/she needed to use the bathroom and wait for assistance. The facility failed to provide Resident #5's Progress Notes as requested from 05/10/2021 to current. Instead, the facility provided Progress Notes for 02/01/2022 to 04/30/2022. Review of the Fall Event Report, dated 06/01/2021 at 7:30 PM, revealed Resident #5 had a witnessed fall. A nurse observed Resident #5 as he/she walked down the hall, the nurse noted the resident shuffled his/her feet and held the walker way out in front of him/her. The nurse reminded the resident to hold the walker closer and to pick up his/her feet, which the resident did. A few minutes later the Certified Nursing Assistant (CNA) informed the nurse the resident had fallen in the doorway of his/her room. The resident rubbed his/her right hand and right knee and stated they both hurt. It was noted the resident had on house slippers which were too big when this fall occurred. Resident #5 told the nurse his/her slipper twisted and caused him/her to fall. This fall was witnessed by a resident across the hall. The Event Report also revealed the resident was on Analgesics, Anticonvulsants, and Antihypertensives at the time of this fall. Continued review of the Fall Event for 06/01/2021, revealed the facility identified the RC for this fall as the resident's slippers were too big. It was also noted Resident #5 needed smaller shoes to fit him/her properly. X-rays were negative for fractures. Review of the facility's Fall Management Event dated 06/19/2021 at 7:30 PM, revealed Resident #5 had an unwitnessed fall. A Nurse Assistant (NA) reported to the nurse she heard Resident #5 yell from the room. When staff entered the room, the resident was found on the floor, halfway between the television stand and the bathroom doorway. Resident's pants were halfway down, and the resident did not have shoes or socks on. Staff placed nonskid socks on the resident's feet and resident was helped up. No injuries were documented with this fall. The IDT determined the RC was resident's attempt to toilet himself/herself and the resident did not pull up his/her pants nor did the resident have shoes on. It was also noted the resident was on Antipsychotic's at the time of this fall. Review of the facility's Fall Management Event dated 06/19/2021 at 7:30 PM, revealed Resident #5 had an unwitnessed fall. The NA found the resident on the bathroom floor. It was noted resident had slipped and hit his/her head and sustained a laceration of 2.3 cm x 1.4 cm to the back on his/her head and it bled badly. The facility sent Resident #5 out to the ED for a CT scan of his/her head. Resident #5 had suffered a previous fall about thirty (30) minutes prior to this fall. It was documented at the time of this fall that the resident had taken Antipsychotics and sleeping medication. Continued review of the fall event for 06/19/2021 revealed the IDT determined this fall was caused when the resident attempted to toilet himself/herself. The resident did not use the walker to assist him/her to the bathroom. Resident #5 was given a urinal to use at the bedside. Review of the facility's Fall Management Event dated 08/10/2021 at 8:00 AM, revealed Resident #5 had an unwitnessed fall when he/she tried to put his/her slippers on. The event noted the resident was last seen on the side of his/her bed. The resident complained of pain to the right wrist. An x-ray was taken and no injury was found. Resident #5 was noted to be on Antihypertensives and Antipsychotics at the time of this fall. The IDT determined the resident's slippers were out of reach was the cause of this fall. Review of the Fall Management Event dated 10/08/2021 at 3:45 PM, revealed Resident #5 had a witnessed fall when he/she ambulated in the hallway with his/her walker when the walker got caught up with another resident's walker. Resident #5 attempted to lock the breaks on his/her walker and turned to sit in the seat of the walker when he/she missed and fell to the floor. The RC of this fall was determined to be the resident's misjudgment of the distance of the walker seat when he/she attempted to sit on it. The facility related this fall to the resident's low cognitive function, history of falls and abnormal gait and mobility issues contributed to this fall. Review of the Fall Management Event dated 10/15/2021 at 7:15 AM, revealed Resident #5 had an unwitnessed fall. The resident left his/her room without assistance, without socks, and helmet and walker. It was noted the resident attempted to use the bathroom, in a hurry. It was also noted the resident did not make it to the bathroom and had an incontinent episode. He/She was cleaned up and assisted back to bed. The nurse who responded to the fall reminded the resident to use his/her helmet, ensure shoes were on and to use the call light before ambulation. Resident was noted to have poor safety awareness, the IDT discussed concerns and determined the interventions in place were appropriate. Review of the Fall Management Event dated 11/09/2021 at 5:45 PM, revealed Resident #5 had a witnessed fall in the common area as he/she ambulated from the dining table and attempted to pick up his/her coffee. It was noted the resident reached for his/her coffee and lost his/her balance and fell . Resident #5 was noted to be on Anticonvulsant's, Antihypertensives, and Antipsychotic's at the time of this fall. The IDT determined staff would provide assistance to the resident to get his/her items back to the room after meals. Review of the Fall Management Event dated 11/18/2021 at 10:45 AM, revealed Resident #5 had a witnessed fall, when he/she ambulated unassisted with house shoes on his/her feet. The house shoes the resident had on were worn out; the resident was given another pair. It was noted Resident #5 had redness to both hands and knees, skin was intact, and no injuries were noted. The IDT referred the resident for therapy. Review of the Fall Management Event, dated 12/02/2021 at 2:15 PM, revealed Resident #5 had a witnessed fall when he/she attempted to stand up, staggered backward, bumped into an arm chair a fell to the floor and landed on his/her buttocks. The IDT determined physical therapy would continue and deemed this intervention as appropriate. Review of the Fall Management Event, dated 12/09/2021 at 6:45 AM, revealed Resident #5 ambulated with the walker toward the dining room. It was noted the resident shuffled his/her feet and had his/her shoes on the wrong feet, the resident fell in front of kitchen staff. It was noted the resident complained of right knee pain and had a contusion on the knee. The IDT determined this fall was caused by the resident's shuffle when he/she walked and because the resident had his/her shoes on the wrong feet. Staff were informed they needed to ensure the resident had on proper footwear. Review of the Fall Management Event, dated 12/09/2021 at 4:45 PM, revealed Resident #5 had an unwitnessed fall. The resident stated he/she fell when he/she tried to get to the bathroom. Resident #5 was noted without shoes or socks on. There were no injuries noted. The IDT determined the RC of this fall was the resident attempted to ambulate without socks on. No new interventions were identified. Review of the Fall Management Event, dated 12/19/2021 at 5:00 PM, revealed Resident #5 had an unwitnessed fall when he/she attempted to go to the bathroom. The resident did not use his/her wheelchair, did not have socks or shoes on and reported pain to the left elbow, sore to the touch. The IDT determined the RC was the resident's inability to recognize his/her own limitations and the resident's history of falls. The resident was expected to have a decline in Activities of Daily Living (ADL) based on his/her history of falls and diagnoses upon entry to the facility. Physical Therapy would continue to work with the resident to ensure he/she used their wheelchair when the resident was tired and for long distances. Review of the Fall Management Event, dated 01/04/2022 at 7:41 AM, revealed Resident #5 had an unwitnessed fall when he/she attempted to get to the bathroom. No injuries were identified and a bed alarm was put in place. The Root Cause Analysis (RCA) revealed the resident continued to get up even when instructed not to without asking for assistance related to history of diagnosis with poor safety awareness, and a history of falls since admission. Intervention was to have bed alarms used as the resident would allow or would tolerate them. Review of the Fall Management Event, dated 02/10/2022 at 1:30 PM, revealed Resident #5 had an unwitnessed fall. The resident was found in his/her room on the floor after an episode of diarrhea which caused the resident to be weak. The resident also recovered from COVID at the time of this fall. The facility's RCA determined this fall was caused because of the resident's increased weakness from COVID and several episodes of diarrhea. Review of Resident #5's Progress Notes and the for 02/10/2022 at 2:45 AM, revealed the Assistant Director of Nursing (ADON) documented the resident had three (3) large diarrhea stools and was incontinent with each episode. Resident #5 did not complain of any pain and did not have any nausea or vomiting at the time. Staff encouraged resident to drink more fluids. Review of the Fall Management Event, dated Progress Notes, both 02/18/2022 at 5:53 PM, revealed Resident #5 had an unwitnessed fall. Resident #5's roommate called down the hall to alert staff he/she had fallen. When staff entered the room, the resident was found on the floor on his/her back. Resident #5 complained of pain in his/her upper left leg and a skin assessment revealed redness to the leg. Staff reeducated the resident about his/her call light, to ask for assistance to ambulate and to wear nonskid socks. The event noted the resident was seated in his/her wheelchair prior to the fall and the resident fell as he/she tried to get to the bathroom. This event did not identify a RCA . Review of the Fall Management Event, dated 02/19/2022 at 6:15 PM, revealed Resident #5 had a witnessed fall as he/she ambulated in the hallway without assistance of his/her walker. The event noted the resident sat down on the floor. The RCA was determined to be the resident ambulated without the use of his/her walker or wheelchair. It was decided the resident would be moved closer to the Nurses' Station. Review of Resident #5's room assignments revealed the resident was in Room 18 B from 01/31/2022 until 02/21/2022 at which time the resident was moved to Room 8 B. Resident #5 was moved to Room 3 A on 05/03/2022 at 4:11 PM. Review of Resident #5's Progress Notes, dated 02/19/2022 at 11:45 PM, revealed while the resident ambulated outside of his/her room without assistance of a walker or staff, the resident lost his/her balance and sat of the floor. A complete skin assessment was done and a superficial, nonbleeding abrasion was found on the resident's left elbow. Resident #5 complained only of slight discomfort. No new orders were received. Review of Facility's Fall Management Event, dated 02/25/2022 at 10:30 PM, revealed Resident #5 had an unwitnessed fall when he/she attempted to use the bathroom unassisted. An aide reported to the nurse she heard the resident call for help. When staff entered the room, it was noted the resident had his/her hand stretched out, as to ask for help up and told staff he/she got weak and fell . The facility determined the RCA was the resident's attempt to get to the bathroom without assistance. At this time, the facility placed a bed alarm and provided the resident an urinal. The resident reported weakness was the cause of the fall. Review of the Fall Management Event, dated 03/11/2022 at 6:00 PM, revealed Resident #5 had an unwitnessed fall when he/she attempted to get to the bathroom. Staff were informed by the resident in the adjoined room Resident #5 had fallen. Resident #5 was found on the bathroom floor with his/her pants down to their knees, on his/her side. The walker was also knocked over on the side. The facility identified the RCA was the resident got out of bed before he/she called for assistance through the call light. It was noted this fall happened at shift change, but the resident was put to bed after his/her needs were met. Resident #5's walker was removed from the room because of his/her limited insight for safety awareness. Therapy would continue to work with resident on his/her balance and transfers. Review of Resident #5's Progress Notes, for 03/11/2022, revealed the ADON noted the resident had another fall. Resident #5 stated he/she had just used the bathroom and had fallen. No injuries were noted. The resident was placed back in bed, with the bed alarms as ordered and the call light was within reach. On 03/12/2022, Resident #5 complained of left flank pain and a urine sample was taken, to check for an Urinary Tract Infection ([CONDITION(S)]). Review of the Fall Management Event, dated 03/15/2022 at 12:30 PM, revealed Resident #5 had an unwitnessed fall as the resident attempted to get to the bathroom. Staff found the resident seated on the bathroom floor with his/her head rested against the wall. The facility determined the RCA was the resident attempted to ambulate to the bathroom by himself/herself. A tab alarm was attached to resident at this time. Review of Resident #5's Progress Notes revealed, on 03/15/2022 at 9:47 PM, the resident was found on the bathroom floor by housekeeping staff. Resident #5 was helped up and back to bed. Resident #5 informed staff he/she was up to use the bathroom, but his/her wheelchair was across the room and the brakes were locked on it. Further review revealed Resident #5 stated, I know, I am a lot of trouble. Resident # 5 agreed to stay in the wheelchair so staff could do neuro checks on him/her just in case the resident had hit his/her head. About one (1) hour later, the resident was helped back to bed and complained of left hip pain. The Nurse Practitioner (NP) was contacted and an x-ray was ordered for left hip/pelvic area. On 03/16/2022, review of the report received showed the x-ray was negative. Review of the Fall Management Event, dated 04/06/2022 at 1:15 PM, revealed Resident #5 had an unwitnessed fall when the resident attempted to get to the bathroom. Resident #5 was found on the floor of his/her bathroom propped up on his/her right side against the wall. The resident stated he/she lost his/her balance and fell . The IDT determined nonskid strips would be placed at the resident's toilet area. Review of the facility's Fall Management Event, dated 04/06/2022 at 2:30 PM, revealed Resident #5 had an unwitnessed fall after he/she was placed in bed. The facility determined after the resident was placed in bed, he/she stood up and fell . Staff would now encourage the resident to remain in the common area when he/she was up in the wheelchair. The IDT determined the RCA to be the resident lost his/her balance. Physical and Occupational Therapy would evaluate and a chair alarm would be used as a preventive measure. Review of Resident #5's Progress Notes, dated 04/13/2022 at 6:26 PM, revealed the resident was observed on the floor next to his/her wheelchair. Resident #5 informed Licensed Practical Nurse (LPN) he/she had removed the alarm so it was not going off. Resident #5 did not complain of any pain and no Range of Motion (ROM) concerns were noted. Review of the Progress Note, dated 04/13/2022 at 6:44 PM, revealed the facility placed non skid strips at the front of the resident's bedside table. Review of the Fall Management Event, dated 04/15/2022 at 6:00 PM, revealed Resident #5 had an unwitnessed fall when he resident attempted to stretch and reach for something on his/her bedside table. It was noted the resident had a pull tab alarm attached to him/her while seated in the wheelchair. Further review revealed the resident stated, he/she took the alarm off. At this time the resident was provided a Reacher tool to assist him/her. The IDT determined Resident #5 was very independent with the desire to maintain his/her independence as long as possible. Resident #5 did not ask for help and disconnected his/her alarm on his/her own. Review of the Fall Management Event, dated 04/17/2022 at 6:00 PM, revealed Resident #5 had an unwitnessed fall. Staff had placed the resident in his/her room and left to go to another room. Once the staff member left, the alarm sounded and by time staff returned to Resident #5's room, the resident was on the floor. Resident #5 complained of pain to his/her left wrist/hand and could not make a fist as it caused pain. The facility requested an x-ray of his/her left wrist/hand. Resident #5 did not require to use the bathroom at this time. The resident had his/her shoes on, and the alarm tag was reapplied to resident. The resident was placed on fifteen (15) minute checks. Review of the facility's Fall History, dated 04/17/2022, revealed the facility assessed Resident #5 with intermittent confusion, three (3) or more falls within the past three (3) months, he/she was ambulatory and incontinent, could see adequately with/without glasses, and required the use of an assistive device (cane, walker or wheelchair). Resident #5 did not have a drop in his/her Systolic Blood Pressure (SBP) when repositioned from a lying to standing position. He/She was assessed to take one (1) to two (2) medications that could cause impairments but had not had any medication reductions in the past seven (7) days. Resident #5 was listed with three (3) or more of the following conditions: Predisposing disease, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], Diuretics, Hypnotics, Psychotropics, [NAME] Diazepines, Hypoglycemic, Cathartics or Sedatives. Resident was scored a nineteen (19) for a fall risk, a ten (10) or higher was considered high risk. Review of the Fall Management Event dated 04/25/2022 at 3:30 PM, revealed Resident #5 had an unwitnessed fall in his/her room. When staff entered the room, they assisted him/her back up to the wheelchair. Further review revealed the staff interviewed determined the resident had taken himself/herself back to their room. Resident #5 changed his/her own clothes and put himself/herself to bed. It was determined staff had not placed the resident in bed for the night. No injuries were identified. The IDT identified through RCA the resident required additional supervision and was not to be left in his/her room unassisted. Review of Resident #5's Progress Notes, revealed on 04/18/2022, Resident #5's hand was noted to have light purple bruising to the base of the little and ring finger. Resident #5 was able to hold his/her cup to drink water with his/her left hand. Review of Resident #5's Progress Notes, revealed on 04/20/2022, the facility contacted the resident's brother to inform him the resident had a fractured finger and a new order for [MEDICATION(S)] as needed for pain. The Medical Director saw Resident #5 on 04/20/2022 and determined the resident needed a splint for his/her finger. Review of the Fall Management Event, dated 04/25/2022 at 3:30 PM, revealed Resident #5 had an unwitnessed fall when the resident returned to his/her room and changed his/her clothes. Although the resident was on fifteen (15) minute watches, he/she was able to return to his/her room, remove his/her shirt, put on another shirt and attempted to change his/her pants. Once discovered, the resident was found on the floor, laying flat without pants on. It was determined the resident self-propelled back to his/her room and closed the door half-way. The IDT determined staff would be reeducated to monitor Resident #5 and not to allow him/her to be in the room unassisted. Review of the Fall Management Event, dated 05/01/2022 at 1:00 AM, revealed the bed alarm for Resident #5 sounded and staff entered to check on the resident, staff witnessed the resident fall out of the bed as he/she attempted to get up to use the bathroom. Resident #5 hit the wheelchair, which was next to the bed, as he/she fell out of the bed and landed on the floor on his/her bottom. The writer of the event noted the resident was in bed and decided to get up to use the bathroom. The resident complained about right thigh pain and pain across the lower abdomen area. The IDT identified through RCA the resident would have a pressure alarm, clipped alarm and the bed was put in the lowest position. Review of Resident #5's Fall History dated 05/01/2022 revealed the facility assessed Resident #5 with intermittent confusion, three (3) or more falls within the past three (3) months. Resident #5 scored a twenty-one (21) for a fall risk, a ten (10) or higher was considered high risk. Interview with LPN #1, on 05/06/2022 at 4:00 PM, revealed Resident #5 was very independent and would often remove chair and bed alarms. She stated the resident often refused any type of help from staff. She believed there was no way to get Resident #5 to ask for or even accept help. She described the resident as very proud. LPN #1 stated it helped to keep the resident up in the common area as he/she really liked to socialize and travel up and down the halls. Attempted interview with LPN #2 on 05/06/2022 at 5:00 PM, unable to make contact and a voice message was left. Attempted interview with LPN #3 (completed event for 06/19/2021 fall, resulted in a laceration to head) on 05/06/2022 at 5:05 PM, phone number provided by the facility was no longer in service. Interview with the Minimum Data Set Coordinator (MDSC), on 05/06/2022 at 5:20 PM, revealed the facility met weekly to discuss falls and tried to determine what was the reason for the falls, what was in place to prevent the fall and if it worked. She stated if the intervention did not work, the team would work to establish a plan for a new intervention which worked. Interview with the Director of Nursing (DON), on 05/06/2022 at 5:20 PM, revealed she felt like the facility tried everything they could to prevent Resident #5 from falls. She revealed the resident was very independent and the facility wanted to allow for that. She also revealed the resident had a helmet he/she brought when he/she first arrived at the facility and it was for the resident to use when he/she wanted to. Continued interview with the DON, on 05/06/2022 at 5:20 PM, revealed when a resident had a fall, an immediate intervention was put into place. She was to be notified and the intervention would then be discussed to determine how appropriate it was. The fall would be discussed at the next IDT meeting, if it was on a weekday, it would be the very next day. If the fall happened on a Friday or Saturday it would be discussed on Monday. The DON stated the Medical Director or the Nurse Practitioner were notified for every fall, not just injury falls. The DON stated what ever actions were taken for falls would be listed under the intervention section of the care plan as a record to show the facility took some kind of action. Interview with the Administrator, on 05/06/2022 at 9:00 PM, revealed he had only been in his position about four (4) months and felt facility staff had done quite a bit to develop interventions for Resident #5. He stated all falls were discussed in weekly meetings and in QAPI. The Administrator stated he expected the interventions listed on the Fall Event to be followed as well as the policies and procedures of the facility. He also revealed Quality Assurance had identified the facility had a high number of falls. Further interview revealed a plan was developed on 04/28/2022, to include the use of the bed alarms. He stated the facility worked hard to determine which bed alarms could be reduced and to look at each resident and their falls to determine what interventions could be put in place. The Administrator stated it was most important for the residents to feel the facility was their home and he tried to make sure they stayed safe and got great care.

Based on observation, interview, record review and review of the facility's policy it was determined the facility failed to provide the needed care and services to ensure the residents met the highest practical physical, mental and psychosocial needs for one (1) of thirty-three (33) sampled residents (Resident #41). The findings include: Record review revealed the facility admitted Resident #41, on 01/17/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #41 Quarterly Minimum Data Set (MDS) assessment, dated 10/01/2020, revealed the facility assessed Resident #41's cognition as impaired with a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident was not interviewable. Review of Section G: Functional Status, revealed the facility assessed the resident as totally dependent for care. Review of Resident #41's care plan revealed the resident was to wear Thera Carrots (a device placed in the palm Review of Resident #41's care plan, revealed the resident was care planned to wear Thera Carrots (device used to prevent/treat contractures), to bilateral hands daily, for two (2) hours, related to contractures. Further review revealed restorative nursing was responsible to place the device in the resident's hands. Observations on several days revealed, the thera carrots were never put in place, per Doctors orders Observations on 05/03/2022 at 6:20 AM, 10:00 AM, and 12:49 PM, revealed Resident #41 was noted to have contractures to bilateral hands, the palms of his/ her hands were white, dry with a scaly appearance, with redness. Resident #41 did not have Thera Carrots in place. Observations on 05/04/2022 at 8:00 AM, 12:00 PM, and 3:30 PM,revealed Resident # 41's hands continued to be clinched with a much tighter looking grip. Observations on 05/05/2022 at 10:00 AM, 2:00 PM, and 4:00 PM, revealed Resident #41's Thera Carrots were not in place. Observation on 05/06/2022 at 10:30 AM, revealed Resident #41 continued to have clinched hands bilaterally. The Thera Carrots were not in place. Interview with Registered Nurse (RN) #1, 05/06/2022 at 10:36 AM, revealed, she was familiar with the resident, but had only worked with the facility for about one (1) month. RN #1 was unaware of any treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Certified Nursing Assistant (CNA) #6, on 05/06/2022 at 10:30 AM, revealed CNA was aware of the Thera Carrots. CNA #6 stated she had never placed them in the resident's hands and she did not know how and was afraid of hurting the resident. CNA #6 stated there was no restorative nursing. Interview with the Administrator, on 05/06/2022 at 10:35 AM, related to his expectations of restorative nursing care plans being performed. Administrator stated, the facility does not have designated restorative staff, his expectations would be that the CNA's on duty would perform restorative duties. Interview with Staff Development Coordinator (SDC), on 05/06/2022 at 10:40 AM, related to completing education for staff who are unaware of job requirements and job duties, SDC stated she had only been in the position for a few weeks, but her expectation would be to train any staff that are unaware of procedures.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to revise a comprehensive person-centered care plan for residents with measurable objectives to meet a resident's medical, nursing, and mental and psychosocial needs for two (2) of thirty-three (33) sampled residents (Resident's #5 and #6). The facility failed to update Resident #5's care plan after the resident fell on [DATE], 06/01/2021, 08/10/2021, 10/08/2021, 11/09/2021, and 03/11/2022, to reflect the interventions staff implemented on the resident's fall report. The facility failed to update Resident #6's care plan with a tab alarm after the resident had a fall on 12/31/2021. Resident #5 sustained a fall on 05/10/2021, 06/01/2021, 08/10/2021, 10/08/2021, 10/15/2021, 11/09/2021, 12/02/2021, 12/09/2021, 02/18/2022, 03/11/2022, and 04/25/2022. The facility failed to revise the resident's Comprehensive Care Plan (CCP) to establish interventions for each of the noted falls. The findings include: The facility revealed they used the Resident Assessment Tool to develop the CCP and did not have a policy. Review of the facility's policy, Falls Standard of Practice, last reviewed 07/2020, revealed the facility was to immediately put interventions in place once the resident's Fall Assessment was completed. The policy also revealed at the time of a fall; appropriate interventions were to be determined. After a fall, the Interdisciplinary Team (IDT) would review the interventions and determine if they were effective or if new interventions were required to prevent continued falls. Review of the facility's policy, Incidents and Hazards Standards of Practice, last revised on 02/2021, revealed all incidents and/or hazards were to be identified, evaluated, interventions determined, monitored, reviewed and changed when a fall took place. The IDT was responsible to ensure appropriate interventions were used. They were also expected to track and trend falls and establish new interventions if the current ones were not effective. 1. Review of Resident #5's Electronic Medical Record (EMR) revealed the facility admitted Resident #5 on 03/18/2021, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, Resident #5 was diagnosed as [CONDITION(S)] and [CONDITION(S)]. Review of Resident #5's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15), which indicated severe cognitive impairment. The facility also assessed the resident to require the physical assistance of one (1) staff member for bed mobility, to transfer, to dress, to eat, to toilet and for personal hygiene. Resident #5 could ambulate with his/her walker. Review of Resident #5's Quarterly MDS, dated [DATE], revealed the facility assessed the resident with a BIMS of six (6) out of fifteen (15), which indicated sever cognitive impairment. The facility also assessed the resident to require physical assistance of two (2) staff members for bed mobility, to toilet and for personal hygiene. Resident #5 was assessed to require one (1) staff member for physical assistance to transfer and to dress. Resident #5 only required set-up for his/her meals. Review of Resident #5's CCP, dated 03/18/2021, revealed the facility identified him/her as a fall risk and identified the resident's bed would be up against the wall to enhance functionality of the room (03/18/2021). Fall assessments would be done on admission, quarterly and with changes or falls. On 03/27/2021, a new intervention was added to ensure the resident was taken to the bathroom when he/she woke up, at each meal and at bedtime. Review of the facility's Fall Management Event dated 05/10/2021, revealed Resident #5 had an unwitnessed fall at 4:15 PM. The facility determined through Root Cause Analysis (RCA) the resident needed to wear tennis shoes instead of house shoes. However, this information was not updated on the CCP. Review of the facility's Fall Management Event, dated 06/01/2021, revealed Resident #5 had a witnessed fall at 11:15 AM. Through the RCA, the facility determined the resident needed smaller shoes. The fall event noted the resident informed staff he/she had pain in the right hand, right knee and right hip. The facility determined the resident required smaller shoes, however that was not documented on the CCP. Review of the Fall Management Event, dated 08/10/2021, revealed Resident #5 had an unwitnessed fall at 8:00 AM as he/she attempted to put slippers on without assistance. The facility determined the resident's slippers needed to be placed where they were easily accessible to the resident. This information was not documented on the CCP. Review of the Fall Management Event, dated 10/08/2021, revealed Resident #5 had a witnessed fall at 3:45 PM. The facility established an intervention to place bright colored tape on the resident's walker seat to better help him/her judge the distance to the seat. This information was not documented on the CP. Review of the Fall Management Event dated 11/09/2021, revealed Resident #5 had a witnessed fall at 5:45 PM. The facility determined the resident required additional assistance when he/she attempted to take items back to the room. This intervention was not documented on the CP. Review of the Fall Management Event dated 03/11/2022, revealed Resident #5 had an unwitnessed fall at 6:00 PM. The facility determined the resident's walker should be removed from the resident's room due to the resident's continued cognitive decline. This intervention was not carried over to the CP. Review of the Fall Management Event dated 04/25/2022 revealed Resident #5 had an unwitnessed fall. The facility noted they would encourage the resident to use his/her personal helmet. This intervention was not listed on the CP. Interview with Certified Nursing Assistant (CNA) #7, on 05/06/2022 at 4:40 PM, revealed she learned of the care required for each resident from the Care Plan and the Kardex. She also revealed she received shift report. CNA #7 revealed the use of the plan helped to prevent harm of the resident. Interview with Certified Nursing Assistant (CNA) #6, on 05/06/2022 at 4:45 PM, revealed she used the Kardex to determine how to care for each resident. She revealed this was important to ensure the residents got the proper and best care to ensure their needs were met. Interview with Certified Medication Aide (CMA), on 05/06/2022 at 4:30 PM, revealed when she arrived for shift she got report from the off going staff. She stated resident care was determined by the Care Plan and the Kardex. The CMA revealed the Care Plan was the guide for care and it helped to prevent the residents from harm. Interview with the MDS Coordinator (MDSC) on 05/06/2022 at 5:20 PM, revealed the nursing staff was responsible to update the Care Plan after a resident had a fall. She revealed she would go behind the nurse staff and look at the Care Plan for any updates. The MDSC revealed the IDT met after each fall and discussed the fall as a team. They would discuss the possible cause of the fall, what interventions were already in place, if they worked and what interventions needed to be revised. Attempted interview with Licensed Practical Nurse (LPN) #3 on 05/06/2022 at 4:20 PM, revealed the phone number provided by the facility was no longer in service. Attempted interview with LPN #2 on 05/06/2022 at 4:22 PM, left a voice message was and return call was not received. Interview with the Director of Nursing (DON) 05/06/2022 at 5:20 PM, revealed all nurse staff were expected to update and revise Care Plans, if they felt comfortable to do so. She revealed she would work with management staff to ensure they were trained on how to update the Care Plan and to ensure they understood why it was important to review and revise it. She revealed falls were to immediately be updated and a new interventions put in place if deemed necessary. She also stated staff were to call her and let her know that a fall occurred, and they would discuss the new intervention to ensure it was appropriate. The DON stated it was important to review and revise the Care Plan to make sure the resident received the best care to keep them safe. She also revealed she expected all nurse staff to follow the Care Plan. Interview with the Administrator, on 05/06/2022 at 9:01 PM, revealed Care Plans were to be updated anytime a resident had a change in condition and they needed to be reviewed to determine if the intervention were effective. He expected staff to follow the Care Plan because the care provided was always about the resident. The Administrator also revealed if a resident refused to participate in treatment or refused services that should be documented in the resident's Progress Notes and on the Care Plan. He also revealed it was important for all staff to follow the resident's individual Care Plan because it was tailored to the resident to ensure the best possible care for them. The Administrator revealed each fall was discussed with the IDT and in Quality Assurance, they discussed the interventions, if they worked and what interventions needed to be changed. He felt the facility did everything it could to prevent Resident #5 from more falls. He also revealed any information for interventions listed on the Fall Event should have been carried over to the resident's Care Plan. 2. Review of Resident #6's EMR (electronic medical record) revealed the facility admitted the resident on 09/22/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's readmission MDS, dated [DATE] revealed the resident had a BIMS of nine (9) out of fifteen (15) which indicated moderate cognitive impairment. The facility assessed Resident #6 as a one (1) person physical assistance for bed mobility, to transfer, to ambulate around the facility, to dress, to eat, to toilet and for personal hygiene. Review of Resident #6's Quarterly MDS, dated [DATE], revealed the resident's BIMS was ten (10) out of fifteen (15) which indicated moderate cognitive impairment. The assessment revealed the resident required an extensive physical assist of one (1) staff. The resident was noted without any upper or lower extremity impairments and now required a wheelchair to ambulate. Review of Resident #6's Progress Notes, revealed on 12/31/2021, the resident had two (2) back to back falls. One at 9:30 AM, when the resident was found by staff on the floor and it was noted resident hit his/her head. Also at 5:33 PM, the resident was again found on the floor, as he/she attempted to use the bathroom. The Nurse Practitioner ordered for the resident to have a pull tab alarm attached to him/her. Review of Resident #6's Care Plan Report established on 09/21/2020, revealed resident was at risk for injury related to falls and needed assistance due to weakness related to liver, lung, bowel, muscle weakness and altered mental status (10/12/2020). Resident #6 had a fall on 04/07/2021 and 06/14/2021. Per this Care Plan, fall interventions were established on 10/12/2020 to ensure proper footwear was on resident while out of bed, to notify Medical Director (MD) and family of falls or falls with injuries as needed. Resident was to have an anti- rollback wheelchair as well. Additional interventions were added on 04/19/2021 to ensure staff checked placement of bed covers with each round and to ensure medication was reviewed by the MD. On 01/01/2022, the resident's bed was moved to the lowest position. However, continued review revealed no intervention for the pull tab alarm ordered by the Nurse Practitioner. Interview with Certified Nursing Assistant (CNA) #7, on 05/06/2022 at 4:40 PM, revealed she learned of the care required for each resident from the Care Plan and the Kardex. She also revealed she received shift report. CNA #7 revealed the use of the plan helped to prevent harm of the resident. Interview with Certified Nursing Assistant (CNA) #6, on 05/06/2022 at 4:45 PM, revealed she used the Kardex to determine how to care for each resident. She revealed this was important to ensure the residents got the proper and best care to ensure their needs were met. Interview with Certified Medication Aide (CMA), on 05/06/2022 at 4:30 PM, revealed when she arrived for shift she got report from the off going staff. She stated resident care was determined by the Care Plan and the Kardex. The CMA revealed the Care Plan was the guide for care and it helped to prevent the residents from harm. Interview with the MDS Coordinator (MDSC) on 05/06/2022 at 5:20 PM, revealed the nursing staff was responsible to update the Care Plan after a resident had a fall. She revealed she would go behind the nurse staff and look at the Care Plan for any updates. The MDSC revealed the IDT met after each fall and discussed the fall as a team. They would discuss the possible cause of the fall, what interventions were already in place, if they worked and what interventions needed to be revised. Attempted interview with Licensed Practical Nurse (LPN) #3 on 05/06/2022 at 4:20 PM, revealed the phone number provided by the facility was no longer in service. Attempted interview with LPN #2 on 05/06/2022 at 4:22 PM, left a voice message was and return call was not received. Interview with the Director of Nursing (DON) 05/06/2022 at 5:20 PM, revealed all nurse staff were expected to update and revise Care Plans, if they felt comfortable to do so. She revealed she would work with management staff to ensure they were trained on how to update the Care Plan and to ensure they understood why it was important to review and revise it. She revealed falls were to immediately be updated and a new interventions put in place if deemed necessary. She also stated staff were to call her and let her know that a fall occurred, and they would discuss the new intervention to ensure it was appropriate. The DON stated it was important to review and revise the Care Plan to make sure the resident received the best care to keep them safe. She also revealed she expected all nurse staff to follow the Care Plan. Interview with the Administrator, on 05/06/2022 at 9:01 PM, revealed Care Plans were to be updated anytime a resident had a change in condition and they needed to be reviewed to determine if the intervention were effective. He expected staff to follow the Care Plan because the care provided was always about the resident. The Administrator also revealed if a resident refused to participate in treatment or refused services that should be documented in the resident's Progress Notes and on the Care Plan. He also revealed it was important for all staff to follow the resident's individual Care Plan because it was tailored to the resident to ensure the best possible care for them. The Administrator revealed each fall was discussed with the IDT and in Quality Assurance, they discussed the interventions, if they worked and what interventions needed to be changed. He felt the facility did everything it could to prevent Resident #5 from more falls. He also revealed any information for interventions listed on the Fall Event should have been carried over to the resident's Care Plan.

Based on observation, interview, record review, review of the facility's polices and the Resident Assessment Instrument (RAI) it was determined the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives to meet the resident's medical, nursing, mental and psychosocial needs for three (3) of thirty-three (33) sampled residents (Residents #5, #21 and #41). Resident #5 sustained twenty-six (26) falls from 05/01/2021 to 05/01/2022. The facility failed to follow the resident's Care Plan to ensure the resident was assisted as he/she ambulated throughout the facility. On 06/19/2021, Resident #5 sustained a fall and was transferred to the Emergency Department (ED). This fall resulted in a laceration on the back on his/her head which measured 2.4 centimeters (cm) by 1.3 cm. Additionally, the facility failed to ensure the resident was monitored every fifteen minutes and had on appropriate shoes at all times. Review of the incident reports revealed Resident #21 experienced multiple falls while alone in the rest room. Review of Resident #21's care plan revealed an intervention for an alarm on the bathroom door to alert staff to assist the resident. Observations during survey revealed the alarm in place; however the alarm was turned off. The facility failed to follow Resident #41's restorative care plan to ensure the resident's carrot pad was placed into his/her hands. The findings include: The facility revealed they used the Resident Assessment Instrument (RAI) to develop the Comprehensive Care Plan (CCP) and did not have a policy. 1. Record review revealed the facility admitted Resident #41, on 01/17/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #41 Quarterly Minimum Data Set (MDS) assessment, dated 10/01/2020, revealed the facility assessed Resident #41's cognition as impaired with a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident was not interviewable. Review of Section G: Functional Status, revealed the facility assessed the resident as totally dependent for care. Review of Resident #41's care plan revealed the resident was to wear Thera Carrots (a device placed in the palm to help with contractures), to the hands daily, for two (2) hours, related to contractures. Further review revealed Restorative Nursing was to place the Thera Carrots in the resident's hands. Observations, on 05/03/2022 at 6:20 AM, 10:00 AM, and 12:49 PM, revealed Resident #41 was noted to have contractures to his/her bilateral hands. The resident's palms were white, and dry, with a scaly appearance. Resident #41 did not have the Thera Carrots in place. Observations on 05/04/2022 at 8:00 AM, 12:00 PM, and 3:30 PM, revealed Resident # 41's Thera Carrots were not in place. Observations on 05/05/2022 at 10:00 AM, 2:00 PM, and 4:00 PM, revealed Resident #41's Thera Carrots were not in place. Observation on 05/06/2022 at 10:30 AM, revealed Resident #41's Thera Carrots were not in place. Interview with Registered Nurse (RN) #1, on 05/06/2022 at 10:36 AM, revealed she was unaware of any treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Certified Nursing Assistant (CNA) #6, on 05/06/2022 at 10:30 AM, revealed she was aware of Resident #41's Thera Carrots and immediately picked them up. However, CNA #6 stated she had never placed them in the resident's hands. She stated she did not know how and, she was afraid of hurting the resident. During interview with CNA #6 related to Restorative Nursing putting the Thera Carrots in place, she stated there was no restorative. Interview with the Administrator, on 05/06/2022 at 10:35 AM, related to his expectations for Restorative Nursing implementing Resident #41's care plans revealed the facility did not have designated restorative staff. He stated his expectations would be that the CNA's on duty would perform the restorative duties. Interview with the Staff Development Coordinator (SDC), on 05/06/2022 at 10:40 AM, revealed she expected staff to be trained on restorative devices for residents. 2. Record review revealed the facility admitted Resident #21, on 11/20/2017,with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS), dated [DATE], revealed the resident the facility assessed Resident #21 with a Brief Interview for Mental Status (BIMS) score of six (6), which indicated the resident was cognitively impaired. Review of Resident #21's care plan, related to Falls, revealed an intervention dated 07/09/2021, the resident would have a door alarm to the bathroom door to alert staff of his/her need for supervision and/or assistance with toileting. Review of incident reports related to Resident #21's falls, revealed a fall occurred on 07/09/2021 at 3:00 AM. Further review revealed Resident #21 was trying to clean himself/herself in the bathroom after a bowel movement, on 08/26/2021 at 11:00 PM and fell . The resident slipped in the bathroom while emptying a urinal on 09/10/2021 at 7:30 PM, and stood up from wheelchair to toilet and fell on [DATE] at 5:50 PM. Other falls included the resident fell while in bathroom on 11/02/2021 at 8:45 AM; the resident came out of bathroom lost balance and fell , 11:05/2021 at 8:15 AM; resident came out of bathroom lost balance and fell on [DATE] at 12:30 AM. Additionally, the resident up to bathroom on 02/14/2022 at 11:00 AM, and self reported a fall in bathroom and on 03/31/2022 at 7:00 AM. Interview with Registered Nurse (RN) #2, on 05/05/2022 at 10:43 AM, revealed when the door was open the alarm would sound. However, observation at time of interview revealed the bathroom door was open and the alarm was not sounding. Further review revealed the alarm was in place, but was turned off. Further observation during the interview revealed RN #2 turned on the bathroom door alarm. Interview with Certified Nursing Assistant (CNA) #6, on 05/06/2022 at 4:45 PM, related to Resident #21's care plans and use of alarms revealed she followed the cardix for providing resident care. CNA #6 stated, the alarms were put in place to alert staff when the resident was up and needed assistance. CNA #6 stated Resident #21 would get up and turn the alarm off. The CNA stated she actually had to turn the door alarm on six (6) times today. Interview with Certified Medication Aide (CMA), on 05/06/2022 at 4:30 PM, related to Resident #21's care and following the resident's care plan revealed they got report and followed the CNA's care plan/cardex to provide care. She stated the CNA care plan listed the alarms. 3. Review of Resident #5's Electronic Medical Record (EMR) revealed the facility admitted Resident #5 on 03/18/2021 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Mental Interview Status (BIMS) of seven (7) out of fifteen (15), which indicated severe cognitive impairment. The facility also assessed the resident to require the physical assistance of one (1) staff member for bed mobility, to transfer, to dress, to eat, to toilet and for personal hygiene. Resident #5 could ambulate with his/her walker. Review of Resident #5's Quarterly MDS, dated [DATE], revealed the facility assessed the resident with a BIMS' score of six (6) out of fifteen (15), which indicated severe cognitive impairment. The facility also assessed the resident to require the physical assistance of two (2) staff members for bed mobility, to toilet and for personal hygiene. The facility assessed Resident #5 to require one (1) staff member for physical assistance to transfer and to dress. Further review revealed the facility assessed Resident #21 to require set-up only, for his/her meals. Review of Resident #5's Comprehensive Care Plan established on 03/18/2021 and a start date of 02/14/2022, revealed the facility assessed the resident to need additional assistance of staff for Activities of Daily Living (ADLs) related to decline in ability to walk and decline in his/her cognition due to [CONDITION(S)]. As of 03/02/2022, the resident was only to use his/her walker to travel short distances and to use his/her wheelchair for long distances. Continued review of Resident #5's CCP revealed on 08/18/2021 staff were to check to ensure the resident had on nonskid shoes at all times (No discontinued date provided for this intervention). Also, staff were to encourage the resident to take longer even steps while ambulating. Resident was also care planned to participate in the daily dressing and grooming program. Review of Resident #5's Fall Management Event dated 10/15/2021 revealed the resident had a witnessed fall in the hallway. The resident did not have on non-skid socks or shoes. Review of Resident #5's Fall Management Event dated 11/18/2021, revealed the resident had a witnessed fall as he/she ambulated to the dining room. It was noted the resident had on house shoes/slippers and they were old and worn. Staff provided the resident with a new pair of house shoes. However, staff did not ensure the resident had on non-skid shoes as per his/her CP intervention dated 08/18/2021. Review of Resident #5's Fall Management Event dated 12/09/2021, revealed the resident used his/her walker to ambulate unassisted to the dining room. The event noted the resident had his/her shoes on the wrong feet. Review of Resident's #5's CP revealed the resident had an intervention in place for staff to ensure he/she had on non-skid shoes at all times. Additionally, the resident's CP reflected staff were to encourage the resident to take longer strides (08/18/2021), but the resident was noted to shuffle his/her feet without redirection prior to the fall. Review of the facility's Fall Management Event dated 12/09/2021 at 4:45 PM revealed Resident #5 had an unwitnessed fall and the facility determined the resident did not have on appropriate footwear. The CP revealed the resident was to be checked for proper footwear before he/she ambulated (08/18/2021). Review of the facility Fall Management Event dated 12/19/2021 at 5:00 PM, revealed Resident #5 had an unwitnessed fall. The facility determined this fall was caused because the resident did not have on appropriate footwear. Review of the facility's Fall Management Event dated 01/04/2022 at 7:41 AM, revealed the resident had an unwitnessed fall when the resident continued to get up even when instructed not to without asking for assistance. Resident #5 was care planned for additional assistance when he/she ambulated (08/18/2021). The facility did not ensure resident's CP was followed to prevent the resident from potential harm. Resident had a BIMS of seven (7) which indicated he/she had a severe cognitive impairment. Review of the facility's Fall Management Event dated 02/18/2022 at 5:53 PM, revealed Resident #5 had an unwitnessed fall when he/she attempted to ambulate unassisted. The facility failed to ensure the resident's CP was followed and that resident was safe from falls. Review of the facility's Fall Management Event dated 02/19/2022 at 6:15 PM, revealed Resident #5 ambulated outside of his/her room without assistance of staff and without assistance of his/her walker. Review of the facility's Fall Management Events dated 02/25/2022 at 10:30 PM; 03/11/2022 at 6:00 PM; 03/15/2022 at 12:30 PM; 04/06/2022 at 1:15 PM; and 2:30 PM revealed Resident #5 had unwitnessed falls when he/she attempted to go to the bathroom without assistance. The resident's CP revealed the resident required extra assistance to ambulate, however the facility failed to ensure the resident had assistance he/she needed. Review of the facility's Fall Management Event dated 04/13/2022 at 6:00 PM, revealed Resident #5 had an unwitnessed fall when he/she attempted ambulate without assistance. The resident's CP revealed resident required extra assistance to ambulate, however the facility failed to ensure the resident had assistance he/she needed. The CP was not followed. Review of the facility's Fall Management Event dated 04/17/2022 at 6:00 PM, revealed Resident #5 had an unwitnessed fall when he/she removed the pull tab alarm and attempted to ambulate without staff assistance. The facility was aware the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Fall Management Event, dated 04/25/2022 at 3:30 PM, revealed Resident #5 had an unwitnessed fall when he/she returned to his/her room unassisted. Review of the facility's Fall Management Event, dated 04/17/2022, revealed immediate intervention put in place of fifteen (15) minute checks was initiated. The facility allowed the resident to ambulate unassisted back to his/her room which resulted in a fall. Interview with Certified Nursing Assistant (CNA) #7, on 05/06/2022 at 4:40 PM, revealed she learned of the care required for each resident from the Care Plan and the Kardex. She also revealed she received pass down information from the prior shift. CNA #7 revealed the use of the plan helped to prevent harm of the resident. Interview with Certified Nursing Assistant (CNA) #6, on 05/06/2022 at 4:45 PM, revealed she used the Kardex to determine how to care of each resident. She revealed this was important to ensure the residents got the proper and best care to ensure their needs were met. Interview with Certified Medication Aide (CMA), on 05/06/2022 at 0 4:30 PM, revealed when she arrived for shift she got pass down' (report) information from the off going staff. She stated Resident #5's care was determined by the Care Plan and the Kardex and helped to prevent the residents from harm. Interview with the MDS Coordinator (MDSC) on 05/06/2022 at 5:20 PM, revealed the nurse staff were responsible to update the Care Plan after a resident had a fall. She revealed she would check behind the nurse staff and look at the Care Plan for any updates. The MDSC revealed the Interdisciplinary Team (IDT) met after each fall and discussed the fall as a team. They would discuss the possible cause of the fall. Attempted interview with Licensed Practical Nurse (LPN) #3 on 05/06/2022 at 4:20 PM, revealed the phone number provided by the facility was no longer in service. Attempted interview with LPN #2 on 05/06/2022 at 4:22 PM, left a voice message was and return call was not received. Interview with the Director of Nursing (DON), ON 05/06/2022 at 5:20 PM, revealed all nurse staff were expected to update and revise care plans if they felt comfortable to do so. She revealed falls were to immediately be updated and a new intervention put in place if deemed necessary. She also revealed staff were to call her and let her know that a fall occurred, and they would discuss the new intervention to ensure it was appropriate. The DON revealed it was important to review and revise the Care Plan to make sure the resident received the best care to keep them safe. She also revealed she expected all nurse staff to follow the Care Plan. Interview with the Administrator on 05/06/2022 at 9:01 PM, revealed Care Plans were to be updated anytime a resident had a Change in Condition (CIC) and they needed to be reviewed to determine if the intervention was effective or not. He expected staff to follow the care plan because the care provided was always about the resident. The Administrator also revealed if a resident refused to participate in treatment or refused services that should be documented in the resident's progress notes and on the Care Plan. Continued interview revealed it was important for all staff to follow the resident's individual Care Plan because it was tailored to the resident to ensure the best possible care for them. The Administrator revealed each fall was discussed with the IDT and in Quality Assurance, they discussed the interventions, if they worked and what interventions needed to be changed. He felt the facility did everything it could to prevent Resident #5 from more falls. He also revealed any information for interventions listed on the Fall Event should have been carried over to the resident's Care Plan.

Based on record review, interview, facility policy review, and review of a facility investigation, it was determined the facility failed to ensure an allegation of abuse was reported to the state survey agency and other officials in accordance with State Law for one (1) of fourteen (14) sampled residents (Resident #6). Resident #6 reported to staff on 05/09/2021 that SRNA #3 verbally and physically abuse him/her; however the facility failed to report the physical abuse to the state survey agency and other state agencies. The findings include: Review of the facility's policy, Abuse Prohibition Standard of Practice, with Revision date of 5/2020, revealed alleged violations that involved abuse, neglect, exploitation, misappropriation of resident property, (including injuries of unknown origin, mistreatment and involuntary seclusion), shall be reported to the state survey agency, adult protective services, and all required agencies within specified time frames. An attachment to the abuse policy directed staff to report a crime immediately, but no later than two (2) hours after forming the suspicion. The policy further stated the Administrator, Director of Nursing (DON), or Designee would report the findings of the allegations to the appropriate state and federal agencies, including law enforcement as required within five (5) working days of the alleged violation initial report. Review of Resident #6's medical record revealed the facility admitted the resident on 04/01/2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident required extensive assistance of two (2) persons with transfers and toileting. Per the MDS, the resident was assessed to have a Brief interview for Mental status(BIMS) score of seven (7) indicating severe cognitive impairment. Review of the facility investigations revealed during a facility investigation of an allegation of verbal abuse reported by Resident #5, the former Administrator interviewed Resident #6. During the interview, Resident #6 reported SRNA #3 had called him bad names and refused to assist him/her with toileting. The Resident stated he/she had to lay in bowel movement for a while. Resident #6 reported SRNA #3 eventually assisted him/her with toileting. The resident reported SRNA #3 had pulled him up from the chair by his/her neck and threw him/her down on the toilet. The Resident reported when the SRNA transferred him/her back to the wheelchair, the SRNA again picked him/her up by the neck and without cleaning his/her butt, threw him/her into the wheelchair hurting the resident's neck and legs. Per the resident interview, the resident had requested water to drink after being assisted back to bed and SRNA #3 refused to get the resident water. Also included with the investigation findings for Resident #5 were handwritten statements from LPN #1 and LPN #2 dated 05/09/2021 which documented Resident #6 had reported SRNA #3 had slammed him/her down on the toilet twice. The statements also revealed the resident reported being afraid of the SRNA #3. However, there was no evidence the allegation of physical and verbal abuse reported by Resident #6 was reported to the state survey agency and other state agencies. According to the investigation involving Resident #5, as of 05/09/2021, SRNA #3 was no longer employed at the facility. Interview with the Former Administrator, on 10/08/2021 at 12:15 PM, revealed she had assumed role of Administrator in November 2020 and served as Administrator until mid May 2021. The former Administrator stated she reported the abuse reported by Resident #6 to corporate staff but was directed by corporate staff to only report the verbal abuse reported by Resident #5 to the state agencies. Per the former Administrator, the abuse reported by Resident #6 was not reported to the state agencies per facility policy. Interview with interim Administrator on 10/08/2021 at 3:00 PM, revealed she assumed role of Interim Administrator in May 2021. Per the Administrator, the facility process for abuse allegations was to ensure resident safety and to then report the allegation to the supervisor. The interim Administrator stated resident abuse allegation should be immediately reported and investigated by the facility.

Based on interview, record review and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined the facility failed to conduct a discharge Minimum Data Set (MDS) assessment within the required timeframe for one (1) of fourteen (14) sampled residents. Record review revealed Resident #1 was discharged from the facility on 08/02/2021; however, the facility failed to complete a discharge assessment. The findings include: Interview with the Administrator, on 10/08/2021 at 2:32 PM, revealed the facility did not have a policy related to completing MDS assessments; however, the facility followed the procedures in the RAI User's Manual. Review of the RAI 3.0 User's Manual revealed a discharge assessment, return not anticipated, must be completed when the resident was discharged from the facility and not expected to return to the facility within thirty (30) days. Per the manual, a discharge assessment must be completed within fourteen (14) days after the discharge. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurse's progress notes revealed Resident #1 left the faciity on [DATE] to have surgery and the resident did not return to the facility from the hospital following the surgery. As of 10/08/2021, the facility had not completed a discharge MDS for the resident. Interview with the MDS Coordinator, on 10/08/2021 at 10:48 AM, revealed she has been the MDS Coordinator for the past eight (8) weeks. Per the MDS Coordinator, another employee was the MDS Coordinator during the time Resident #1 was discharged from the facility. The MDS Coordinator stated she had been trained to do a MDS assessment when a resident is discharged from the facility. The MDS Coordinator stated a discharge MDS assessment should have been completed when Resident #1 was discharged . Interview with the Director of Nursing (DON), on 10/07/2021 at 11:44 AM, revealed she does not review the MDS assessment for accuracy. Interview with the Administrator, on 10/08/2021 at 2:32 PM, revealed she was not aware a discharge MDS assessment had not been completed for Resident #1. The Administrator further revealed a discharge MDS assessment should be done if a resident does not return to the facility and the RAI User's Manual should be followed.

Based on record review, interview, facility policy review, and facility investigation review, it was determined the facility failed to ensure an allegation of abuse was thoroughly investigated by the facility for one (1) of fourteen (14) sampled residents (Resident #6). Resident #5 reported verbal by Stated Registered Nurse Aide (SRNA) #3 on 05/09/2021. During an investigation of the abuse reported by Resident #5, other resident interviews were completed by the facility. Resident #6 reported in an interview with staff on 05/09/2021, that SRNA #3 had verbally and physically abused him/her; however, the facility failed to investigate the alleged abuse. The findings include: Review of the facility's policy, Abuse Prohibition Standard of Practice, with Revision date of 5/2020, revealed alleged violations that involved abuse, neglect, exploitation, misappropriation of resident property, (including injuries of unknown origin, mistreatment and involuntary seclusion), shall be investigated immediately. The policy further stated the Administrator, Director of Nursing (DON), or Designee would oversee the center in conducting an internal investigation, to include, (a) notification of physician, resident/resident representative, (b) identification of alleged person or persons, (c) Type of abuse, and where and when the incident occurred (d) Interviews of all involved persons (e) Follow-up resolution (f) all material and documentation of the pertinent data collected, maintained, and safeguarded by the center and (g) the investigation form or state required form be completed after the investigation is complete and provided to survey agencies when requested or required by state of federal law. Per the policy, investigation findings were to be reported within 5 working days of the alleged violation initial report. Review of Resident #6's record revealed the facility admitted the resident on 04/01/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident required extensive assistance of two (2) persons with transfers and toileting. Per the MDS, the resident was assessed to have a Brief interview for Mental status(BIMS) score of [NAME] (7) indicating severe cognitive impairment. Further record review revealed no documentation recorded in Resident #6's record of a progress note or of an assessment completed on date of 5/09/2021. Resident #6 was observed on 10/08/2021, 12:01 PM, up in a wheelchair in the hallway. An attempt to interview the resident was unsuccessful due to the resident's cognitive status and incoherent speech. Review of the facility investigations revealed the facility investigated the allegation of verbal abuse reported by Resident #5 and had completed a resident interview with Resident #6. During the interview, Resident #6 reported to staff SRNA #3 had called him bad names, refused to assist him/her with toileting, and refused to give the resident water to drink. Resident #6 reported SRNA #3 eventually assisted him/her with toileting. The resident reported SRNA #3 had pulled him up from the chair by his/her neck and threw him/her down on the toilet. The Resident reported when the SRNA transferred him/her back to the wheelchair, the SRNA again picked him/her up by the neck and without cleaning his/her butt, threw him/her into the wheelchair hurting the resident's neck and legs. Further review of the verbal abuse investigation regarding Resident #5, revealed a skin assessment form dated 5/09/2021, completed by RN #5 which indicated Resident #6 had no injuries noted. Also included with the investigation findings for Resident #5 were handwritten statements from LPN #1 and LPN #2 dated 05/09/2021 which documented Resident #6 had reported SRNA #3 had slammed him/her down on the toilet twice. The statements also revealed the resident reported being afraid of the SRNA #3. However, there was no evidence or documentation of an investigation of the verbal and physical abuse alleged by Resident #6 on 05/09/2021. Interview with the Former Administrator, on 10/08/2021 at 12:15 PM, revealed she was the Director of Nursing (DON) at the facility until assuming the Administrator position in November, 2020 and left employment at the facility around the middle of May, 2021. Per the former Administrator, she investigated the allegation of verbal abuse reported by Resident #5 and interviewed Resident #6 during the course of the investigation. The former Administrator stated Resident #6 reported the verbal and physical abuse allegation to her and she reported the allegation to the facility's corporate staff. The former Administrator stated she attempted to contact SRNA #3 to interview the SRNA regarding the allegation of abuse. However, was unable to reach the SRNA and SRNA #3 was no longer an employee. Per the former Administrator, SRNA #3 had given report and walked out of the facility on 05/09/2021 and had not returned. The Administrator stated after reporting the abuse allegation reported by Resident #6 to corporate staff, she was instructed via email to only report the verbal abuse on Resident #5. Further interview with the former Administrator revealed she did complete an investigation into Resident #6's abuse allegations, but did report to corporate the physical and verbal allegations. Interview with interim Administrator on 10/08/2021 at 3:00 PM , revealed she and current DON were not employed in their current positions at the facility when the abuse investigation involving Resident #5 was completed in May, 2021. The interim Administrator stated that resident abuse allegation should be immediately reported and investigated by the facility.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Minimum Data Set (MDS) User's Manual, it was determined the facility failed to accurately assess two (2) of sixteen (16) sampled residents to reflect his/her status (Resident #28 and #45). The findings include: 1. Review of the RAI MDS 3.0 Manual revealed steps for assessment of weight: upon admission, weigh the resident and record results. For subsequent assessments, check the medical record and enter the weight taken within thirty (30) days of the Assessment Reference Date (ARD) of the assessment. Record review revealed the facility admitted Resident #28 on 04/02/18 with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment, dated 05/19/19 , revealed the facility assessed Resident #28's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fourteen (14), indicating the resident was interviewable. Review of Section K-Swallowing/Nutritional Status of the Annual MDS assessment, dated 05/19/19, revealed box K0300-weight loss and K0310-weight gain, were both checked, indicating the resident had both a weight loss and gain during this assessment period. However, review of Resident #28's weights revealed no significant weight loss or gain during the assessment period. Interview with the MDS Coordinator on 07/03/19 at 10:57 AM, revealed she coded number two (2) in both sections in error because when reviewing Resident #28's weights there was no significant weight gain or loss during the assessment period. She stated it was just an error on her part and she can submit a correction. Interview with the Director of Nursing (DON) on 07/03/19 at 5:00 PM, revealed she would expect the MDS Coordinator to review the residents weights when completing resident MDS assessments to ensure it was completed accurately. 2. Record review revealed the facility admitted Resident #45 on 01/03/15 and readmitted him/her on 03/02/19 with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment, dated 08/28/18; Quarterly MDS assessment, dated 03/10/19; and Quarterly MDS assessment, dated 06/08/19; for Range of Motion (ROM) revealed the facility assessed Resident #45 had impairment on one (1) side in the upper extremities (coded 1/0). However, observation on 07/02/19 at 10:11 AM, and on 07/03/19 at 9:26 AM, revealed the resident to have full function of the Bilateral Upper Extremity (BUE). Interview with the MDS Coordinator, on 07/03/19 at 11:15 AM, revealed the coding was an error on her part and she would send a correction. She stated Resident #45's impairment was on his/her BLE, not upper extremities. Interview with the Director of Nursing (DON) on 07/03/19 at 5:00 PM, revealed she expected the MDS Coordinator to review the resident's performance before completing the resident's MDS to ensure it was completed accurately.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure one (1) of 16 (sixteen) sampled residents who entered a facility without limited Range of Motion (ROM) does not experience a reduction in ROM unless clinical condition demonstrates a reduction in ROM is avoidable (Resident #45). On 07/19/18, therapy recommended Restorative provide Resident #45 passive stretching to bilateral ankles and to perform twenty (20) repetitions of Active Range of Motion (AROM) exercises to both lower extremities (BLE); however, there was no documented evidence the resident received restorative services. The findings include: Review of facility policy titled, Restorative Nursing, not dated, revealed the facility will ensure a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrates that diminution was unavoidable. This includes the resident's ability to transfer and ambulate. The policy further revealed restorative will work closely with the Therapy department, following programs as prescribed; consult with the Therapy department, as needed; and attend Utilization meetings. Record review revealed the facility admitted Resident #45 on 01/03/15 and readmitted him/her on 03/02/19 with [DIAGNOSES REDACTED]. Review of a Annual Minimum Data Set (MDS) assessment, dated 08/21/18 and a Quarterly MDS assessment, dated 03/10/19, revealed the facility assessed Resident #45 did not walk (coded 8/8) and his/her lower extremities ROM was not impaired (coded 1/0). Review of a form titled, Therapy to Restorative Nursing Communication, dated 07/19/18 revealed therapy recommended Resident #45 to receive passive stretching to bilateral ankles and to perform twenty (20) repetitions of Active Range of Motion (AROM) exercises to both lower extremities (BLE). Further review revealed the form was signed off by nursing on 07/16/18. However, review of a the Nurse Tech Information Kardex, or Certified Nurse Aide (CNA) care plan, not dated, revealed under the topic Restorative, there was no documented evidence the resident was to receive Restorative Services. Review of an Annual MDS assessment, dated 06/08/19 revealed the facility assessed Resident #45's cognition to be intact with a Brief Interview for Mental Status (BIMS) score of fourteen (14) which indicated the resident was interviewable. Interview with and observation of Resident #45 on 07/02/19 at 10:11 AM revealed the resident was lying in bed, eating a banana. The resident stated he/she had drop foot for a while and was unable to walk; and, he/she had not received any restorative services or ROM exercises. Interview with the Physical Therapy Assistant (PTA), on 07/03/19 at 3:30 PM revealed Resident #45 was discontinued (D/C) from therapy in (MONTH) (YEAR) and a member of nursing staff who was no longer employed by the facility signed off that it would be completed. Interview with Licensed Practical Nurse (LPN) #2/Unit Manager (UM) on 07/03/19 at 4:47 PM revealed the facility was trying to put a restorative program together and she was in charge. She stated the program had been in effect about one (1) month but it had probably been several years since the facility had a restorative program. Interview with the acting Director of Nursing (DON) on 07/03/19 at 3:18 PM revealed there was no documented evidence when Resident #45 started declining in ROM or that he/she was picked up by restorative per therapy recommendation. Further interview with the DON on 07/03/19 at 5:13 PM revealed she expected Restorative to follow through with the therapy request, and Restorative exercises should be provided by nursing, if Restorative, was not available.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to review and revise a comprehensive person-centered care plan for two (2) of sixteen (16) sampled residents (Residents #60 and #40). Resident #40 had a fall on 03/21/19 while making his/her bed with an intervention developed to encourage resident to allow staff to help with housekeeping; however, review of the Certified Nurse Aide (CNA) Care Plan revealed the care plan was not revised to assist resident with housekeeping. Resident #60 sustained falls on 02/23/19, 03/21/19 and 05/14/19; however, the facility failed to revise the Comprehenisve Care Plan with an intervention after each fall to try to prevent future falls and injuries. The findings include: Review of the facility policy titled Comprehensive Care Plans Standard of Practice, dated (MONTH) (YEAR) revealed it is the practice of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 1. Record review revealed the facility readmitted Resident #60 on 12/27/12, with [DIAGNOSES REDACTED]. Review of Quarterly Minimum Data Set (MDS) assessment, dated 05/15/19, revealed the facility assessed Resident #60's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated this resident was interviewable. Review of Situation, Background, Assessment, Recommendation (SBAR) Communication Form dated 02/23/19 revealed Resident #60 had a fall and was complaining of (R) shoulder pain. Review of Radiology Report dated 02/23/19 revealed Resident #60 had a [MEDICAL CONDITION] distal clavicle. Review of Fall Incident Report dated 03/21/19 revealed Resident #60 had a fall due to losing balance when getting out of bed and going to the restroom to put deodorant on. The following day (03/22/19), the resident was sent out to the ER to have (R) hip x-rayed. Review of the Hospital Summary dated 03/23/19 revealed Resident #60 had a right femoral neck acute fracture and a hemiarthroplasty procedure was performed. In addition, review of Facility Fall Investigation dated 05/14/19 revealed Resident #60 was ambulating without assistance to closet in room and turned and fell hitting buttocks and head. Further review of the investigation revealed the root cause of the fall was related to Resident #60 having weakness related to recent right [MEDICAL CONDITION] and repair. However, review of Resident #60's Comprehensive Care Plan for Falls risk dated 05/11/18 revealed there was no documented evidence the care plan was revised with interventions to try to prevent future falls and injury after each of the three (3) falls. Review of the Certified Nursing Aide (CNA) Care Plan printed 07/03/19 revealed there were no interventions listed under safety. Interview with CNA #5 on 07/03/19 at approximately 2:10 PM revealed staff check on Resident #60 every two (2) hours to see if he/she needs assistance to use the bathroom. CNA #5 stated she was not aware of any safety interventions in place for Resident #60 related to falls. Interview with CNA #4 on 07/03/19 at approximately 2:16 PM revealed each wing had CNA care plans for all the residents but she was certain the care plans were not updated regularly. CNA #4 revealed she was not aware of any safety interventions in place for Resident #60 because there was none listed on the CNA care plan. Interview with CNA #3 on 07/03/19 at approximately 2:55 PM revealed she was not aware of any safety interventions in place for Resident #60. Interview with Licensed Practical Nurse (LPN) #1 on 07/03/19 at approximately 1:20 PM revealed the facility protocol when a fall occurs in the facility the nurse should identify any immediate interventions that need to be put in place and the Unit manager was the person responsible for updating the care plan with any identified interventions. LPN #1 further stated she could not remember what, if any interventions were put in place for Resident #60 and she was not sure of any current interventions in place for Resident #60 related to falls safety. Interview with Unit Manager on 07/03/19 at approximately 1:30 PM revealed she was in charge of all the falls that occur in the facility. The Unit Manager stated she was responsible for identifying root cause of fall, and interventions. She revealed all falls are discussed the following morning in the clinical morning meeting and are also discussed weekly by the IDT team. She stated during the clinical morning meeting the care plan is updated with new interventions and the tasks are divided among the staff present but that at the end of the meeting the care plan should be updated. The Unit Manager was unable to provide an explanation as to why the care plans did not have any updates or revisions to them. She stated she was not sure what if any interventions were in place currently for Resident #60 or what interventions had been identified for the falls that occurred on 02/21/19 and 03/23/19 which resulted in serious injury. She revealed she was not sure what could be done to ensure that falls are followed up on and that interventions are updated on the care plans. Interview with the Staff Development Coordinator (SDC) on 07/03/19 at approximately 11:30 AM revealed the Unit Manager was responsible for all the documentation related to falls and she keeps a falls binder that has all the information in it related to all the falls that occur in the facility. The SDC stated the Interdisciplinary Team (IDT) team meets daily and reviews the falls and the care plan should be updated during that meeting. 2. Record review revealed the facility admitted Resident #40 on 02/10/17 with a [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment, dated 05/30/19, revealed the facility assessed Resident #40's cognation was severely impaired and he/she was unable to completed the BIMS. Review of Resident #40's Resident Incident Report revealed a fall was investigated on 07/01/19 with major injury and an intervention was put in place to encourage resident to allow staff to assist with general housekeeping that resident chooses to perform. Review of the Comprehensive Care Plan, dated 12/15/17, revealed an intervention was added on 07/01/19 to encourage to allow staff to assist with general housekeeping that resident chooses to perform. However, review of the CNA Care Plan, not dated, revealed the care plan had not been revised to include encourage to allow staff to assist with general housekeeping that resident chooses to perform. Observation of Resident #40 on 07/02/19 at 9:08 AM revealed the resident was in his/her room, making the bed without assistance. Interview with CNA #6, on 07/03/19 at 10:16 AM revealed Resident #40 usually makes his/her own bed and will ask for help, if needed. The CNA stated she was not aware of the intervention to assist with making bed related to the resident's last fall. Interview on 07/03/19 at approximately 4:55 PM with the acting Director of Nursing (DON) revealed she expected staff to ensure the Comprehensive and CNA Care Plans were updated to reflect new interventions.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to assess or re-evaluate the use of a restraint for one (1) of one (1) sampled residents (Resident #32). Resident #32 had an alarming lapbelt attached to the wheelchair that was not removed during meals. The findings include: Review of the facility's policy, Restraints Standard of Practice, dated (MONTH) 2019, revealed facility standard to allow residents to be free from physical or chemical restraints unless medically necessary as outlined in Federal Regulatory Guidelines. Any restraint order obtained must have medical [DIAGNOSES REDACTED]. Attempted reduction of restraints with description of how attempt was made and results will be documented. Further review revealed reduce restraints accordingly as needed and document in the medical record as well as the care plan. Record review revealed the facility readmitted Resident #32 on 04/17/19, with [DIAGNOSES REDACTED]. Review of Resident #32's Quarterly Minimum Data Set (MDS) assessment, dated 05/16/19, revealed the facility assessed the resident was rarely/never understood and his/her cognitive skills for daily decision making were severely impaired. Review of Resident #32's Comprehensive Care Plan, dated 04/09/18, revealed a problem of at risk for falls related to [MEDICAL CONDITION] with impaired cognition and poor safety awareness. Further review revealed interventions for an alarming lapbelt while up in wheelchair, and to check placement and function each shift; and, release alarming lapbelt every two (2) hours, at meals, and during activities. Review of a physician's orders [REDACTED]. Review of Resident #32's Nurse Tech Information Kardex, not dated, revealed the alarming lapbelt was to be released during meals. Observation on 07/02/19 at 11:10 AM, revealed Resident #32 was sitting up in his/her wheelchair in the dining area being assisted with the lunch meal by staff. Further observation revealed Resident #32's lapbelt was locked in place and not released during the meal service. Interview with Certified Nurse Aide (CNA) #1 on 07/02/19 at 11:30 AM, revealed she should have released the lapbelt but she had forgotten to do so. She stated the lapbelt was released at all meals, during care, and activities. Interview with the Director of Nursing (DON) on 07/03/19 at 5:00 PM, revealed the aides should ensure the lapbelt is released during all meals. The DON stated she expected the aides to follow the resident care plans while providing care.

Based on interview, record review, and facility policy review, it was determined the facility failed to complete a Significant Change Minimum Data Set (MDS) assessment within fourteen (14) days after the facility determines, or should have determined, there was a significant change in the resident's physical or mental condition for two (2) of sixteen (16) sampled residents (Residents #60 and #20) . Review of Resident's #60 and #20's MDS assessments revealed the facility failed to complete a Significant Change in Status Assessment (SCSA) within the fourteen (14) day time frame after Residents #20 and #60 had a decline in bed mobility, transfer and toileting. The findings Include: Review of the facility policy, MDS Assessment Completion, last revised (MONTH) (YEAR), revealed the facility will conduct and submit resident assessments in accordance with the RAI Manual including deferral and state submission timeframe's. Further review revealed significant change in Status assessment will be completed on the fourteenth (14th) calendar day after determination of significant change in status. Record review the facility readmitted Resident #60 on 12/27/12, with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment, dated 03/01/19, revealed the facility assessed Resident #60 to require supervision/set-up help only (coded 1/1) for bed mobility, and limited assistance on one (1) person (coded 2/2) for transfer and toileting. Review of a Quarterly MDS assessment, dated 04/02/19, revealed the facility assessed the resident had declined and required extensive assistance of two (2) staff for bed mobility, transfer and toileting. The resident had declined in three (3) areas; however, there was no documented evidence a Significant Change MDS assessment was completed. 2. Record review revealed the facility readmitted Resident #20 on 05/24/18, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 02/05/19, revealed the facility assessed Resident #20 to require supervision/set-up help only (coded 1/1) for bed mobility, transfer, and eating, and extensive assistance of two (2) staff (coded 3/3) for toileting. Review of an Annual MDS assessment, dated 05/08/19, revealed the facility assessed the resident had declined and was totally dependent on two (2) staff (coded 4/3) for bed mobility, transfer and toileting; and totally dependent on one (1) staff (coded 4/2) for eating. The resident had declined in three (3) areas; however, there was no documented evidence a Significant Change MDS assessment was completed. Interview with the MDS Coordinator on 07/03/19 at approximately 2:40 PM, revealed it was an oversight on behalf of the MDS Coordinator that the Significant Change assessment was not completed. The MDS Coordinator stated she did not catch it and there was not a system set up that alerted her when a Significant Change occurred, so that a Significant Change assessment could be completed. The MDS Coordinator stated she will be more careful going forward to ensure she does not overlook these changes on the assessment. Interview with the Director of Nursing (DON) on 07/03/19 at approximately 5:03 PM, revealed she expected a Significant Change MDS assessment to be completed whenever a resident had an improvement or decline in their functions.

Based on interview, record review, review of Hospital emergency room Records and review of facility policy/procedures, it was determined the facility failed to implement the plan of care for one (1) of four (4) sampled residents (Resident #1), related to providing a therapeutic mechanical soft diet; and, monitoring the resident's tolerance of the texture of the diet and signs and symptoms of aspiration. The facility admitted Resident #1 with multiple [DIAGNOSES REDACTED]. Resident #1 was assessed and care planned for staff to provide a diet of mechanical soft foods, and to monitor for tolerance of diet texture and for signs and symptoms of aspiration. On [DATE], Resident #1 became choked during the lunch meal after Certified Nurse Aide (CNA) #1 fed the resident scalloped potatoes that had been identified as undercooked and had not been peeled. The resident became choked a second time the same day when CNA #2 attempted to feed him/her the supper meal and he/she was unable to swallow. The incidents were reported to licensed staff; however, the licensed staff failed to monitor the resident for tolerance to the diet and for signs and symptoms of aspiration after the choking incidents. On the morning of [DATE], Resident #1 was sent to the hospital in [MEDICAL CONDITION]. While at the hospital, a piece of scalloped potato that was undercooked and had the peel on it was removed from the resident's throat during intubation. The resident was admitted to the Intensive Care Unit (ICU) with [MEDICAL CONDITION], Pneumonia [MEDICAL CONDITION] in critical condition on a ventilator. The facility's failure to ensure staff implemented the care plan caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] alleging the IJ was removed on [DATE]. The State Survey Agency validated on [DATE] that the Immediate Jeopardy was removed on [DATE], as alleged. The Scope and Severity was lowered to a "D" while the facility develops and implements the Plan of Correction (POC); and, the facility's Quality Assurance monitors the effectiveness of the system changes. The findings include: Review of the facility's policy titled, "Resident Comprehensive Care Plan", dated ,[DATE], revealed the resident's comprehensive care plan should be viewed as an interdisciplinary approach to managing the acute and chronic needs of the resident living in the facility. Review of a manual titled, "Simplified Diet Manual", eleventh edition, utilized by the facility, revealed a Mechanical Soft Diet is designed to permit easy chewing. The General Diet is modified in consistency and texture by cooking, grinding, chopping, mincing or mashing. The diet includes foods soft in texture such as cooked fruits and vegetables, moist ground meat and soft bread and cereal products. Foods that dissolve readily when held in the mouth such as graham crackers and some ready-to-eat cereals are also appropriate. It is most important to individualize or adjust it to the tolerance of the resident. Table 3.1 Mechanical Soft revealed to avoid raw or undercooked vegetables and those with tough skins, whole kernel corn and fried vegetables. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed the resident with a Brief Interview of Mental Status (BIMS) score of "99", indicating the resident was not interviewable. Further review of the assessment revealed the resident required extensive assistance of one person for eating and had a therapeutic diet of mechanically altered foods. Review of a Speech Therapy Evaluation, dated [DATE], revealed the resident was at risk for weight loss and aspiration; and, required close supervision during meal intake and assistance with all meals due to risk of [MEDICAL CONDITION] and requiring maximum cues to not talk while eating, and swallowing everything before taking another bite. Review of Resident #1's Comprehensive Care Plan for Risk for Alteration in Nutrition, dated [DATE], revealed interventions to provide diet as ordered, mechanically soft; and monitor for tolerance to diet texture and signs and symptoms of aspiration. Review of Nursing Note, revealed a late note, dated [DATE] at 3:28 PM, which stated at 11:45 AM, the CNA reported Resident #1 was having problems swallowing fluids with his/her meal. The nurse reported the incident to the Speech Therapist (ST) and the ST said she would assess the resident Interview on [DATE] at 2:00 PM with CNA #1 revealed on [DATE] during the lunch meal, Resident #1 became choked when she fed the resident scalloped potatoes. The resident coughed, spitting up some of the potatoes and his/her face became red. The CNA stated she reported the incident to Registered Nurse (RN) #1. Interview on [DATE] at 2:15 PM with RN #1 revealed CNA #1 had reported to her on [DATE] that Resident #1 was having trouble swallowing milk at lunch. RN #1 stated she requested the ST to look at the resident. During her observation, she noted that Resident #1 had a deeper voice like he/she needed to cough but she was unable to get the resident to cough. RN #1 stated she did not assess the resident for signs and symptoms of aspiration by assessing the resident's lung sounds, obtaining the resident's oxygen saturation and vital signs; and she did not monitor to ensure the resident's diet was appropriate. Interview with facility Cook #1, on [DATE] at 1:00 PM, revealed on [DATE] she used fresh potatoes to make scalloped potatoes for the lunch meal on [DATE]. Cook #1 stated she sliced the potatoes but did not peel them. She then cooked the potatoes according to the spread sheet. Cook #1 revealed she was alerted by a staff member that the scalloped potatoes were not cooked enough when meal trays were served in the dining room. Cook #1 stated she was aware that one of the hall tray carts had already been delivered to the hall for residents to be served meals in their rooms to include residents on a mechanical soft diet but she did not take any action to retrieve the residents' trays with the scalloped potatoes. Cook #1 revealed she continued to serve the scalloped potatoes by picking out the thinner slices. She stated she placed the thicker slices of potatoes in the refrigerator with a note indicating the potatoes required cooking if served again. Interview, on [DATE] at 2:15 PM with RN #1, revealed CNA #1 reported Resident #1 was having trouble swallowing milk at lunch on [DATE]. RN #1 stated she requested the ST to look at the resident. RN #1 revealed when she observed Resident #1 with the ST there was no coughing and the resident's color was good. RN #1 stated she noticed the resident had a deeper voice like he/she needed to cough but she was unable to get the resident to cough. RN #1 stated she did not notify the physician but decided to observe the resident's temperature every shift just in case he/she had aspirated. Interview with CNA #2, on [DATE] at 3:10 PM, revealed he attempted to feed Resident #1's supper meal on [DATE] and when he gave Resident #1 a bite, the resident would chew and attempt to swallow, but couldn't. CNA #2 stated the resident coughed, got red in the face and the CNA thought the resident had "swallowed the wrong way". CNA #2 revealed the resident did the same thing when milk was offered and acted like he/she didn't want to eat so the CNA #2 notified Licensed Practical Nurse (LPN) #1. CNA #2 stated he did not know if LPN #1 had assessed Resident #1 or not. Interview with LPN #1, on [DATE] at 3:20 PM, revealed she did not recall anyone reporting to her that Resident #1 had choked on his/her supper meal. She stated she did not monitor Resident #1 for signs and symptoms of aspiration or to ensure the resident was able to tolerate the diet. Review of a Nursing Note, dated [DATE] at 8:40 PM by RN #2, revealed the resident's temperature was 99.1 F, the resident coughed up some thick mucus, drank chocolate milk without difficulty, and there was no noted swallowing problems. Interview on [DATE] at 8:40 PM with RN #2 revealed on [DATE] she was told in report to check Resident #1's temperature due to the resident having difficulty swallowing earlier in the day and the ST had looked at the resident but didn't know anything for sure. RN #2 stated Resident #1 had a "little rattle" when breathing and she was unsuccessful in getting the resident to cough and she saw a glob of mucus in the resident's beard. RN #2 stated she did not monitor for signs and symptoms of aspiration by assessing the resident's lung sounds with a stethoscope and obtaining the resident's oxygen saturation and vital signs because she was afraid the resident would "hit" her. Review of a Nursing Note, dated [DATE] at 8:32 AM, revealed at 7:55 AM, the resident presented with difficulty breathing, gasping for air, and oxygen saturation was fluctuating in the 80s (normal ,[DATE]). Oxygen was administered at 8/L per minute with oxygen saturation continuing to fluctuate up and down. The resident's pulse was 102 (normal ,[DATE]), respirations were 30 (normal ,[DATE]) per minute, temperature was 100 F (normal 98.6). Notifications were made to the Guardian and Physician and the resident was transported to the hospital by ambulance. Review of Resident #1's Hospital emergency room Records, dated [DATE], revealed the resident suffered from Acute [MEDICAL CONDITION] with [MEDICAL CONDITION] (body deprived of oxygen) and a slice of uncooked potato the size of a silver dollar and one-fourth inch thick was removed from the resident's throat during intubation. There was collapse/consolidation of the right lung, lower lobe and posterior medial basal segments left lower lobe; and pneumonia. The resident was placed on a ventilator and admitted to the Intensive Care Unit (ICU) in critical condition. Interview with the Emergency Department (ED) Physician, on [DATE] at 11:00 AM revealed on [DATE], Resident #1 was very mentally challenged and was in [MEDICAL CONDITION]. He stated when intubating the resident a one and one-half inch circular piece of potato that still had the peel on it was in the resident's throat. The Physician revealed the resident might have been able to swallow some liquids because the circular piece of potato may have acted like a ball valve. He stated the resident couldn't get the epiglottis to close over the trachea. The physician revealed the resident did have pneumonia from aspiration. He revealed the circular potato piece was removed intact and was very firm. He further stated Resident #1 could have died from the potato piece cutting off his/her airway or could have died from the Aspiration Pneumonia. Interview with the Director of Nursing (DON), on [DATE] at 12:15 PM, revealed the ST did evaluate Resident #1, but if a wrong food item was sent out and served to the resident then obviously the care plan was not followed. She stated she expected the resident's care plan to be followed and if it couldn't be followed or changed the physician should have been notified and a change made. Interview with the Administrator, on [DATE] at 11:40 AM, revealed CNA #1 had said she mashed the potatoes with a fork but was unable to explain why a whole potato slice was found lodged in Resident #1's throat. She additionally stated she had never heard of leaving the peel on potatoes when preparing scalloped potatoes. The Administrator expected resident care plans to be followed. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], Resident #1 was sent to the hospital and admitted for Airway Obstruction and Aspiration Pneumonia. Resident #1 returned to the facility on [DATE] on a mechanically soft diet; the facility downgraded the diet to puree on [DATE]. 2. On [DATE], the Director of Nursing, Assistant Director of Nursing, Unit Manager, MDS Nurse or Medical Records Nurse conducted an assessment of Resident #1 to determine if there were any medical needs, and or ongoing assessments required that were not already being completed or any significant change in condition that required MD notification. Resident #1's assessment revealed no change in condition that required further Physician notification and noted that appropriate assessments were on-going. 3. The MDS Nurse on [DATE] reviewed Resident #1's plans of care and determined that all interventions were in place. 4. Beginning on [DATE] and completed on [DATE] the Director of Nursing, Assistant Director of Nursing, Unit Manager, MDS Nurse and Medical Records Nurse reviewed all current residents' plan of care to determine if all interventions were being followed. No further concerns were identified. 5. On [DATE], the Dietary Services Manager observed Resident #1's lunch meal and determined the diet served was prepared per recipe and was correct per physician's orders [REDACTED]. The Dietary Services Manager also observed the meal tray line during lunch and noted that staff was following the recipe and spreadsheet and providing the diet as ordered for Resident #1 and food was properly prepared. 6. On [DATE], the Director of Nursing, Assistant Director of Nursing, Unit Manager, MDS Nurse or Medical Records Nurse conducted assessments of all current residents to determine if there were any medical needs requiring Physician notification and or ongoing assessments required that were not already being completed. Any identified residents who had a change in condition had their Physician notified with orders obtained and follow up assessments. 7. On [DATE], the Dietary Services Manager conducted an audit of all current residents' meal trays served from the kitchen and noted that the recipe was followed, diet was correct and served per Physician order [REDACTED]. 8. On [DATE], the Regional Quality Manager re-educated the Director of Nursing, Assistant Director of Nursing and Unit Manager, MDS Nurse and Medical Records Nurse on conducting an assessment based on resident condition to include the INTERACT process, follow up assessments as well as Physician notification for a significant change in condition referring to the INTERACT process but not to supersede nursing judgement. The INTERACT process is an evidence based program developed under funding from CMS to prevent unnecessary acute care transfers, to provide guidance to nurses on when to notify the physician and care paths for certain common symptoms. A competency test was administered to validate understanding. In addition, they were educated and a competency test was given related to following the plan of care, and if the plan of care cannot be followed and an alternative is not within their scope of practice that the Physician must be notified 9. On [DATE] ,the Director of Nursing, Assistant Director of Nursing and Unit Manager, MDS Nurse and Medical Records Nurse began re-education with all licensed nursing staff related to conducting an assessment based on resident condition to include the INTERACT process, follow up assessments as well as Physician notification for a significant change in condition referring to the INTERACT process but not to supersede nursing judgement. A competency test was administered to validate understanding. No licensed staff will work after [DATE] without having completed this re-education and competency test. In addition, reeducation was provided on the requirement to follow the plan of care and if the plan of care cannot be followed and an alternative is not within their scope of practice the physician must be notified. No licensed Nurse worked after [DATE] without having received this re-education and competency test. 10. Beginning [DATE], all Certified Nursing Assistants were re-educated with competency test related to following the plan of care and if they were unable to follow the plan of care they must report it to the Charge Nurse. No Certified Nursing Assistants will work after [DATE] without having received this re-education and competency test. 11. On [DATE] and [DATE], the Regional Dietician reviewed all current recipes to determine if any recipe called for food products that according to the spreadsheet would not be appropriate for mechanically altered diets. No other concerns were identified. 12. On [DATE], the Regional Dietician conducted re-education with the Dietary Services Manager including competency testing related to following the recipe and serving foods per the spreadsheet for correct prescribed diet. 13. Beginning [DATE] and ongoing, the Dietary Service Manager will conduct re-education with all Dietary Staff related to following the recipe and the spreadsheet to assure diets are served per the Physician order. This re-education will include a competency test and will be conducted prior to any staff beginning work. No Dietary staff worked after [DATE] without having completed the re-education and competency test. 14. On [DATE], a contract provider verified the convection oven was working appropriately and the regular oven in which the potatoes were cooked was cooking hotter than the setting on the oven. A new stove/oven was ordered and approved on [DATE]. 15. Beginning [DATE], all dietary staff was instructed by the Dietary Service Manager to only cook on the convection oven. No staff will work after [DATE] without having had this re-education. Beginning [DATE], all dietary staff will be educated by the Dietary Service Manager that if a concern is identified with the food prepared it should be removed from the tray line and if already served dietary staff should report the concerns to the Nurse. No dietary staff will work after [DATE] without having received this education. 16. Beginning [DATE] and ongoing, all nursing staff was educated by the Director of Nursing, Assistant Director of Nursing, Unit Manager MDS Nurse or Medical Records Nurse on notification of the nurse if meals appear to be prepared incorrectly such as overcooked, undercooked or hard to cut foods. No nursing staff will work after [DATE] without having received this education. In addition, beginning on [DATE] and on going, all Certified Nursing Assistants were re-educated with competency test related to following the plan of care and if they were unable to follow the plan of care they must report it to the Charge Nurse. No Certified Nursing Assistants will work after [DATE] without having received this re-education and competency test. 17. Beginning [DATE], the Director of Nursing, Assistant Director of Nursing or Unit Manager will review with the facility staff the residents' condition each shift to determine if licensed staff are notifying the Physician of significant changes in condition as well as completing ongoing assessment as needed. This will continue every shift until abatement then five (5) times per week for twelve (12)weeks thereafter. 18. The Director of Nursing, Assistant Director of Nursing or Unit Manager will review five (5) residents' plans of care per week for twelve (12) weeks to evaluate if interventions are in place and being followed. The results of these audits will be reviewed with the Quality Assurance and Improvement Committee weekly until substantial compliance then monthly thereafter. 19. Beginning [DATE], the Director of Nursing, Assistant Director of Nursing or Unit Manager will review all Nurses Notes daily to determine if any significant change in condition has occurred without Physician notification or any significant change in condition requiring ongoing assessment that has not occurred. This will occur daily until abatement of Immediate Jeopardy and then five (5) times per week for twelve (12) weeks. 20. Beginning [DATE], a Dietary Service Manager or a Registered Dietician will observe one meal service per day to assure staff are following the recipe, serving and using the diet spreadsheet and that food is properly prepared to meet the individual needs. This will continue until abatement of the Immediate Jeopardy and then five (5) times per week for twelve (12) weeks thereafter. 21. The results of these audits will be reviewed with the Quality Assurance and Improvement Committee (QAPI) weekly until substantial compliance then monthly thereafter. The QAPI committee will meet weekly or anytime concerns are identified until substantial compliance, then monthly thereafter. Members of the QAPI Committee will consist of at a minimum the Director of Nursing, Assistant Director of Nursing, Social Services Director, Maintenance Director, Activity Director and Business Office Manager with the Medical Director participating at least quarterly and as needed. 22. On [DATE], an ad hock Quality Assurance and Performance Improvement Committee was convened to review the facility's investigation and concerns. An Allegation of Compliance was developed and reviewed with the Medical Director who attended via phone. In attendance was the Administrator, Director of Nursing, Assistant Director of Nursing, Unit Manager, Medical Records Clerk, MDS Nurse, Social Services Director, Dietary Services Manager and Activity director. No further recommendations were made at this time. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of the Nursing Notes and Physician order [REDACTED].#1 was sent to the hospital and admitted for Airway Obstruction and Aspiration Pneumonia. Resident #1 returned to the facility on [DATE] on a mechanically soft diet and the facility downgraded the diet to pureed on [DATE]. Observation of the lunch meal on [DATE] at 12:00 PM, revealed the resident was being fed by the Speech Therapist. The food was in pureed form, as per the resident's diet card on the tray. 2. Review of an assessment conducted by the Director of Nursing, Assistant Director of Nursing, Unit Manager, MDS Nurse or Medical Records Nurse of Resident #1 on [DATE], revealed there were no change in condition that required further Physician notification and noted that appropriate assessments were on-going. 3. Review of documentation by the MDS Nurse, dated [DATE], revealed she reviewed Resident #1's plans of care and determined that all interventions were in place. 4. Review of documentation verified on [DATE] through [DATE] the DON, ADON, Unit Manager, MDS Nurse and Medical Records Nurse reviewed all current resident's plans of care to determine if all interventions were being followed. The documentation revealed which residents' plans of care were reviewed by which administrative staff. 5. Review of documentation by the Dietary Manager, dated [DATE], revealed the Dietary Manager observed Resident #1's lunch meal and determined the diet served was prepared per recipe and was correct per physician's orders [REDACTED]. In addition, the documentation revealed she also observed the tray line and determined staff was following the recipe and spreadsheet and providing the diets as ordered. 6. Review of residents' assessments conducted on [DATE] revealed all resident assessments were completed and any residents who had an identified change in condition had their physician notified. The assessments were conducted by the DON, ADON, Unit Manager MDS Nurse and Medical Records Nurse. 7. Review of documentation dated [DATE] revealed the Dietary Services Manager conducted an audit of all current residents' meal trays served from the kitchen and verified the recipe was followed, diet was correct and served per Physician Order, to meet the needs of the resident and properly prepared. 8. Review of documentation of re-education by the Regional Quality Manager to the DON, ADON, Unit Manager, MDS Nurse and Medical Records Nurse, dated [DATE], verified they were reeducated on the INTERACT process, follow up assessments, Physician notification for significant change, following the plan of care, and if the plan of care cannot be followed and an alternative is not within their scope of practice the Physician must be notified. Review of the competency tests revealed each of them completed the test on [DATE]. 9. Review of inservice sign in sheets and competency tests, beginning [DATE], revealed all licensed staff was re-educated beginning [DATE] and competency tests were administered and passed related to the INTERACT process, follow up assessments, Physician notification for significant change, following the plan of care, and if the plan of care cannot be followed and an alternative is not within their scope of practice the Physician must be notified. Review of the competency tests revealed each of them completed the test on [DATE]. Interview with the Administrator, on [DATE] at 1:35 PM, revealed the DON provided education to the staff related to assessments, INTERACT tool for assessments and Physician notification. Staff was educated about care plan interventions ensuring their appropriateness and implementation Interview with the DON, on [DATE] at 1:30 PM, revealed she provided education on the INTERACT tool for assessments and Physician notification and had also educated staff on updating care plans according to their scope of practice. The Twenty Four Hour Report was also topic. Nursing staff was given competency tests on following the INTERACT tool and nursing judgement. CNAs required a post test as well. Interview with RN #3, on [DATE] at 12:30 PM, revealed she received education related to the INTERACT system utilized by the facility which was a tool for assessments and included why, when, who and Physician notification. The education included follow up documentation on any type of complaint or anything out of the normal for a resident. Information was to be passed on to the next shift if not resolved and follow up was to be done the next day. A post test was given which RN #3 passed. Interview with LPN #3, on [DATE] at 12:35 PM, revealed education was provided to her by the DON that resident assessments should be conducted before, during, and after any type of an event and gave examples of elevated temperature, shortness of breath, and chest pain. LPN #3 was given a post test and passed. Education was also given to her about Physician notification, follow up documentation and implementing the care plan. She stated if the care plan needed changed or could not be implemented to notify the DON. Interview with LPN #4, on [DATE] at 12:40 PM, revealed she had been educated by the DON related to the INTERACT tools for resident assessment, physician notification and documentation. The Physician was to be notified for any significant change. Assessments were to be completed, the resident monitored and reassessed. The assessments were to include the resident's vital signs as blood pressure, respiration, oxygen saturation, pulse and temperature. LPN #4 was required to pass a post test. Interview with RN #1, on [DATE] at 12:50 PM, revealed she had been provided education by the DON related to a change in condition of a resident including if the resident was having trouble swallowing. For any emergency "911" was to be called and then notify the Physician. The INTERACT tool which reflects how, what and when to notify the Physician was to be utilized, as well, as the Stop and Watch tool which anyone could fill out and give to the nurse. Any change of condition of a resident required a complete assessment, including if a resident became choked while eating. Seventy-two (72)hour documentation was required for any changes, this included the resident's vital signs and if symptoms persisted the physician should be notified again. In addition, care plan education was provided related how to access that information from the headsets worn by the CNAs. The care plan had to match the resident's needs and if not the CNAs were to notify the nurse. A post test was completed to validate understanding. Interview with RN #4, on [DATE] at 12:55 PM, revealed she had recent education by the DON related to assessments. The INTERACT tool was a step by step guide on how, what and when to do anything and Physician notification. In addition, education was provided on care plans that included information about carrying out the interventions and revising when needed. CNAs were to report any problems with the care plan and the Physician was to be notified. She stated she had to take a post test and pass. 10. Interview with CNA #5, on [DATE] at 1:00 PM, revealed education was provided on care plans related to accessing the information on the CNA headset and to always inform the nurse when something did not seem right about the information. A post test was taken and had to be passed. Interview with CNA #6, on [DATE] at 1:05 PM, revealed education was provided on care plans and she was to ensure the care plan was followed and if the care plan did not seem appropriated she was to speak with the nurse immediately. Interview with CNA #7, on [DATE] at 1:10 PM, revealed she was educated on implementation of care plans and a post test was given and she passed. Interview with CNA #8, on [DATE] at 1:15 PM, revealed she had recently been educated that she was required to be familiar with each resident's care plan an it was accessible through the head set that she wears. CNA #8 stated if she could not follow the resident's care plan she was to go to the nurse for clarification. She revealed she had to take a post test and pass. 11. Interview with the Administrator, on [DATE] at 1:35 PM, revealed the spread sheets and recipes were reviewed and the spread sheet for the scalloped potato recipe was revised to include peeling potatoes before cooking. Interview with the Registered Dietician, on [DATE] at 11:35 AM, revealed she had revised the spread sheet and recipe for scalloped potatoes to indicate peeling the potatoes. 12. Interview with the Dietary Manager, on [DATE] at 11:30 AM, revealed she had received inservice from the Registered Dietician on reading and following spreadsheets and recipes. Education was provided that potato skins were not part of the Mechanical Soft Diet. She was educated on reading and calibrating thermometers and using only the left oven on the stove instead of the malfunction right side oven and the recipe and spread sheet for scalloped potatoes had been revised to instruct to peel the potatoes. One meal every day was being monitored to ensure the spread sheet and recipe as well as the tray cards were being followed. 13. Interview with the Administrator, on [DATE] at 1:35 PM, revealed dietary staff was educated over recipes and spread sheet, meal preparation and diets per the physician's orders [REDACTED]. Interview with the Registered Dietician, on [DATE] at 11:35 AM, revealed she had provided education to the dietary staff related to the spread sheets and recipes. She stated the reading of the tray cards was also covered in education as well as what to do if a food item did not turn out that included not serving that food item. Interview with Cook #1, on [DATE] at 11:40 AM, revealed she had been educated about how to set and use thermometers for checking food temperatures and about how to follow the spread sheet recipes. She stated a test was given to verify she understood the education. Interview with Dietary Aide #3, on [DATE] at 11:45 AM, revealed she had received education by the Dietary Manager on how to follow the spread sheets and recipes. She stated she also had to take a test to verify she understood the education. 14. On [DATE] a contract provider verified that the convection oven was working appropriately and that the regular oven in which the potatoes were cooked was cooking hotter than the setting on the oven. A new stove/oven was ordered and approved on [DATE]. Interview with the Administrator, on [DATE], revealed a

Based on interview, record review, review of the Hospital Emergency Department Records and review of the facility's policies and procedures it was determined the facility failed to notify the physician for one (1) of four (4) sampled residents (Resident #1). On 01/23/15 , Resident #1 experienced a choking episode while being fed scalloped potatoes during the lunch meal and, experienced another choking episode on 01/23/15 while being fed the supper meal. The Speech Therapist (ST) evaluated the resident and determined the resident needed to sit at a ninety degree angle when fed. Registered Nurse (RN) #1 noted the resident was speaking in a deeper voice as if he/she needed to cough but she was unable to get the resident to cough. RN #1 decided to monitor the resident's temperature due to the resident's choking episodes and risk for aspiration; however, she did not notify the physician. At 8:40 PM, RN #2 obtained Resident #1's temperature which was elevated at 99.1 degrees Fahrenheit (F) and the resident had an audible rattle when breathing. RN #2 tried unsuccessfully to get the resident to cough and observed a "thick glob" of mucus the resident had coughed up later in the shift; however, RN #1 failed to notify the physician of these observations. On 01/24/15 at 7:55 AM, Resident #1 was found in severe respiratory distress and was gasping for air. The resident's oxygen saturation was fluctuating in the 80s (normal 98-100) with oxygen at eight (8) liters per minute. The resident's pulse was 102 (normal 60 to 80), respirations were 30 per minute (normal 16-20), temperature of 100.8 F and blood pressure of 100/50 (normal 120/80). The resident was transported to the hospital. A piece of undercooked potato with the skin intact was removed from the resident's throat during intubation. The resident was admitted to the Intensive Care Unit (ICU) in critical condition and diagnosed with [REDACTED]. The facility's failure to notify the physician has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 02/02/15 and determined to exist on 01/23/15. An acceptable Allegation of Compliance (AoC) was received on 02/10/15 alleging the Immediate Jeopardy was removed on 02/05/15. The State Survey Agency validated the Immediate Jeopardy was removed on 02/05/15, as alleged. The Scope and Severity was lowered to a "D" while the facility develops and implements the Plan of Correction (POC); and, the facility's Quality Assurance monitors the effectiveness of the system changes. The findings include: Review of the facility's policy titled, "Notification of Resident Change in Condition", (no date), revealed clinicians should immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). Record review revealed the facility admitted Resident #1 on 06/26/14 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 07/03/14, revealed the facility assessed the resident as having a Brief Interview of Mental Status (BIMS) score of "99", which indicated the resident was not interviewable. The facility also assessed the resident as requiring the extensive assistance of one (1) person for eating. Review of the January 2015 physician's orders [REDACTED]. Review of Resident #1's Nursing Note, dated 01/23/15 at 3:28 PM, revealed a late entry for 11:45 AM which stated the "CNA (Certified Nursing Assistant) reported the resident seemed to be having trouble swallowing fluids with meal. Nurse reported to Speech Therapy (ST). ST stated she would evaluate". Interview with CNA #1, on 01/30/15 at 2:00 PM, revealed Resident #1 was on a mechanical soft diet and preferred to sit on the bed and lean against the wall when he/she ate, which he/she did that day. CNA #1 stated when she was feeding Resident #1 scalloped potatoes on 01/23/15 during lunch, the resident became red in the face and was coughing and spit up some of what he/she had been fed. CNA #1 stated she reported the incident to the nurse who requested the ST to see the resident. Interview, on 01/30/15 at 2:15 PM with RN #1, revealed CNA #1 reported to her that Resident #1 was having trouble swallowing milk at lunch on 01/23/15. RN #1 stated she requested the ST to look at the resident. RN #1 stated she noticed the resident had a deeper voice like he/she needed to cough but she was unable to get the resident to cough. She stated she did not notify the physician as she decided to observe the resident's temperature every shift just in case he/she had aspirated. Interview with CNA #2, on 01/30/15 at 3:10 PM, revealed he attempted to feed Resident #1 his/her supper meal on 01/23/15 and when he gave Resident #1 a bite, the resident would chew and attempt to swallow, but couldn't. CNA #2 stated the resident coughed, got red in the face and he thought the resident had "swallowed the wrong way". CNA #2 stated the resident did the same thing when he/she was offered milk. He stated the resident acted like he/she didn't want to eat so he notified LPN #1. Review of Nursing Notes, dated 01/23/15, revealed there was no documented evidence the physician was notified. Interview with LPN #1, on 01/30/15 at 3:20 PM, revealed she did not recall any staff notifying her that Resident #1 choked and the physician was not notified. Review of Resident #1's Nursing Note, dated 01/23/15 at 8:40 PM, revealed the resident's temperature was 99.1 F and he/she had coughed up some thick mucus. Interview, on 01/31/15 at 8:40 PM with RN #2, revealed on 01/23/15 she had been told in report to check Resident #1's temperature due to the resident having difficulty swallowing earlier in the day and the ST had seen the resident but didn't know anything for sure about the resident having difficulty swallowing. RN #2 stated Resident #1 had a "little rattle" when breathing and she had tried to get the resident to cough but he/she wouldn't or couldn't. RN #2 stated when she checked the resident later she observed a "thick glob of mucous" in the resident's beard and the resident was sounding clearer then. RN #2 revealed she did not notify the resident's physician of the elevated temperature, the "rattle" noted when the resident breathed; or, the mucus she had noted in the resident's beard. Review of a Nursing Note, dated 01/24/15 at 7:55 AM, revealed the resident presented with difficulty breathing, was gasping for air and his/her oxygen saturation was fluctuating in the 80s with oxygen at eight (8) liters (L) per minute. The resident's pulse was 102 , respirations were 30 per minute, his/her temperature of 100.8 F and blood pressure of 100/50. The resident was transported by ambulance to the hospital. Further interview with RN #1, on 01/30/15 at 2:15 PM, revealed on the morning of 01/24/15 staff reported to her Resident #1 was not acting or breathing right. RN #1 stated when she assessed Resident #1 at approximately 7:55 AM, the resident seemed to be struggling to breath and his/her oxygen saturation was in the low 80s. She stated the resident's oxygen saturation continued to fluctuate after 8/L of oxygen was administered. RN #1 stated the resident's breathing was short and labored so she transferred the resident to the hospital. Review of the Hospital Emergency Department records, dated 01/24/15, revealed the resident suffered from Acute [MEDICAL CONDITION] with [MEDICAL CONDITION] (body deprived o oxygen). Further review revealed a slice of uncooked potato, the size of a silver dollar and one-fourth inch thick was removed from the resident's throat during intubation. The resident also had a collapse/consolidation of the right lung, lower lobe; posterior medial basal segments left lower lobe and pneumonia. The resident was placed on a ventilator and admitted to the Intensive Care Unit (ICU) in critical condition. Interview with the Director of Nursing (DON), on 02/02/15 at 11:50 AM, revealed she would have expected staff to notify the Physician when there was any incident or change of condition of a resident. Interview, on 02/03/15 at 11;45 AM, with the Medical Director, who is also Resident #1's Primary Physician revealed he recalled being informed when the resident was sent out in respiratory distress on 01/24/15, but he did not recall being informed of the episodes of difficulty swallowing and choking the day before but staff should have informed him. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 01/24/15, Resident #1 was sent to the hospital and admitted for Airway Obstruction and Aspiration Pneumonia. Resident #1 returned to the facility on [DATE] on a mechanically soft diet; the facility downgraded the diet to puree on 01/28/15. 2. On 01/30/15, the Director of Nursing, Assistant Director of Nursing, Unit Manager, MDS Nurse or Medical Records Nurse conducted an assessment of Resident #1 to determine if there were any medical needs, and or ongoing assessments required that were not already being completed or any significant change in condition that required MD notification. Resident #1's assessment revealed no change in condition that required further Physician notification and noted that appropriate assessments were on-going. 3. The MDS Nurse on 01/30/15 reviewed Resident #1's plans of care and determined that all interventions were in place. 4. Beginning on 01/30/15 and completed on 02/02/15 the Director of Nursing, Assistant Director of Nursing, Unit Manager, MDS Nurse and Medical Records Nurse reviewed all current residents' plan of care to determine if all interventions were being followed. No further concerns were identified. 5. On 01/31/15, the Dietary Services Manager observed Resident #1's lunch meal and determined the diet served was prepared per recipe and was correct per physician's orders [REDACTED]. The Dietary Services Manager also observed the meal tray line during lunch and noted that staff was following the recipe and spreadsheet and providing the diet as ordered for Resident #1 and food was properly prepared. 6. On 01/30/15, the Director of Nursing, Assistant Director of Nursing, Unit Manager, MDS Nurse or Medical Records Nurse conducted assessments of all current residents to determine if there were any medical needs requiring Physician notification and or ongoing assessments required that were not already being completed. Any identified residents who had a change in condition had their Physician notified with orders obtained and follow up assessments. 7. On 01/31/15, the Dietary Services Manager conducted an audit of all current residents' meal trays served from the kitchen and noted that the recipe was followed, diet was correct and served per Physician order [REDACTED]. 8. On 01/30/15, the Regional Quality Manager re-educated the Director of Nursing, Assistant Director of Nursing and Unit Manager, MDS Nurse and Medical Records Nurse on conducting an assessment based on resident condition to include the INTERACT process, follow up assessments as well as Physician notification for a significant change in condition referring to the INTERACT process but not to supersede nursing judgement. The INTERACT process is an evidence based program developed under funding from CMS to prevent unnecessary acute care transfers, to provide guidance to nurses on when to notify the physician and care paths for certain common symptoms. A competency test was administered to validate understanding. In addition, they were educated and a competency test was given related to following the plan of care, and if the plan of care cannot be followed and an alternative is not within their scope of practice that the Physician must be notified 9. On 01/30/15 ,the Director of Nursing, Assistant Director of Nursing and Unit Manager, MDS Nurse and Medical Records Nurse began re-education with all licensed nursing staff related to conducting an assessment based on resident condition to include the INTERACT process, follow up assessments as well as Physician notification for a significant change in condition referring to the INTERACT process but not to supersede nursing judgement. A competency test was administered to validate understanding. No licensed staff will work after 02/04/15 without having completed this re-education and competency test. In addition, reeducation was provided on the requirement to follow the plan of care and if the plan of care cannot be followed and an alternative is not within their scope of practice the physician must be notified. No licensed Nurse worked after 01/30/15 without having received this re-education and competency test. 10. Beginning 02/03/15, all Certified Nursing Assistants were re-educated with competency test related to following the plan of care and if they were unable to follow the plan of care they must report it to the Charge Nurse. No Certified Nursing Assistants will work after 02/03/15 without having received this re-education and competency test. 11. On 02/02/15 and 02/03/15, the Regional Dietician reviewed all current recipes to determine if any recipe called for food products that according to the spreadsheet would not be appropriate for mechanically altered diets. No other concerns were identified. 12. On 01/30/15, the Regional Dietician conducted re-education with the Dietary Services Manager including competency testing related to following the recipe and serving foods per the spreadsheet for correct prescribed diet. 13. Beginning 01/31/15 and ongoing, the Dietary Service Manager will conduct re-education with all Dietary Staff related to following the recipe and the spreadsheet to assure diets are served per the Physician order. This re-education will include a competency test and will be conducted prior to any staff beginning work. No Dietary staff worked after 01/31/15 without having completed the re-education and competency test. 14. On 02/03/15, a contract provider verified the convection oven was working appropriately and the regular oven in which the potatoes were cooked was cooking hotter than the setting on the oven. A new stove/oven was ordered and approved on 03/03/15. 15. Beginning 02/03/15, all dietary staff was instructed by the Dietary Service Manager to only cook on the convection oven. No staff will work after 03/03/15 without having had this re-education. Beginning 02/04/15, all dietary staff will be educated by the Dietary Service Manager that if a concern is identified with the food prepared it should be removed from the tray line and if already served dietary staff should report the concerns to the Nurse. No dietary staff will work after 02/04/15 without having received this education. 16. Beginning 01/28/15 and ongoing, all nursing staff was educated by the Director of Nursing, Assistant Director of Nursing, Unit Manager MDS Nurse or Medical Records Nurse on notification of the nurse if meals appear to be prepared incorrectly such as overcooked, undercooked or hard to cut foods. No nursing staff will work after 02/04/15 without having received this education. In addition, beginning on 02/03/15 and on going, all Certified Nursing Assistants were re-educated with competency test related to following the plan of care and if they were unable to follow the plan of care they must report it to the Charge Nurse. No Certified Nursing Assistants will work after 02/03/15 without having received this re-education and competency test. 17. Beginning 01/31/15, the Director of Nursing, Assistant Director of Nursing or Unit Manager will review with the facility staff the residents' condition each shift to determine if licensed staff are notifying the Physician of significant changes in condition as well as completing ongoing assessment as needed. This will continue every shift until abatement then five (5) times per week for twelve (12)weeks thereafter. 18. The Director of Nursing, Assistant Director of Nursing or Unit Manager will review five (5) residents' plans of care per week for twelve (12) weeks to evaluate if interventions are in place and being followed. The results of these audits will be reviewed with the Quality Assurance and Improvement Committee weekly until substantial compliance then monthly thereafter. 19. Beginning 02/01/15, the Director of Nursing, Assistant Director of Nursing or Unit Manager will review all Nurses Notes daily to determine if any significant change in condition has occurred without Physician notification or any significant change in condition requiring ongoing assessment that has not occurred. This will occur daily until abatement of Immediate Jeopardy and then five (5) times per week for twelve (12) weeks. 20. Beginning 01/31/15, a Dietary Service Manager or a Registered Dietician will observe one meal service per day to assure staff are following the recipe, serving and using the diet spreadsheet and that food is properly prepared to meet the individual needs. This will continue until abatement of the Immediate Jeopardy and then five (5) times per week for twelve (12) weeks thereafter. 21. The results of these audits will be reviewed with the Quality Assurance and Improvement Committee (QAPI) weekly until substantial compliance then monthly thereafter. The QAPI committee will meet weekly or anytime concerns are identified until substantial compliance, then monthly thereafter. Members of the QAPI Committee will consist of at a minimum the Director of Nursing, Assistant Director of Nursing, Social Services Director, Maintenance Director, Activity Director and Business Office Manager with the Medical Director participating at least quarterly and as needed. 22. On 01/30/15, an ad hock Quality Assurance and Performance Improvement Committee was convened to review the facility's investigation and concerns. An Allegation of Compliance was developed and reviewed with the Medical Director who attended via phone. In attendance was the Administrator, Director of Nursing, Assistant Director of Nursing, Unit Manager, Medical Records Clerk, MDS Nurse, Social Services Director, Dietary Services Manager and Activity director. No further recommendations were made at this time. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of the Nursing Notes and Physician order [REDACTED].#1 was sent to the hospital and admitted for Airway Obstruction and Aspiration Pneumonia. Resident #1 returned to the facility on [DATE] on a mechanically soft diet and the facility downgraded the diet to pureed on 01/28/15. Observation of the lunch meal on 02/12/15 at 12:00 PM, revealed the resident was being fed by the Speech Therapist. The food was in pureed form, as per the resident's diet card on the tray. 2. Review of an assessment conducted by the Director of Nursing, Assistant Director of Nursing, Unit Manager, MDS Nurse or Medical Records Nurse of Resident #1 on 01/30/15, revealed there were no change in condition that required further Physician notification and noted that appropriate assessments were on-going. 3. Review of documentation by the MDS Nurse, dated 01/30/15, revealed she reviewed Resident #1's plans of care and determined that all interventions were in place. 4. Review of documentation verified on 01/30/15 through 02/02/15 the DON, ADON, Unit Manager, MDS Nurse and Medical Records Nurse reviewed all current resident's plans of care to determine if all interventions were being followed. The documentation revealed which residents' plans of care were reviewed by which administrative staff. 5. Review of documentation by the Dietary Manager, dated 01/31/15, revealed the Dietary Manager observed Resident #1's lunch meal and determined the diet served was prepared per recipe and was correct per physician's orders [REDACTED]. In addition, the documentation revealed she also observed the tray line and determined staff was following the recipe and spreadsheet and providing the diets as ordered. 6. Review of residents' assessments conducted on 01/30/15 revealed all resident assessments were completed and any residents who had an identified change in condition had their physician notified. The assessments were conducted by the DON, ADON, Unit Manager MDS Nurse and Medical Records Nurse. 7. Review of documentation dated 01/31/15 revealed the Dietary Services Manager conducted an audit of all current residents' meal trays served from the kitchen and verified the recipe was followed, diet was correct and served per Physician Order, to meet the needs of the resident and properly prepared. 8. Review of documentation of re-education by the Regional Quality Manager to the DON, ADON, Unit Manager, MDS Nurse and Medical Records Nurse, dated 01/30/15, verified they were reeducated on the INTERACT process, follow up assessments, Physician notification for significant change, following the plan of care, and if the plan of care cannot be followed and an alternative is not within their scope of practice the Physician must be notified. Review of the competency tests revealed each of them completed the test on 01/30/15. 9. Review of inservice sign in sheets and competency tests, beginning 01/30/15, revealed all licensed staff was re-educated beginning 01/30/15 and competency tests were administered and passed related to the INTERACT process, follow up assessments, Physician notification for significant change, following the plan of care, and if the plan of care cannot be followed and an alternative is not within their scope of practice the Physician must be notified. Review of the competency tests revealed each of them completed the test on 01/30/15. Interview with the Administrator, on 02/12/15 at 1:35 PM, revealed the DON provided education to the staff related to assessments, INTERACT tool for assessments and Physician notification. Staff was educated about care plan interventions ensuring their appropriateness and implementation Interview with the DON, on 02/12/15 at 1:30 PM, revealed she provided education on the INTERACT tool for assessments and Physician notification and had also educated staff on updating care plans according to their scope of practice. The Twenty Four Hour Report was also topic. Nursing staff was given competency tests on following the INTERACT tool and nursing judgement. CNAs required a post test as well. Interview with RN #3, on 02/12/15 at 12:30 PM, revealed she received education related to the INTERACT system utilized by the facility which was a tool for assessments and included why, when, who and Physician notification. The education included follow up documentation on any type of complaint or anything out of the normal for a resident. Information was to be passed on to the next shift if not resolved and follow up was to be done the next day. A post test was given which RN #3 passed. Interview with LPN #3, on 02/12/15 at 12:35 PM, revealed education was provided to her by the DON that resident assessments should be conducted before, during, and after any type of an event and gave examples of elevated temperature, shortness of breath, and chest pain. LPN #3 was given a post test and passed. Education was also given to her about Physician notification, follow up documentation and implementing the care plan. She stated if the care plan needed changed or could not be implemented to notify the DON. Interview with LPN #4, on 02/12/15 at 12:40 PM, revealed she had been educated by the DON related to the INTERACT tools for resident assessment, physician notification and documentation. The Physician was to be notified for any significant change. Assessments were to be completed, the resident monitored and reassessed. The assessments were to include the resident's vital signs as blood pressure, respiration, oxygen saturation, pulse and temperature. LPN #4 was required to pass a post test. Interview with RN #1, on 02/12/15 at 12:50 PM, revealed she had been provided education by the DON related to a change in condition of a resident including if the resident was having trouble swallowing. For any emergency "911" was to be called and then notify the Physician. The INTERACT tool which reflects how, what and when to notify the Physician was to be utilized, as well, as the Stop and Watch tool which anyone could fill out and give to the nurse. Any change of condition of a resident required a complete assessment, including if a resident became choked while eating. Seventy-two (72)hour documentation was required for any changes, this included the resident's vital signs and if symptoms persisted the physician should be notified again. In addition, care plan education was provided related how to access that information from the headsets worn by the CNAs. The care plan had to match the resident's needs and if not the CNAs were to notify the nurse. A post test was completed to validate understanding. Interview with RN #4, on 02/12/15 at 12:55 PM, revealed she had recent education by the DON related to assessments. The INTERACT tool was a step by step guide on how, what and when to do anything and Physician notification. In addition, education was provided on care plans that included information about carrying out the interventions and revising when needed. CNAs were to report any problems with the care plan and the Physician was to be notified. She stated she had to take a post test and pass. 10. Interview with CNA #5, on 02/12/15 at 1:00 PM, revealed education was provided on care plans related to accessing the information on the CNA headset and to always inform the nurse when something did not seem right about the information. A post test was taken and had to be passed. Interview with CNA #6, on 01/12/15 at 1:05 PM, revealed education was provided on care plans and she was to ensure the care plan was followed and if the care plan did not seem appropriated she was to speak with the nurse immediately. Interview with CNA #7, on 02/12/15 at 1:10 PM, revealed she was educated on implementation of care plans and a post test was given and she passed. Interview with CNA #8, on 02/12/15 at 1:15 PM, revealed she had recently been educated that she was required to be familiar with each resident's care plan an it was accessible through the head set that she wears. CNA #8 stated if she could not follow the resident's care plan she was to go to the nurse for clarification. She revealed she had to take a post test and pass. 11. Interview with the Administrator, on 02/12/15 at 1:35 PM, revealed the spread sheets and recipes were reviewed and the spread sheet for the scalloped potato recipe was revised to include peeling potatoes before cooking. Interview with the Registered Dietician, on 02/12/15 at 11:35 AM, revealed she had revised the spread sheet and recipe for scalloped potatoes to indicate peeling the potatoes. 12. Interview with the Dietary Manager, on 02/12/15 at 11:30 AM, revealed she had received inservice from the Registered Dietician on reading and following spreadsheets and recipes. Education was provided that potato skins were not part of the Mechanical Soft Diet. She was educated on reading and calibrating thermometers and using only the left oven on the stove instead of the malfunction right side oven and the recipe and spread sheet for scalloped potatoes had been revised to instruct to peel the potatoes. One meal every day was being monitored to ensure the spread sheet and recipe as well as the tray cards were being followed. 13. Interview with the Administrator, on 02/12/15 at 1:35 PM, revealed dietary staff was educated over recipes and spread sheet, meal preparation and diets per the physician's orders [REDACTED]. Interview with the Registered Dietician, on 02/12/15 at 11:35 AM, revealed she had provided education to the dietary staff related to the spread sheets and recipes. She stated the reading of the tray cards was also covered in education as well as what to do if a food item did not turn out that included not serving that food item. Interview with Cook #1, on 02/12/15 at 11:40 AM, revealed she had been educated about how to set and use thermometers for checking food temperatures and about how to follow the spread sheet recipes. She stated a test was given to verify she understood the education. Interview with Dietary Aide #3, on 02/12/15 at 11:45 AM, revealed she had received education by the Dietary Manager on how to follow the spread sheets and recipes. She stated she also had to take a test to verify she understood the education. 14. On 02/03/15 a contract provider verified that the convection oven was working appropriately and that the regular oven in which the potatoes were cooked was cooking hotter than the setting on the oven. A new stove/oven was ordered and approved on 02/03/15. Interview with the Administrator, on 02/12/15, revealed a new stove had been ordered for the facility and should be installed in about three weeks. The facility was also getting a new :"Leer"" (blender/mixer) for puree foods and also a meat slicer for evenness. 15. Interview with the Administrator, on 02/12/15 at 1:35 PM, revealed the dietary staff had been educated to use the left oven until the new stove was installed. Interview with Cook #1, on 02/12/15 at 11:40 AM, revealed she had been educated that the oven on the right side of the stove was not to be used until the new stove was delivered. Cook #1 stated she also received educated on what to do if food does not turn out right for any reason, The food is to be pulled off the tray line and not served. She stated if a food item was discovered to not be "right" after it goes out to the residents she was to tell the nurse. Interview with Dietary Aide #3, on 02/12/15 at 11:45 AM, revealed she had received education by the Dietary Manager not to use the left side oven of the stove. Dietary Aide #3 stated she also received education by the Dietary Manager to double check residents' diet cards and if food was not right for some reason it was to be pulled off the line and not served. She stated if it was discovered after it goes out, the nurse was to be notified. 16. Interview with the DON, on 02/12/15 at 1:30 PM, revealed she started education related to small bites, under and over cooked food on 01/28/15. Staff was not to serve any food that did not match the meal ticket and CNAs were to report to the nurse and then the dietary staff was to be notified. Interview with RN #3, on 02/12/15 at 12:30 PM, revealed she had received education from the Director of Nursing (DON) related to ensuring food that was served was properly prepared and gave example of over or undercooked food. Certified Nurse Aides were to inform the nurse if something did not seem right about a resident's tray and it was not to be served. A post test was given which RN #3 passed. Interview with LPN #3, on 02/12/15 at 12:35 PM, revealed education was provided to her by the DON related to notifying the nurse if a food item to be served to a resident was wrong. She stated the first thing was to not give it to the resident then notify the nurse and the kitchen. The meal ticket was to be followed; staff was to ensure the residents were given small bites. LPN #3 was given a post test and passed. Interview with LPN #4, on 02/12/15 at 12:40 PM, revealed she had been educated by the DON related to residents' meals and following the appropriate diets. She stated if a meal served to a resident was not appropriate it was to be removed and an appropriate alternate provided to the resident. The CNAs were required to report any diet concerns to the nurse and the kitchen was to be notified. A post test was given related to the dietary education and had to be passed. Interview with RN #1, on 02/12/15 at 12:50 PM, revealed she

Based on observation, interview, record review, review of Hospital emergency room Records and review of facility policies it was determined the facility failed to ensure one (1) of four (4) sampled residents (Resident #1), received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance the comprehensive assessment and plan of care. The facility failed to provide a mechanical soft diet for Resident #1 and failed to assess Resident #1 for signs and symptoms of aspiration after two (2) episodes of choking. On [DATE], during the lunch meal, Resident #1 became choked when Certified Nurse Aide (CNA) #1 fed the resident scalloped potatoes. The resident coughed spitting up some of the potatoes and his/her face became red. CNA #1 informed the nurse, who did not assess the resident, but notified the Speech Therapist (ST). The ST gave the resident chocolate milk and determined the problem was the resident needed to be sitting at a ninety degree angle when fed. The ST did not look in the resident's mouth or do any hands on assessment. The nurse did not assess the resident for lung sounds, obtain oxygen saturation levels, or obtain vital signs. The resident experienced another choking episode when being fed the supper meal. The CNA notified Licensed Practical Nurse (LPN) #1 who did not assess the resident. At 8:40 PM, the resident presented with an elevated temperature of 99.1 F (normal 98.6 F), coughed up some thick mucus, and had a noted "little rattle" when breathing; however, the nurse (RN #2), did not assess the resident's respiratory status, lung sounds or oxygen saturation. Resident #1 was found to be in respiratory distress the next morning on [DATE] at 7:55 AM. The resident was sent to the Emergency Department and a circular piece of potato with the skin on it was found in the resident's throat during intubation. The resident was admitted to the hospital with [REDACTED]. The facility's failure to ensure the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care was provided has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] alleging the IJ was removed on [DATE]. The State Survey Agency validated the Immediate Jeopardy was removed on [DATE], as alleged. The Scope and Severity was lowered to a "D" while the facility develops and implements the Plan of Correction (POC); and, the facility's Quality Assurance monitors the effectiveness of the system changes. The findings include: Review of the facility's policy titled, Resident Comprehensive Care Plan, dated ,[DATE], revealed the resident's comprehensive care plan should be viewed as an interdisciplinary approach to managing the acute and chronic needs of the resident living in the facility. Review of a manual titled, "Simplified Diet Manual", eleventh edition, utilized by the facility, revealed a Mechanical Soft Diet is designed to permit easy chewing. The General Diet is modified in consistency and texture by cooking, grinding, chopping, mincing or mashing. The diet includes foods soft in texture such as cooked fruits and vegetables, moist ground meat and soft bread and cereal products. Foods that dissolve readily when held in the mouth such as graham crackers and some ready-to-eat cereals are also appropriate. It is most important to individualize or adjust it to the tolerance of the resident. Table 3.1 Mechanical Soft revealed to avoid raw or undercooked vegetables and those with tough skins; and whole kernel corn and fried vegetables. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed the resident's cognitive status with a Brief Interview of Mental Status score of "99", indicating the resident as not interviewable; the facility assessed the resident as requiring extensive assistance of one (1) person for eating. Review of Resident #1's physician's orders [REDACTED]. Review of Resident #1's Comprehensive Care Plan for Risk for Alteration in Nutrition, dated [DATE], revealed interventions to monitor intake and offer alternates/substitutes as needed, provide diet as ordered; mechanically soft, assist with meals, and to monitor tolerance to diet texture and for signs and symptoms of aspiration. Observation, on [DATE] at 9:40 AM, revealed Resident #1 lying on the bed which was in a low position and fall mats covering most of the room floor. The resident made eye contact when spoken to and responded only with repetitive guttural sounds. Observation at 11:45 AM revealed the resident sitting in a wheelchair and the Speech Therapist (ST) attempting to feed the resident. The resident repeatedly turned his/her head to the side and said "no" repeatedly. A Late Entry Nursing Note, dated [DATE] at 3:28 PM for 11:45 AM, revealed a CNA had reported Resident #1 had trouble swallowing and the nurse reported to the Speech Therapist (ST) who said she would evaluate. There was no documented evidence the nurse had assessed the resident for signs and symptoms of aspiration. Interview with CNA #1, on [DATE] at 2:00 PM, revealed Resident #1 normally ate very well and she knew the resident's diet order was for mechanical soft. CNA #1 stated Resident #1 was resistive at times to sitting in a chair and preferred to sit on the bed and lean against the wall, which he/she did that day. CNA #1 revealed when she was feeding Resident #1 scalloped potatoes on [DATE] during lunch, the resident got really red in the face and was coughing and had spit up some of what he/she had been fed. CNA #1 stated she reported the incident to the nurse who requested the ST to see the resident. CNA #1 revealed the ST came fairly quickly and gave the resident two (2) to three (3) sips of chocolate milk after sitting the resident in a more upright position. Interview with CNA #3, on [DATE] at 12:36 PM, revealed at lunch time on [DATE], CNA #1 came and got her and said the resident was coughing. CNA #3 stated she went and saw Resident #1 who looked red faced. CNA #3 was in the room when the ST gave Resident #1 chocolate milk. Interview, on [DATE] at 2:15 PM with RN #1, revealed CNA #1 reported Resident #1 was having trouble swallowing milk at lunch on [DATE] and she had the ST look at the resident. RN #1 revealed when she observed Resident #1 with the ST there was no coughing and the resident's color was good. RN #1 stated she noticed the resident had a deeper voice like he/she needed to cough but she was unable to get the resident to cough. RN #1 stated she did not assess the resident for signs and symptoms of aspiration but decided to observe the resident's temperature every shift just in case he/she had aspirated. Interview with the Speech Therapist (ST), on [DATE] at 10:40 AM, revealed she had received a call from a nurse on [DATE] stating Resident #1 had a choking episode during lunch. She stated she went to Resident #1's room and determined the resident required better positioning and needed to be sitting up at 90 degrees for meals and educated the CNAs that day. The ST stated she did not assess the resident's oral cavity or ability to swallow food but had observed him/her to drink chocolate milk while sitting at a 90 degree position without difficulty. Interview with CNA #2, on [DATE] at 3:10 PM, revealed he attempted to feed Resident #1 the supper meal on [DATE] and when he gave Resident #1 a bite, the resident would chew and attempt to swallow, but couldn't. CNA #2 stated the resident coughed, got red in the face and he thought the resident had "swallowed the wrong way". CNA #2 revealed the resident did the same thing when milk was offered and acted like he/she didn't want to eat so the CNA #2 notified LPN #1. CNA #2 stated he did not know if LPN #1 had assessed Resident #1 or not. Interview with Cook #1, on [DATE] at 1:00 PM, revealed fresh potatoes had been used to make scalloped potatoes for the lunch meal on [DATE]. Cook #1 stated she did not peel the potatoes and had cooked them for one and one half hours. She revealed she was notified by a staff member the scalloped potatoes were not cooked enough when the meal trays were served to residents in the dining room. Further interview revealed she was aware at that time the hall tray carts had already been delivered for residents to be served meals in their rooms and she took no action to retrieve the residents' trays with the scalloped potatoes. She revealed she continued to serve the scalloped potatoes by picking out the thinner slices and refrigerated the remaining potatoes with a note on the pan indicating the potatoes required cooking if served again. Interview with LPN #1, on [DATE] at 3:20 PM revealed she did not recall CNA #2 saying anything to her about Resident #1 and Resident #1 was not her resident and if someone reported something about a resident she would tell them to talk to that resident's nurse. LPN #1 did not assess the resident. Review of Nursing Note, dated [DATE] at 8:40 PM, revealed Resident #1's temperature was 99.1 F; he/she had coughed up thick mucus, drank chocolate milk without difficulty, and had no swallowing problems. Interview, on [DATE] at 8:40 PM with RN #2, revealed on [DATE] she had been told in report to check Resident #1's temperature due to the resident having difficulty swallowing earlier in the day and the ST had looked at the resident but didn't know anything for sure. RN #2 stated Resident #1 had a "little rattle" when breathing and she had tried to get the resident to cough but he/she wouldn't or couldn't. RN #2 revealed when she checked the resident later she had observed a "thick glob of mucous" in the resident's beard and the resident was sounding clearer then. RN #2 stated she did not assess the resident's lung sounds or obtain oxygen saturation and stated the resident had behaviors and "would have hit me". Review of a Nursing Note, dated [DATE] at 7:55 AM, revealed Resident #1 was found in severe respiratory distress and was gasping for air. The resident's oxygen saturation was fluctuating in the 80s (normal ,[DATE]) with oxygen at eight (8) liters per minute. The resident's pulse was 102 (normal 60 to 80), respirations were 30 per minute (normal ,[DATE]), temperature of 100.8 F and blood pressure of ,[DATE] (normal ,[DATE]). The resident was transported to the hospital. Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 2:35 PM, revealed on the morning of [DATE], staff had informed her Resident #1 didn't sound right and was having a hard time breathing. She stated she assessed the resident with a stethoscope but couldn't hear any lung sounds due to the noise of the resident trying to breath and gasping. Resident #1 was assisted to sit up and was gasping for air when transferred out by EMS (Emergency Medical Services). Review of Hospital Emergency Department Records, dated [DATE], revealed the resident suffered from Acute [MEDICAL CONDITION] with [MEDICAL CONDITION] (a condition where the body is deprived of adequate oxygen supply). Further review revealed a slice of uncooked potato the size of a silver dollar and one-fourth inch thick was removed from the resident's throat during intubation. Resident #1 had a collapse/consolidation of the right lung, lower lobe; posterior medial basal segments left lower lobe and pneumonia. The resident was placed on a ventilator and admitted to the Intensive Care Unit (ICU) in critical condition. Interview with the Emergency Department Physician (ED), on [DATE] at 11:00 AM, revealed Resident #1 was in [MEDICAL CONDITION] on [DATE] when brought to the Emergency Department. He stated when he intubated Resident #1 he identified a one and one half inch circular piece of potato that still had the peeling on it stuck in the resident's throat. He stated the potato probably acted like a ball valve and the resident may have been able to swallow some liquids. Further interview revealed the resident could not get the epiglottis to close over the trachea. He stated Resident #1 had pneumonia from aspiration and the circular potato piece he removed was intact and very firm. The ED Physician stated Resident #1 could have died from the potato piece cutting off his/her airway or could have died from the aspiration pneumonia. Interview with the Director of Nursing (DON), on [DATE] at 3:00 PM revealed she would have expected the nurse to do a respiratory assessment after the choking incidents. She revealed the ST had evaluated Resident #1 but if a wrong food item was sent out and served to the resident then obviously the resident food was not according to the resident's assessed needs and the resident should have been assessed and monitored for aspiration after each episode of choking as well as the elevated temperature. Interview with the Medical Director/Primary Physician of Resident #1, on [DATE] at 11:45 AM revealed he was aware now the resident had an partially cooked potato piece lodged in his/her trachea and had developed pneumonia and was on antibiotics. Interview with the Administrator on [DATE] at 11:40 AM revealed CNA #1 had been unable to explain how a whole potato slice was found lodged in Resident #1's throat even though she said she had mashed the potatoes with a fork. She additionally stated she had never heard of leaving the peel on potatoes when preparing scalloped potatoes. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], Resident #1 was sent to the hospital and admitted for Airway Obstruction and Aspiration Pneumonia. Resident #1 returned to the facility on [DATE] on a mechanically soft diet; the facility downgraded the diet to puree on [DATE]. 2. On [DATE], the Director of Nursing, Assistant Director of Nursing, Unit Manager, MDS Nurse or Medical Records Nurse conducted an assessment of Resident #1 to determine if there were any medical needs, and or ongoing assessments required that were not already being completed or any significant change in condition that required MD notification. Resident #1's assessment revealed no change in condition that required further Physician notification and noted that appropriate assessments were on-going. 3. The MDS Nurse on [DATE] reviewed Resident #1's plans of care and determined that all interventions were in place. 4. Beginning on [DATE] and completed on [DATE] the Director of Nursing, Assistant Director of Nursing, Unit Manager, MDS Nurse and Medical Records Nurse reviewed all current residents' plan of care to determine if all interventions were being followed. No further concerns were identified. 5. On [DATE], the Dietary Services Manager observed Resident #1's lunch meal and determined the diet served was prepared per recipe and was correct per physician's orders [REDACTED]. The Dietary Services Manager also observed the meal tray line during lunch and noted that staff was following the recipe and spreadsheet and providing the diet as ordered for Resident #1 and food was properly prepared. 6. On [DATE], the Director of Nursing, Assistant Director of Nursing, Unit Manager, MDS Nurse or Medical Records Nurse conducted assessments of all current residents to determine if there were any medical needs requiring Physician notification and or ongoing assessments required that were not already being completed. Any identified residents who had a change in condition had their Physician notified with orders obtained and follow up assessments. 7. On [DATE], the Dietary Services Manager conducted an audit of all current residents' meal trays served from the kitchen and noted that the recipe was followed, diet was correct and served per Physician order [REDACTED]. 8. On [DATE], the Regional Quality Manager re-educated the Director of Nursing, Assistant Director of Nursing and Unit Manager, MDS Nurse and Medical Records Nurse on conducting an assessment based on resident condition to include the INTERACT process, follow up assessments as well as Physician notification for a significant change in condition referring to the INTERACT process but not to supersede nursing judgement. The INTERACT process is an evidence based program developed under funding from CMS to prevent unnecessary acute care transfers, to provide guidance to nurses on when to notify the physician and care paths for certain common symptoms. A competency test was administered to validate understanding. In addition, they were educated and a competency test was given related to following the plan of care, and if the plan of care cannot be followed and an alternative is not within their scope of practice that the Physician must be notified 9. On [DATE] ,the Director of Nursing, Assistant Director of Nursing and Unit Manager, MDS Nurse and Medical Records Nurse began re-education with all licensed nursing staff related to conducting an assessment based on resident condition to include the INTERACT process, follow up assessments as well as Physician notification for a significant change in condition referring to the INTERACT process but not to supersede nursing judgement. A competency test was administered to validate understanding. No licensed staff will work after [DATE] without having completed this re-education and competency test. In addition, reeducation was provided on the requirement to follow the plan of care and if the plan of care cannot be followed and an alternative is not within their scope of practice the physician must be notified. No licensed Nurse worked after [DATE] without having received this re-education and competency test. 10. Beginning [DATE], all Certified Nursing Assistants were re-educated with competency test related to following the plan of care and if they were unable to follow the plan of care they must report it to the Charge Nurse. No Certified Nursing Assistants will work after [DATE] without having received this re-education and competency test. 11. On [DATE] and [DATE], the Regional Dietician reviewed all current recipes to determine if any recipe called for food products that according to the spreadsheet would not be appropriate for mechanically altered diets. No other concerns were identified. 12. On [DATE], the Regional Dietician conducted re-education with the Dietary Services Manager including competency testing related to following the recipe and serving foods per the spreadsheet for correct prescribed diet. 13. Beginning [DATE] and ongoing, the Dietary Service Manager will conduct re-education with all Dietary Staff related to following the recipe and the spreadsheet to assure diets are served per the Physician order. This re-education will include a competency test and will be conducted prior to any staff beginning work. No Dietary staff worked after [DATE] without having completed the re-education and competency test. 14. On [DATE], a contract provider verified the convection oven was working appropriately and the regular oven in which the potatoes were cooked was cooking hotter than the setting on the oven. A new stove/oven was ordered and approved on [DATE]. 15. Beginning [DATE], all dietary staff was instructed by the Dietary Service Manager to only cook on the convection oven. No staff will work after [DATE] without having had this re-education. Beginning [DATE], all dietary staff will be educated by the Dietary Service Manager that if a concern is identified with the food prepared it should be removed from the tray line and if already served dietary staff should report the concerns to the Nurse. No dietary staff will work after [DATE] without having received this education. 16. Beginning [DATE] and ongoing, all nursing staff was educated by the Director of Nursing, Assistant Director of Nursing, Unit Manager MDS Nurse or Medical Records Nurse on notification of the nurse if meals appear to be prepared incorrectly such as overcooked, undercooked or hard to cut foods. No nursing staff will work after [DATE] without having received this education. In addition, beginning on [DATE] and on going, all Certified Nursing Assistants were re-educated with competency test related to following the plan of care and if they were unable to follow the plan of care they must report it to the Charge Nurse. No Certified Nursing Assistants will work after [DATE] without having received this re-education and competency test. 17. Beginning [DATE], the Director of Nursing, Assistant Director of Nursing or Unit Manager will review with the facility staff the residents' condition each shift to determine if licensed staff are notifying the Physician of significant changes in condition as well as completing ongoing assessment as needed. This will continue every shift until abatement then five (5) times per week for twelve (12)weeks thereafter. 18. The Director of Nursing, Assistant Director of Nursing or Unit Manager will review five (5) residents' plans of care per week for twelve (12) weeks to evaluate if interventions are in place and being followed. The results of these audits will be reviewed with the Quality Assurance and Improvement Committee weekly until substantial compliance then monthly thereafter. 19. Beginning [DATE], the Director of Nursing, Assistant Director of Nursing or Unit Manager will review all Nurses Notes daily to determine if any significant change in condition has occurred without Physician notification or any significant change in condition requiring ongoing assessment that has not occurred. This will occur daily until abatement of Immediate Jeopardy and then five (5) times per week for twelve (12) weeks. 20. Beginning [DATE], a Dietary Service Manager or a Registered Dietician will observe one meal service per day to assure staff are following the recipe, serving and using the diet spreadsheet and that food is properly prepared to meet the individual needs. This will continue until abatement of the Immediate Jeopardy and then five (5) times per week for twelve (12) weeks thereafter. 21. The results of these audits will be reviewed with the Quality Assurance and Improvement Committee (QAPI) weekly until substantial compliance then monthly thereafter. The QAPI committee will meet weekly or anytime concerns are identified until substantial compliance, then monthly thereafter. Members of the QAPI Committee will consist of at a minimum the Director of Nursing, Assistant Director of Nursing, Social Services Director, Maintenance Director, Activity Director and Business Office Manager with the Medical Director participating at least quarterly and as needed. 22. On [DATE], an ad hock Quality Assurance and Performance Improvement Committee was convened to review the facility's investigation and concerns. An Allegation of Compliance was developed and reviewed with the Medical Director who attended via phone. In attendance was the Administrator, Director of Nursing, Assistant Director of Nursing, Unit Manager, Medical Records Clerk, MDS Nurse, Social Services Director, Dietary Services Manager and Activity director. No further recommendations were made at this time. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of the Nursing Notes and Physician order [REDACTED].#1 was sent to the hospital and admitted for Airway Obstruction and Aspiration Pneumonia. Resident #1 returned to the facility on [DATE] on a mechanically soft diet and the facility downgraded the diet to pureed on [DATE]. Observation of the lunch meal on [DATE] at 12:00 PM, revealed the resident was being fed by the Speech Therapist. The food was in pureed form, as per the resident's diet card on the tray. 2. Review of an assessment conducted by the Director of Nursing, Assistant Director of Nursing, Unit Manager, MDS Nurse or Medical Records Nurse of Resident #1 on [DATE], revealed there were no change in condition that required further Physician notification and noted that appropriate assessments were on-going. 3. Review of documentation by the MDS Nurse, dated [DATE], revealed she reviewed Resident #1's plans of care and determined that all interventions were in place. 4. Review of documentation verified on [DATE] through [DATE] the DON, ADON, Unit Manager, MDS Nurse and Medical Records Nurse reviewed all current resident's plans of care to determine if all interventions were being followed. The documentation revealed which residents' plans of care were reviewed by which administrative staff. 5. Review of documentation by the Dietary Manager, dated [DATE], revealed the Dietary Manager observed Resident #1's lunch meal and determined the diet served was prepared per recipe and was correct per physician's orders [REDACTED]. In addition, the documentation revealed she also observed the tray line and determined staff was following the recipe and spreadsheet and providing the diets as ordered. 6. Review of residents' assessments conducted on [DATE] revealed all resident assessments were completed and any residents who had an identified change in condition had their physician notified. The assessments were conducted by the DON, ADON, Unit Manager MDS Nurse and Medical Records Nurse. 7. Review of documentation dated [DATE] revealed the Dietary Services Manager conducted an audit of all current residents' meal trays served from the kitchen and verified the recipe was followed, diet was correct and served per Physician Order, to meet the needs of the resident and properly prepared. 8. Review of documentation of re-education by the Regional Quality Manager to the DON, ADON, Unit Manager, MDS Nurse and Medical Records Nurse, dated [DATE], verified they were reeducated on the INTERACT process, follow up assessments, Physician notification for significant change, following the plan of care, and if the plan of care cannot be followed and an alternative is not within their scope of practice the Physician must be notified. Review of the competency tests revealed each of them completed the test on [DATE]. 9. Review of inservice sign in sheets and competency tests, beginning [DATE], revealed all licensed staff was re-educated beginning [DATE] and competency tests were administered and passed related to the INTERACT process, follow up assessments, Physician notification for significant change, following the plan of care, and if the plan of care cannot be followed and an alternative is not within their scope of practice the Physician must be notified. Review of the competency tests revealed each of them completed the test on [DATE]. Interview with the Administrator, on [DATE] at 1:35 PM, revealed the DON provided education to the staff related to assessments, INTERACT tool for assessments and Physician notification. Staff was educated about care plan interventions ensuring their appropriateness and implementation Interview with the DON, on [DATE] at 1:30 PM, revealed she provided education on the INTERACT tool for assessments and Physician notification and had also educated staff on updating care plans according to their scope of practice. The Twenty Four Hour Report was also topic. Nursing staff was given competency tests on following the INTERACT tool and nursing judgement. CNAs required a post test as well. Interview with RN #3, on [DATE] at 12:30 PM, revealed she received education related to the INTERACT system utilized by the facility which was a tool for assessments and included why, when, who and Physician notification. The education included follow up documentation on any type of complaint or anything out of the normal for a resident. Information was to be passed on to the next shift if not resolved and follow up was to be done the next day. A post test was given which RN #3 passed. Interview with LPN #3, on [DATE] at 12:35 PM, revealed education was provided to her by the DON that resident assessments should be conducted before, during, and after any type of an event and gave examples of elevated temperature, shortness of breath, and chest pain. LPN #3 was given a post test and passed. Education was also given to her about Physician notification, follow up documentation and implementing the care plan. She stated if the care plan needed changed or could not be implemented to notify the DON. Interview with LPN #4, on [DATE] at 12:40 PM, revealed she had been educated by the DON related to the INTERACT tools for resident assessment, physician notification and documentation. The Physician was to be notified for any significant change. Assessments were to be completed, the resident monitored and reassessed. The assessments were to include the resident's vital signs as blood pressure, respiration, oxygen saturation, pulse and temperature. LPN #4 was required to pass a post test. Interview with RN #1, on [DATE] at 12:50 PM, revealed she had been provided education by the DON related to a change in condition of a resident including if the resident was having trouble swallowing. For any emergency "911" was to be called and then notify the Physician. The INTERACT tool which reflects how, what and when to notify the Physician was to be utilized, as well, as the Stop and Watch tool which anyone could fill out and give to the nurse. Any change of condition of a resident required a complete assessment, including if a resident became choked while eating. Seventy-two (72)hour documentation was required for any changes, this included the resident's vital signs and if symptoms persisted the physician should be notified again. In addition, care plan education was provided related how to access that information from the headsets worn by the CNAs. The care plan had to match the resident's needs and if not the CNAs were to notify the nurse. A post test was completed to validate understanding. Interview with RN #4, on [DATE] at 12:55 PM, revealed she had recent education by the DON related to assessments. The INTERACT tool was a step by step guide on how, what and when to do anything and Physician notification. In addition, education was provided on care plans that included information about carrying out the interventions and revising when needed. CNAs were to report any problems with the care plan and the Physician was to be notified. She stated she had to take a post test and pass. 10. Interview with CNA #5, on [DATE] at 1:00 PM, revealed education was provided on care plans related to accessing the information on the CNA headset and to always inform the nurse when something did not seem right about the information. A post test was taken and had to be passed. Interview with CNA #6, on [DATE] at 1:05 PM, revealed education was provided on care plans and she was to ensure the care plan was followed and if the care plan did not seem appropriated she was to speak with the nurse immediately. Interview with CNA #7, on [DATE] at 1:10 PM, revealed she was educated on implementation of care plans and a post test was given and she passed. Interview with CNA #8, on [DATE] at 1:15 PM, revealed she had recently been educated that she was required to be familiar with each resident's care plan an it was accessible through the head set that she wears. CNA #8 stated if she could not follow the resident's care plan she was to go to the nurse for clarification. She revealed she had to take a post test and pass. 11. Interview with the Administrator, on [DATE] at 1:35 PM, revealed the spread sheets and recipes were reviewed and the spread sheet for the scalloped potato recipe was revised to include peeling potatoes

Based on interview, record review and review of facility policy and Simplified Diet Manual, it was determined the facility failed to ensure one (1) of four (4) sampled residents (Resident #1) received the appropriate therapeutic diet prepared in a form designed to meet his/her individual needs. The facility failed to follow their policy and Diet Manual regarding food prepared and served for residents that had been assessed by the facility to require a Mechanical Soft Diet. On 01/23/15, Cook #1 prepared scalloped potatoes using fresh potatoes but did not peel them. The cook baked the potatoes in the oven for one and one half hours. The potatoes were served on resident trays from the steam table to the residents in the dining room and the hall carts. Cook #1 was informed by a staff member that the potatoes were not cooked enough but she continued to serve the potatoes by picking out the thinner sliced pieces leaving the larger pieces in the pan. Cook #1 was aware the hall cart had already been dispatched to the Foxes' Drive hall where ten (10) residents would be served Mechanical Soft diets to include Resident #1. The cook took no action to to retrieve the resident trays with the scalloped potatoes on them. Resident #1, who required assistance with eating, was fed the scalloped potatoes by CNA #1 and became choked. The Speech Therapist (ST) was summoned and assessed the resident determining he/she needed to sit at a ninety degree angle for feeding and she provided education to the Certified Nurse Aides (CNA) to ensure the resident was sitting at a ninety degree angle for meals. Resident #1 was unable to swallow when CNA #2 attempted to feed Resident #1 the supper meal on 01/23/15. Resident #1 became choked a second time. At 8:40 PM, the resident had an elevated temperature of 99.1 degrees Fahrenheit (F) (normal 98.6 F), an audible "rattle", and had coughed up a "thick glob" of mucus. The following morning, 01/24/15 at 7:55 AM, the resident presented with difficulty breathing, was gasping for air and his/her oxygen saturation was fluctuating in the 80s (normal 98-100) with oxygen at eight (8) liters per minute. The resident's pulse was 102 (normal 60 to 80), respirations were 30 per minute (normal 16-20), temperature of 100.8 F and blood pressure of 100/50 (normal 120/80). The resident was transported by ambulance to the hospital. The resident was diagnosed with [REDACTED]. A slice of uncooked potato the size of a silver dollar and one fourth inch thick was removed from the resident's throat during intubation. The resident was placed on a ventilator in critical condition. Based on the above findings it was determined the facility failed to ensure food was appropriately cooked and served in a form to meet Resident #1's needs caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 02/02/15 and determined to exist on 01/23/15. An acceptable Allegation of Compliance (AoC) was received on 02/10/15 alleging the IJ was removed on 02/05/15. The State Survey Agency validated the Immediate Jeopardy was removed on 02/05/15, as alleged. The Scope and Severity was lowered to a "D" while the facility develops and implements the Plan of Correction (POC); and, the facility's Quality Assurance monitors the effectiveness of the system changes. The findings include: Review of manual, Simplified Diet Manual eleventh edition, utilized by the facility, included; The Mechanical Soft Diet is designed to permit easy chewing. The General Diet is modified in consistency and texture by cooking, grinding, chopping, mincing or mashing. The diet includes foods soft in texture such as cooked fruits and vegetables, moist ground meat and soft bread and cereal products. Foods that dissolve readily when held in the mouth such as graham crackers and some ready-to-eat cereals are also appropriate. It is most important to individualize or adjust it to the tolerance of the resident. Table 3.1 Mechanical Soft revealed: Avoid Most raw or undercooked vegetables and those with tough skins. Whole kernel corn. Fried vegetables. Review of the spread sheet titled, "Scalloped Potatoes", indicated rehydrated potatoes or fresh potatoes could be used for the recipe. The baking time was 350 AF for one and one half to two hours. There was no reference to peeling fresh potatoes if used for the recipe. Observation of the facility kitchen conducted on 01/30/15 at 9:35 AM revealed the facility kitchen stove had a spoon wedged between the oven door and the stove frame. There were chicken nuggets cooking and tater tots on baking sheets ready to be placed into the oven. Record review revealed the facility admitted Resident #1 on 06/26/14 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 07/03/14, revealed the facility assessed the resident's cognitive status with a Brief Interview of Mental Status score of "99", indicating the resident was not interviewable. Resident #1 required extensive assistance of one (1) person for eating. Review of Resident #1's physician's orders [REDACTED]. Review of a Nursing Note, dated 01/23/14 at 3:28 PM; and, interviews on 01/30/15 at 2:00 PM with CNA #1 and at 2:15 PM with RN #1 revealed on 01/23/15 during the lunch meal, Resident #1 became choked when CNA #1 fed the resident scalloped potatoes. The resident coughed, spitting up some of the potatoes and his/her face became red. Review of a Nursing Note, dated 01/23/15 at 8:40 PM and interview with RN #2 on 01/31/15 at 8:40 PM revealed Resident #1's temperature was 99.1 Fahrenheit (F). She stated the resident coughed up some thick mucus but was able to drink chocolate milk without difficulty and had no noted swallowing problems. Further review of Resident #1's Nursing Notes and interview with RN #1 revealed the following morning on 01/24/15 at 7:55 AM, the resident presented with difficulty breathing, gasping for air, and his/her oxygen saturation was fluctuating in the 80s. Oxygen was administered at 8/L per minute with oxygen saturation continuing to fluctuate up and down. The resident's pulse was 102, respirations were 30 per minute, temperature was 100. The Physician was notified and the resident was transported to the hospital by ambulance. Review of Hospital Emergency Department records, dated 01/24/15, revealed the resident suffered from Acute [MEDICAL CONDITION] with [MEDICAL CONDITION] and a slice of uncooked potato the size of a silver dollar and one-fourth inch thick was removed from the resident's throat during intubation. There was collapse/consolidation of the right lung, lower lobe; posterior medial basal segments left lower lobe and pneumonia. The resident was placed on a ventilator and admitted to the Intensive Care Unit (ICU) in critical condition. Interview with Cook #1, on 01/30/15 at 1:00 PM, revealed on 01/23/15 she used fresh potatoes to make scalloped potatoes for the lunch meal. She stated she washed and sliced the potatoes without peeling them and cooked them for one and one half hours. Cook #1 revealed during service of the lunch meal on 01/23/15 a staff member alerted her the scalloped potatoes were not cooked enough. She stated she continued to serve the potatoes by picking out the thinner sliced pieces leaving the larger pieces in the pan. Cook #1 stated she was aware the hall cart containing resident meal trays, including Resident #1's tray, had already went out and was being delivered to residents. She revealed she did not try to retrieve the resident trays with the scalloped potatoes on them as she had not received any complaints about the scalloped potatoes from that hall. Cook #1 stated she had been trained by a former kitchen staff and had not been provided any instruction on what to do in a situation where food was discovered to be undercooked and she had used her own judgement and had decided to continue to serve the scalloped potatoes even though she was aware they were undercooked. She stated she had picked out the thinner slices leaving the thick slices in the pan. Interview with Cook #2, on 02/01/15 at 4:00 PM, revealed she had heard someone had choked on scalloped potatoes on 01/23/15. She stated she found scalloped potatoes in the refrigerator with a note that said the potatoes were too hard and if she used them to add milk or water and cook them. She stated the potatoes were "hard" as she had tried to slice through them with a fork and after they were done cooking they were like mashed potatoes. She stated for a few months she had to pull food from the oven and turn it around to ensure appropriate cooking. She stated she did not know why the scalloped potatoes on 01/23/15 were so "hard". Cook #2 stated she had no training by the facility on what to do if food does not turn out right. She also stated she had never prepared scalloped potatoes and would have to go by the spread sheet to know how to fix them. Interview with Kitchen Aide #1, on 01/30/15 at 9:35 AM, revealed there were issues with the oven door having to be kept in the closed position. The facility was wedging a spoon between the oven door and the door frame. Further review revealed the staff had to turn the food multiple times for even cooking as the oven had not been heating evenly. Interview with the Dietary Manager, on 01/30/15 at 9:45 AM, revealed the scalloped potatoes served on 01/23/15 were cooked without being peeled. She stated dehydrated potatoes had been used in the past but the facility was trying to serve more meals that were more "homemade". She revealed the potatoes were served again for the supper meal on 01/23/15. Cook #1 had placed the left over potatoes in the refrigerator with a note by Cook #1 saying the potatoes needed to be cooked more. Cook #2, who prepared the supper meal on 01/23/15 served the potatoes as a substitute for that supper meal. The Dietary Manager stated the malfunctioning oven door may have kept the temperature of the oven from being accurate and could have resulted in the potatoes being undercooked . Interview with the corporate Registered Dietician (RD), on 01/30/15 at 2:40 PM, revealed she had been made aware of the choking incident and had asked about how the scalloped potatoes were prepared. She stated she understood that Cook #1 had peeled and sliced the potatoes for the scalloped potatoes. She revealed Cook #1 was made aware the potatoes were not thoroughly cooked;so the cook took the thinner slices of potatoes out for serving and placed the thicker, bigger slices in a container and made a note for the night cook to cook further because she was concerned. The RD also stated she was concerned about the oven door falling open and said if it happened while cooking it would cause a decrease in temperature. She revealed she was aware there had been a previous problem with the springs on the oven door and it had been fixed. Additional interview with the RD on 02/02/15 at 3:10 PM revealed temperatures in the oven had not been previously monitored for accuracy. She also stated potato skins were not acceptable for Mechanical Soft Diets. Interview with the Administrator, on 02/03/15 at 11:30 AM, revealed she was first aware on the evening of 01/23/15, that Resident #1 was admitted to the hospital with [REDACTED]. The Administrator could not explain why a whole piece of potato was fed to Resident #1. She stated and it was evident the potatoes were found uncooked and the cook had said she stopped serving them. She also stated she had never heard of leaving the peel on potatoes used for scalloped potatoes. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 01/24/15, Resident #1 was sent to the hospital and admitted for Airway Obstruction and Aspiration Pneumonia. Resident #1 returned to the facility on [DATE] on a mechanically soft diet; the facility downgraded the diet to puree on 01/28/15. 2. On 01/30/15, the Director of Nursing, Assistant Director of Nursing, Unit Manager, MDS Nurse or Medical Records Nurse conducted an assessment of Resident #1 to determine if there were any medical needs, and or ongoing assessments required that were not already being completed or any significant change in condition that required MD notification. Resident #1's assessment revealed no change in condition that required further Physician notification and noted that appropriate assessments were on-going. 3. The MDS Nurse on 01/30/15 reviewed Resident #1's plans of care and determined that all interventions were in place. 4. Beginning on 01/30/15 and completed on 02/02/15 the Director of Nursing, Assistant Director of Nursing, Unit Manager, MDS Nurse and Medical Records Nurse reviewed all current residents' plan of care to determine if all interventions were being followed. No further concerns were identified. 5. On 01/31/15, the Dietary Services Manager observed Resident #1's lunch meal and determined the diet served was prepared per recipe and was correct per physician's orders [REDACTED]. The Dietary Services Manager also observed the meal tray line during lunch and noted that staff was following the recipe and spreadsheet and providing the diet as ordered for Resident #1 and food was properly prepared. 6. On 01/30/15, the Director of Nursing, Assistant Director of Nursing, Unit Manager, MDS Nurse or Medical Records Nurse conducted assessments of all current residents to determine if there were any medical needs requiring Physician notification and or ongoing assessments required that were not already being completed. Any identified residents who had a change in condition had their Physician notified with orders obtained and follow up assessments. 7. On 01/31/15, the Dietary Services Manager conducted an audit of all current residents' meal trays served from the kitchen and noted that the recipe was followed, diet was correct and served per Physician order [REDACTED]. 8. On 01/30/15, the Regional Quality Manager re-educated the Director of Nursing, Assistant Director of Nursing and Unit Manager, MDS Nurse and Medical Records Nurse on conducting an assessment based on resident condition to include the INTERACT process, follow up assessments as well as Physician notification for a significant change in condition referring to the INTERACT process but not to supersede nursing judgement. The INTERACT process is an evidence based program developed under funding from CMS to prevent unnecessary acute care transfers, to provide guidance to nurses on when to notify the physician and care paths for certain common symptoms. A competency test was administered to validate understanding. In addition, they were educated and a competency test was given related to following the plan of care, and if the plan of care cannot be followed and an alternative is not within their scope of practice that the Physician must be notified 9. On 01/30/15 ,the Director of Nursing, Assistant Director of Nursing and Unit Manager, MDS Nurse and Medical Records Nurse began re-education with all licensed nursing staff related to conducting an assessment based on resident condition to include the INTERACT process, follow up assessments as well as Physician notification for a significant change in condition referring to the INTERACT process but not to supersede nursing judgement. A competency test was administered to validate understanding. No licensed staff will work after 02/04/15 without having completed this re-education and competency test. In addition, reeducation was provided on the requirement to follow the plan of care and if the plan of care cannot be followed and an alternative is not within their scope of practice the physician must be notified. No licensed Nurse worked after 01/30/15 without having received this re-education and competency test. 10. Beginning 02/03/15, all Certified Nursing Assistants were re-educated with competency test related to following the plan of care and if they were unable to follow the plan of care they must report it to the Charge Nurse. No Certified Nursing Assistants will work after 02/03/15 without having received this re-education and competency test. 11. On 02/02/15 and 02/03/15, the Regional Dietician reviewed all current recipes to determine if any recipe called for food products that according to the spreadsheet would not be appropriate for mechanically altered diets. No other concerns were identified. 12. On 01/30/15, the Regional Dietician conducted re-education with the Dietary Services Manager including competency testing related to following the recipe and serving foods per the spreadsheet for correct prescribed diet. 13. Beginning 01/31/15 and ongoing, the Dietary Service Manager will conduct re-education with all Dietary Staff related to following the recipe and the spreadsheet to assure diets are served per the Physician order. This re-education will include a competency test and will be conducted prior to any staff beginning work. No Dietary staff worked after 01/31/15 without having completed the re-education and competency test. 14. On 02/03/15, a contract provider verified the convection oven was working appropriately and the regular oven in which the potatoes were cooked was cooking hotter than the setting on the oven. A new stove/oven was ordered and approved on 03/03/15. 15. Beginning 02/03/15, all dietary staff was instructed by the Dietary Service Manager to only cook on the convection oven. No staff will work after 03/03/15 without having had this re-education. Beginning 02/04/15, all dietary staff will be educated by the Dietary Service Manager that if a concern is identified with the food prepared it should be removed from the tray line and if already served dietary staff should report the concerns to the Nurse. No dietary staff will work after 02/04/15 without having received this education. 16. Beginning 01/28/15 and ongoing, all nursing staff was educated by the Director of Nursing, Assistant Director of Nursing, Unit Manager MDS Nurse or Medical Records Nurse on notification of the nurse if meals appear to be prepared incorrectly such as overcooked, undercooked or hard to cut foods. No nursing staff will work after 02/04/15 without having received this education. In addition, beginning on 02/03/15 and on going, all Certified Nursing Assistants were re-educated with competency test related to following the plan of care and if they were unable to follow the plan of care they must report it to the Charge Nurse. No Certified Nursing Assistants will work after 02/03/15 without having received this re-education and competency test. 17. Beginning 01/31/15, the Director of Nursing, Assistant Director of Nursing or Unit Manager will review with the facility staff the residents' condition each shift to determine if licensed staff are notifying the Physician of significant changes in condition as well as completing ongoing assessment as needed. This will continue every shift until abatement then five (5) times per week for twelve (12)weeks thereafter. 18. The Director of Nursing, Assistant Director of Nursing or Unit Manager will review five (5) residents' plans of care per week for twelve (12) weeks to evaluate if interventions are in place and being followed. The results of these audits will be reviewed with the Quality Assurance and Improvement Committee weekly until substantial compliance then monthly thereafter. 19. Beginning 02/01/15, the Director of Nursing, Assistant Director of Nursing or Unit Manager will review all Nurses Notes daily to determine if any significant change in condition has occurred without Physician notification or any significant change in condition requiring ongoing assessment that has not occurred. This will occur daily until abatement of Immediate Jeopardy and then five (5) times per week for twelve (12) weeks. 20. Beginning 01/31/15, a Dietary Service Manager or a Registered Dietician will observe one meal service per day to assure staff are following the recipe, serving and using the diet spreadsheet and that food is properly prepared to meet the individual needs. This will continue until abatement of the Immediate Jeopardy and then five (5) times per week for twelve (12) weeks thereafter. 21. The results of these audits will be reviewed with the Quality Assurance and Improvement Committee (QAPI) weekly until substantial compliance then monthly thereafter. The QAPI committee will meet weekly or anytime concerns are identified until substantial compliance, then monthly thereafter. Members of the QAPI Committee will consist of at a minimum the Director of Nursing, Assistant Director of Nursing, Social Services Director, Maintenance Director, Activity Director and Business Office Manager with the Medical Director participating at least quarterly and as needed. 22. On 01/30/15, an ad hock Quality Assurance and Performance Improvement Committee was convened to review the facility's investigation and concerns. An Allegation of Compliance was developed and reviewed with the Medical Director who attended via phone. In attendance was the Administrator, Director of Nursing, Assistant Director of Nursing, Unit Manager, Medical Records Clerk, MDS Nurse, Social Services Director, Dietary Services Manager and Activity director. No further recommendations were made at this time. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of the Nursing Notes and Physician order [REDACTED].#1 was sent to the hospital and admitted for Airway Obstruction and Aspiration Pneumonia. Resident #1 returned to the facility on [DATE] on a mechanically soft diet and the facility downgraded the diet to pureed on 01/28/15. Observation of the lunch meal on 02/12/15 at 12:00 PM, revealed the resident was being fed by the Speech Therapist. The food was in pureed form, as per the resident's diet card on the tray. 2. Review of an assessment conducted by the Director of Nursing, Assistant Director of Nursing, Unit Manager, MDS Nurse or Medical Records Nurse of Resident #1 on 01/30/15, revealed there were no change in condition that required further Physician notification and noted that appropriate assessments were on-going. 3. Review of documentation by the MDS Nurse, dated 01/30/15, revealed she reviewed Resident #1's plans of care and determined that all interventions were in place. 4. Review of documentation verified on 01/30/15 through 02/02/15 the DON, ADON, Unit Manager, MDS Nurse and Medical Records Nurse reviewed all current resident's plans of care to determine if all interventions were being followed. The documentation revealed which residents' plans of care were reviewed by which administrative staff. 5. Review of documentation by the Dietary Manager, dated 01/31/15, revealed the Dietary Manager observed Resident #1's lunch meal and determined the diet served was prepared per recipe and was correct per physician's orders [REDACTED]. In addition, the documentation revealed she also observed the tray line and determined staff was following the recipe and spreadsheet and providing the diets as ordered. 6. Review of residents' assessments conducted on 01/30/15 revealed all resident assessments were completed and any residents who had an identified change in condition had their physician notified. The assessments were conducted by the DON, ADON, Unit Manager MDS Nurse and Medical Records Nurse. 7. Review of documentation dated 01/31/15 revealed the Dietary Services Manager conducted an audit of all current residents' meal trays served from the kitchen and verified the recipe was followed, diet was correct and served per Physician Order, to meet the needs of the resident and properly prepared. 8. Review of documentation of re-education by the Regional Quality Manager to the DON, ADON, Unit Manager, MDS Nurse and Medical Records Nurse, dated 01/30/15, verified they were reeducated on the INTERACT process, follow up assessments, Physician notification for significant change, following the plan of care, and if the plan of care cannot be followed and an alternative is not within their scope of practice the Physician must be notified. Review of the competency tests revealed each of them completed the test on 01/30/15. 9. Review of inservice sign in sheets and competency tests, beginning 01/30/15, revealed all licensed staff was re-educated beginning 01/30/15 and competency tests were administered and passed related to the INTERACT process, follow up assessments, Physician notification for significant change, following the plan of care, and if the plan of care cannot be followed and an alternative is not within their scope of practice the Physician must be notified. Review of the competency tests revealed each of them completed the test on 01/30/15. Interview with the Administrator, on 02/12/15 at 1:35 PM, revealed the DON provided education to the staff related to assessments, INTERACT tool for assessments and Physician notification. Staff was educated about care plan interventions ensuring their appropriateness and implementation Interview with the DON, on 02/12/15 at 1:30 PM, revealed she provided education on the INTERACT tool for assessments and Physician notification and had also educated staff on updating care plans according to their scope of practice. The Twenty Four Hour Report was also topic. Nursing staff was given competency tests on following the INTERACT tool and nursing judgement. CNAs required a post test as well. Interview with RN #3, on 02/12/15 at 12:30 PM, revealed she received education related to the INTERACT system utilized by the facility which was a tool for assessments and included why, when, who and Physician notification. The education included follow up documentation on any type of complaint or anything out of the normal for a resident. Information was to be passed on to the next shift if not resolved and follow up was to be done the next day. A post test was given which RN #3 passed. Interview with LPN #3, on 02/12/15 at 12:35 PM, revealed education was provided to her by the DON that resident assessments should be conducted before, during, and after any type of an event and gave examples of elevated temperature, shortness of breath, and chest pain. LPN #3 was given a post test and passed. Education was also given to her about Physician notification, follow up documentation and implementing the care plan. She stated if the care plan needed changed or could not be implemented to notify the DON. Interview with LPN #4, on 02/12/15 at 12:40 PM, revealed she had been educated by the DON related to the INTERACT tools for resident assessment, physician notification and documentation. The Physician was to be notified for any significant change. Assessments were to be completed, the resident monitored and reassessed. The assessments were to include the resident's vital signs as blood pressure, respiration, oxygen saturation, pulse and temperature. LPN #4 was required to pass a post test. Interview with RN #1, on 02/12/15 at 12:50 PM, revealed she had been provided education by the DON related to a change in condition of a resident including if the resident was having trouble swallowing. For any emergency "911" was to be called and then notify the Physician. The INTERACT tool which reflects how, what and when to notify the Physician was to be utilized, as well, as the Stop and Watch tool which anyone could fill out and give to the nurse. Any change of condition of a resident required a complete assessment, including if a resident became choked while eating. Seventy-two (72)hour documentation was required for any changes, this included the resident's vital signs and if symptoms persisted the physician should be notified again. In addition, care plan education was provided related how to access that information from the headsets worn by the CNAs. The care plan had to match the resident's needs and if not the CNAs were to notify the nurse. A post test was completed to validate understanding. Interview with RN #4, on 02/12/15 at 12:55 PM, revealed she had recent education by the DON related to assessments. The INTERACT tool was a step by step guide on how, what and when to do anything and Physician notification. In addition, education was provided on care plans that included information about carrying out the interventions and revising when needed. CNAs were to report any problems with the care plan and the Physician was to be notified. She stated she had to take a post test and pass. 10. Interview with CNA #5, on 02/12/15 at 1:00 PM, revealed education was provided on care plans related to accessing the information on the CNA headset and to always inform the nurse when something did not seem right about the information. A post test was taken and had to be passed. Interview with CNA #6, on 01/12/15 at 1:05 PM, revealed education was provided on care plans and she was to ensure the care plan was followed and if the care plan did not seem appropriated she was to speak with the nurse immediately. Interview with CNA #7, on 02/12/15 at 1:10 PM, revealed she was educated on implementation of care plans and a post test was given and she passed. Interview with CNA #8, on 02/12/15 at 1:15 PM, revealed she had recently been educated that she was required to be familiar with each resident's care plan an it was accessible through the head set that she wears. CNA #8 stated if she could not follow the resident's care plan she was to go to the nurse for clarification. She revealed she had to take a post test and pass. 11. Interview with the Administrator, on 02/12/15 at 1:35 PM, revealed the spread sheets and recipes were reviewed and the spread sheet for the scalloped potato recipe was revised to include peeling potatoes before cooking. Interview with the Registered Dietician, on 02/12/15 at 11:35 AM, revealed she had revised the spread sheet and recipe for scalloped potatoes to indicate peeling the potatoes. 12. Interview with the Dietary Manager, on 02/12/15 at 11:30 AM, revealed she had received inservice from the Registered Dietician on reading and following spreadsheets and recipes. Education was provided that potato skins were not part of the Mechanical Soft Diet. She was educated on reading and calibrating thermometers and using only the left oven on the stove instead of the malfunction right side oven and the recipe and spread sheet for scalloped potatoes had been revised to instruct to peel the potatoes. One meal every day was being monitored to ensure the spread sheet and recipe as well as the tray cards were being followed. 13. Interview with the Administrator, on 02/12/15 at 1:35 PM, revealed dietary staff was educated over recipes and spread sheet, meal preparation and diets per the physician's orders [REDACTED]. Interview with the Registered Dietician, on 02/12/15 at 11:35 AM, revealed she had provided education to the dietary staff related to the spread sheets and recipes. She stated the reading of the tray cards was also covered in education as well as what to do if a food item did not turn out that included not serving that food item. Interview with Cook #1, on 02/12/15 at 11:40 AM, revealed she had been educated about how to set and use thermometers for checking food temperatures and about how to follow the spread sheet recipes. She stated a test was given to verify she understood the education. Interview with Dietary Aide #3, on 02/12/15 at 11:45 AM, revealed she had received education by the Dietary Manager on how to follow the spread sheets and recipes. She stated she also had to take a test to verify she understood the education. 14. On 02/03/15 a contract provider verified that the convection oven was working appropriately and that the regular oven in which the potatoes were cooked was cooking hotter than the setting on the oven. A new stove/ove