Every finding on record at King Nursing & Rehabilitation Community

This deficient practice pertains to Intake #3110141.Based on observation, interview and record review, the facility failed to protect the resident's right to be free from neglect for one Resident (#1) of three reviewed for abuse and neglect. This deficient practice resulted in Resident #1 sustaining significant bruising to the pelvis and left lower extremity and suffered from uncontrolled severe pain which resulted in a transfer to the emergency room (ER).Findings include:Resident #1 (R1)Review of R1's Electronic Medical Record (EMR) revealed initial admission to the facility on 8/28/25 with diagnoses including hemiplegia and hemiparesis (weakness, partial, or total paralysis) affecting the left side of the body following a cerebral infarction (stroke), need for assistance with personal care, and dysarthria (a motor speech disorder in which the muscles used to produce speech are damaged, paralyzed or weakened). Review of R1's most recent Minimum Data Set (MDS) assessment, dated 5/12/26, revealed a Brief Interview for Mental Status (BIMS) score of 11, indicative of moderate cognitive impairment. Further review of Section GG: Functional Abilities and Goals, revealed R1 was dependent (the caregiver provides 100% of the effort) for all functional transfers.Review of an intake submitted to the State Agency (SA) on 7/24/26, read, in part: Complainant states that when she came in for her shift after the weekend of July 11/12, [R1] had significant bruising on her side and pelvis. Complainant states she asked [R1] what happened and the resident stated it was a [mechanical lift] issue and they [staff] were rough with her but did not want anyone to get in trouble. Complainant states that the DON [Director of Nursing] came into the room with her and insisted that the resident's story was all messed up and that the resident was just confused on what happened. Complainant states that the DON then admitted that the [mechanical lift] did pinch [R1] and when the resident asked them to stop, they did not. Complainant states that [R1] .had a stroke so one side is flaccid.On 8/13/26 at 10:44 AM, an interview was conducted with Nurse Practitioner (NP) A regarding her assessments of R1's injury. NP A stated on the week of July 13th, 2026, she evaluated R1 and observed significant bruising to her entire pelvis, lower stomach, and inside of her left thigh to the level of her knee. NP A acknowledged R1 was prescribed a blood thinner, which can increase propensity and severity of bruising, but stated, This was extensive [bruising], even for a blood thinner. NP A stated upon evaluation, R1 appeared to have extreme fear in her eyes, and stated over the weekend facility staff had been really rough with her while using a mechanical lift. NP A stated R1 asked to be transferred to the ER for further work-up due to significant pain in her left leg. NP A stated, I felt it [the situation] to be extremely serious. I feel like it was a very big deal, not only was the patient hurt, but administration also brushed it under the rug.On 8/17/26 at 10:27 AM, a phone interview was conducted with Family Member B regarding R1's care at the facility. FM B stated R1 conveyed a nursing aide was in a hurry with a mechanical lift and the whole left side of her thigh, her entire crotch, her stomach, was totally bruised. It was all red and purple. The whole area was bruised from that lift. She had so much pain from it, that's why they had to send her to the hospital. FM B stated upon discharge from the ER, R1 requested a transfer to a different facility stating, Those injuries caused her a hospital run. it was unnecessary. FM B agreed to forward photographs of R1's bruising to this Surveyor.On 8/21/26 at 3:02 PM, this Surveyor observed photographs of R1 which revealed significant purple and yellow bruising to the left groin and left inner thigh to the level of the knee. R1's pelvis was covered by a brief due to privacy concerns and was not observed.On 8/17/26 at 11:05 AM, a phone interview was conducted with R1 regarding the significant bruising to her stomach, pelvis, and left leg. R1 stated, I was in the shower room, they shoved that thing [mechanical lift sling] up under my legs. I said it hurt, I asked them to stop, and they kept shoving and shoving it under my legs and butt. A couple days later, I noticed there was bruising up and down my leg. When asked who placed the sling, R1 was able to verify it was nursing aides but could not offer a name. R1 endorsed significant pain in her left leg before requesting to be transferred to the ER.Review of R1's EMR revealed the following progress notes:7/12/26 at 6:42 PM by Registered Nurse (RN) M: Small to medium-size bruise noted to Lt [left] side of pubis area and left inner leg and small bruise on upper rt [right] thigh.States it feels uncomfortable in these regions especially when showering. Referring to the [mechanical lift] sling .7/13/26 at 12:48 PM by RN L: Resident is alert and can make needs known. Voices pain in her left extremity. PRN [as needed] Hydrocodone [narcotic pain reliever] administered per her request.7/13/26 at 7:25 PM by NP A: [R1] denies fall or trauma and reports that she thinks the bruising is from when she was in the [mechanical lift] in the shower the other day. Upon physical exam, ecchymotic (the escape of blood into the tissues from ruptured blood vessels forming blue or purple discoloration commonly referred to as a bruise) are consistent with [mechanical lift] placement.She reports area is tender to touch.7/15/26 at 8:09 AM by RN L: [R1] is having increased pain. Last Hydrocodone 5-325 [milligrams] was given around 2 AM. Prior shift reports increased pain also and states resident required 2 Hydrocodone's. Resident states her pain is 10/10 and describes it as awful and terrible. [R1] stated x 3 [three times] to NP she would like to go to the hospital as she feels it necessary to get her pain under control and she doesn't believe her Hydrocodone to be effective.7/15/26 at 8:36 AM by NP A: .[R1] is being seen today for follow up of ecchymosis to groin reported 7/13/26. Upon physical exam, ecchymosis appears to have spread, now present down her inner left thigh and groin area.she reports pain is 'unbearable' in both legs and in her groin, moreso [sic] on the left leg and is requesting to be seen and evaluated in the ER.7/17/26 at 8:25 AM by NP A: .[R1] reports that she was 'not comfortable' returning back to [Facility Name] and had requested discharging from ER to another facility. she does endorse left leg pain, stating 'it kept me up last night'. Upon physical exam, ecchymosis extends from pelvic area to left groin and left thigh. After discussion and exam, plan was made with orders given to the Nursing staff to increase Norco frequency to 1 tablet 5-325 mg PO QID PRN x [milligrams, by mouth, four times per day, as needed, for) 14 days.On 8/17/26 at 12:35 PM a phone interview was conducted with RN L regarding R1's bruising. RN L stated although she wasn't the nurse who initially discovered the bruise, R1 at one point told her that, Three girls [staff members] had roughed her up.On 8/17/26 at 1:06 PM, an interview was conducted with Certified Nursing Assistant (CNA) E who confirmed R1 required a total body mechanical lift to transfer. When asked what style of transfer sling R1 utilized, CNA E stated, She was supposed to be [using] a full body swing. When CNA E was asked to clarify why she said, supposed to be, she stated some CNAs utilized a U-Sling or a divided-leg sling instead, which attached to the lift after crisscrossing under R1's legs and through the groin area. CNA E explained the U-sling was selected despite R1's preference of the preferential care planned total body sling because it is easier for staff to remove. CNA E recollected she had observed purple bruising along R1's groin and reported it to RN M who stated she had been notified and, a shower aide was rough with her. Review of R1's plan of care reviewed the following approach: Status of transfers: assist x2 with full mechanical lift - green trim sling, initiated 4/14/26.On 8/17/27 at 2:25 PM, CNA E showed this Surveyor two green trimmed slings in the equipment storage room. CNA E confirmed both slings were full body slings as opposed to U-slings. On 8/17/26 at 1:24 PM, a phone interview was conducted with CNA K who stated R1 was supposed to transfer with a total body mechanical lift. When CNA K was asked to clarify why she said, supposed to transfer, she indicated some staff did not follow the care plan and instead used a sit-to-stand lift, a two-person transfer, or a U-sling which was frequently mispositioned during transfers. Review of a physical therapy treatment encounter note written by Physical Therapist (PT) G, dated 7/13/25, read, in part: .discussed new bruises on LLE [left lower extremity] with pt [patient] and with interdisciplinary team, educated pt to advocate for herself. On 8/17/26 at 1:59 PM, a phone interview was conducted with PT G regarding the encounter note written on 7/13/26. PT G recalled R1 was hesitant to participate in therapy that day due to pain and was really concerned with the bruises, where they were located, and how they got there. PT G stated, The bruises were pretty intense; they were pretty closed to the pelvic area and halfway down her inner thigh. PT G stated R1 thought it was from the mechanical lift sling and an issue in the shower. PT G stated given the significance and location of the bruises, she notified her Regional Therapy Director and the Nursing Home Administrator (NHA) who indicated she, already had a plan. When asked if a person could sustain a bruising pattern like R1 by correctly using a mechanical lift sling, PT G said, No. When asked if her answer changed it the person was taking a blood thinner, PT G stated, No.Review of a physical therapy treatment encounter note Physical Therapist Assistant (PTA) F, dated 7/14/25, read, in part: Pt reported.when transferring with the [mechanical lift], she had gotten her LLE hurt over the weekend. Pt reported that she was having shooting pain in LLE knee that was radiating the entire length of her LLE. Pt stated she had 7/10 pain in the LLE and pain in her core as well that made it difficult to sit fwd [forward] in her chair for sitting balance exercises. Response to Tx [treatment]: .pt demonstrated pain every time therapist initially moved the LLE to start PROM [passive range of motion] exercises. Pt was unable to complete static sitting balance exercises today due to pain in her core.On 8/17/27 at 1:38 PM, an interview was conducted with PTA F who verified she observed bruising to R1's left inner leg and groin and small bruise on her upper right thigh during the therapy session on 7/14/26. PTA F stated R1 told her the bruising was from a mechanical lift sling. PTA F explained she reported the bruise and allegation to the Director of Nursing (DON) who stated she was already aware of the incident.On 8/17/26 at 3:28 PM, a phone interview was conducted with CNA H who verified she was familiar with R1's care. When asked how R1 sustained extensive bruising to her pelvis and left lower extremity, CNA H stated, Somebody had used a crisscross sling on her. some of the older CNAs are set in their way, and it caused the bruising. CNA H further explained R1 was supposed to utilize the total body slings because she had vocalized in the past the U-Slings hurt her.On 8/17/26 at 3:58 PM, an interview was conducted with CNA I who differentiated between two different types of total lift slings: the U-sling and total body sling. CNA I stated if the U-Sling was placed correctly, it would not have caused an injury. CNA I stated, People [staff] let it ride up the leg into the groin which is wrong. It ends up pinching and becoming way too tight. When asked why CNAs opt to use the U-slings despite other care planned interventions, she responded, It's easier to remove them [after the transfer].Review of R1's Medication Administration Record (MAR) revealed the following physician orders:Hydrocodone-acetaminophen tablet 5-325 mg, 1 tab, oral, three times a day - PRN, initiated 5/1/26 - 7/17/26.Hydrocodone-acetaminophen tablet 5-325 mg, 1 tab, oral, four times a day - PRN x 14, initiated 7/17/26.Further review of R1's July MAR indicated from 7/1/26 to 7/11/26, R1 did not request PRN pain medication. From 7/12/26 (first identification of pelvic and left leg bruising) until her discharge on [DATE], R1 requested pain medication 20 times.On 8/17/26 at 4:16 PM, an interview was conducted with the DON who endorsed bruising to R1's left inner thigh and right outer thigh was reported to her by RN M. The DON stated a skin incident report was completed and the next day the bruising was spreading. The DON said a provider re-evaluated R1 and because she was complaining of increased pain, she was sent out to the ER for further evaluation. When asked if there was an investigation to determine the origin of the bruising, the DON stated, There was no reason. She's alert and oriented and could tell me what happened. She said she didn't know how she got the bruise. Even the NP said it was spontaneous ecchymosis. When asked if witness statements from staff were collected, the DON replied, I talked to staff. When queried as to whether the witness statements were documented, the DON responded, I probably didn't. When asked if the bruising could have been a result of improper sling use, the DON replied, It's possible. The DON stated it would be her expectation for a staff member to stop a transfer if a resident had requested them to do so.On 8/17/26 at 4:33 PM, an interview was conducted with the NHA who was asked if a formal investigation was conducted to determine the cause of R1's extensive bruising. The NHA replied, It's assumed the bruise was from the sling, either the strap was too tight, or it was bothering her in some way . When queried if the bruising was an indication the equipment wasn't used correctly and therefore should have been reported to the SA, the NHA replied, I can't attest to that.Review of the facility policy titled, Corporate Compliance Policy Manual, dated 8/2/21, read, in part: Resident Rights: .The resident has the right to be free of abuse, neglect and misappropriation of his/her funds.

This deficient practice pertains to Intake #3110141.Based on observation, interview, and record review, the facility failed to ensure an allegation of abuse/neglect was reported to the State Agency (SA) for one Resident (#1) of three residents reviewed for accident and incident reporting.Findings include:Resident #1 (R1)Review of R1's Electronic Medical Record (EMR) revealed initial admission to the facility on 8/28/25 with diagnoses including hemiplegia and hemiparesis (weakness, partial, or total paralysis) affecting the left side of the body following a cerebral infarction (stroke), need for assistance with personal care, and dysarthria (a motor speech disorder in which the muscles used to produce speech are damaged, paralyzed or weakened). Review of R1's most recent Minimum Data Set (MDS) assessment, dated 5/12/26, revealed a Brief Interview for Mental Status (BIMS) score of 11, indicative of moderate cognitive impairment. Further review of Section GG: Functional Abilities and Goals, revealed R1 was dependent (the caregiver provides 100% of the effort) for all functional transfers.Review of an intake submitted to the State Agency (SA) on 7/24/26, read, in part: Complainant states that when she came in for her shift after the weekend of July 11/12, [R1] had significant bruising on her side and pelvis. Complainant states she asked [R1] what happened and the resident stated it was a [mechanical lift] issue and they [staff] were rough with her but did not want anyone to get in trouble. Complainant states that the DON [Director of Nursing] came into the room with her and insisted that the resident's story was all messed up and that the resident was just confused on what happened. Complainant states that the DON then admitted that the [mechanical lift] did pinch [R1] and when the resident asked them to stop, they did not.On 8/13/26 at 10:44 AM, an interview was conducted with Nurse Practitioner (NP) A regarding her assessments of R1's injury. NP A stated on the week of July 13th, 2026, she evaluated R1 and observed significant bruising to her entire pelvis, lower stomach, and inside of her left thigh to the level of her knee. NP A acknowledged R1 was prescribed a blood thinner, which can increase propensity and severity of bruising, but stated, This was extensive [bruising], even for a blood thinner. NP A stated upon evaluation, R1 appeared to have extreme fear in her eyes, and stated over the weekend facility staff had been really rough with her while using a mechanical lift. NP A stated R1 asked to be transferred to the ER for further work-up due to significant pain in her left leg. NP A stated, I felt it [the situation] to be extremely serious. I feel like it was a very big deal, not only was the patient hurt, but administration also brushed it under the rug.On 8/17/26 at 10:27 AM, a phone interview was conducted with Family Member B regarding R1's care at the facility. FM B stated R1 conveyed a nursing aide was in a hurry with a mechanical lift and the whole left side of her thigh, her entire crotch, her stomach, was totally bruised. It was all red and purple. The whole area was bruised from that lift. She had so much pain from it, that's why they had to send her to the hospital. FM B stated upon discharge from the ER, R1 requested a transfer to a different facility stating, Those injuries caused her a hospital run. it was unnecessary. FM B agreed to forward photographs of R1's bruising to this Surveyor.On 8/21/26 at 3:02 PM, this Surveyor observed photographs of R1 which revealed significant purple and yellow bruising to the left groin and left inner thigh to the level of the knee. R1's pelvis was covered by a brief due to privacy concerns and was not observed.On 8/17/26 at 11:05 AM, a phone interview was conducted with R1 regarding the significant bruising to her stomach, pelvis, and left leg. R1 stated, I was in the shower room, they shoved that thing [mechanical lift sling] up under my legs. I said it hurt, I asked them to stop, and they kept shoving and shoving it under my legs and butt. A couple days later, I noticed there was bruising up and down my leg. When asked who placed the sling, R1 was able to verify it was nursing aides but could not offer a name. R1 endorsed significant pain in her left leg before requesting to be transferred to the ER.On 8/17/26 at 12:35 PM a phone interview was conducted with RN L regarding R1's bruising. RN L stated although she wasn't the nurse who initially discovered the bruise, R1 at one point told her that, Three girls [staff members] had roughed her up.On 8/17/26 at 1:06 PM, an interview was conducted with Certified Nursing Assistant (CNA) E who confirmed R1 required a total body mechanical lift to transfer. CNA E recollected she had observed purple bruising along R1's groin and reported it to RN M who stated she had been notified and, a shower aide was rough with her. Review of a physical therapy treatment encounter note written by Physical Therapist (PT) G, dated 7/13/25, read, in part: .discussed new bruises on LLE [left lower extremity] with pt [patient] and with interdisciplinary team, educated pt to advocate for herself. On 8/17/26 at 1:59 PM, a phone interview was conducted with PT G regarding the encounter note written on 7/13/26. PT G recalled R1 was hesitant to participate in therapy that day due to pain and was really concerned with the bruises, where they were located, and how they got there. PT G stated, The bruises were pretty intense; they were pretty closed to the pelvic area and halfway down her inner thigh. PT G stated R1 thought it was from the mechanical lift sling and an issue in the shower. PT G stated given the significance and location of the bruises, she notified her Regional Therapy Director and the Nursing Home Administrator (NHA) who indicated she, already had a plan. When asked if a person could sustain a bruising pattern like R1 by correctly using a mechanical lift sling, PT G said, No. When asked if her answer changed it the person was taking a blood thinner, PT G stated, No.On 8/17/27 at 1:38 PM, an interview was conducted with Physical Therapy Assistant (PTA) F who verified she observed bruising to R1's left inner leg and groin and small bruise on her upper right thigh during the therapy session on 7/14/26. PTA F stated R1 told her the bruising was from a mechanical lift. PTA F explained she reported the bruise and allegation to the Director of Nursing (DON) who stated she was already aware of the incident.On 8/17/26 at 4:16 PM, an interview was conducted with the Director of Nursing (DON) who endorsed bruising to R1's left inner thigh and right outer thigh was reported to her by Registered Nurse (RN) M. The DON stated a skin incident report was completed and the next day the bruising was spreading. The DON said a provider re-evaluated R1 and because she was complaining of increased pain, she was sent out to the ER for further evaluation. When asked if the bruising could have been a result of improper sling use, the DON replied, It's possible. When asked if there was an investigation to determine the origin of the bruising, the DON stated, There was no reason. She's alert and oriented and could tell me what happened. She said she didn't know how she got the bruise. The DON asked if she considered reporting the incident to the SA as an injury of unknown origin to which she replied, No.On 8/17/26 at 4:33 PM, an interview was conducted with the NHA who was asked if a formal investigation was conducted to determine the cause of R1's extensive bruising. The NHA replied, It's assumed the bruise was from the sling, either the strap was too tight, or it was bothering her in some way . When queried if the bruising was an indication the equipment wasn't used correctly and therefore should have been reported to the SA due to neglect, the NHA replied, I can't attest to that.Review of the facility policy titled, Corporate Compliance Policy Manual, dated 8/2/21, read, in part: Resident Rights: .The resident has the right to be free of abuse, neglect and misappropriation of his/her funds. All allegations of abuse, neglect of [sic] misappropriation will be reported to the state agency and law enforcement (in the case of a crime) in accordance with state and federal law .

This deficient practice pertains to Intake #3110141.Based on observation, interview, and record review the facility failed to investigate an incident of abuse/neglect for one Resident (#1) of three residents reviewed for abuse/neglect.Findings include:Resident #1 (R1)Review of R1's Electronic Medical Record (EMR) revealed initial admission to the facility on 8/28/25 with diagnoses including hemiplegia and hemiparesis (weakness, partial, or total paralysis) affecting the left side of the body following a cerebral infarction (stroke), need for assistance with personal care, and dysarthria (a motor speech disorder in which the muscles used to produce speech are damaged, paralyzed or weakened). Review of R1's most recent Minimum Data Set (MDS) assessment, dated 5/12/26, revealed a Brief Interview for Mental Status (BIMS) score of 11, indicative of moderate cognitive impairment. Further review of Section GG: Functional Abilities and Goals, revealed R1 was dependent (the caregiver provides 100% of the effort) for all functional transfers.Review of an intake submitted to the State Agency (SA) on 7/24/26, read, in part: Complainant states that when she came in for her shift after the weekend of July 11/12, [R1] had significant bruising on her side and pelvis. Complainant states she asked [R1] what happened and the resident stated it was a [mechanical lift] issue and they [staff] were rough with her but did not want anyone to get in trouble. Complainant states that the DON [Director of Nursing] came into the room with her and insisted that the resident's story was all messed up and that the resident was just confused on what happened. Complainant states that the DON then admitted that the [mechanical lift] did pinch [R1] and when the resident asked them to stop, they did not. Complainant states that [R1] .had a stroke so one side is flaccid.On 8/13/26 at 10:44 AM, an interview was conducted with Nurse Practitioner (NP) A regarding her assessments of R1's injury. NP A stated on the week of July 13th, 2026, she evaluated R1 and observed significant bruising to her entire pelvis, lower stomach, and inside of her left thigh to the level of her knee. NP A acknowledged R1 was prescribed a blood thinner, which can increase propensity and severity of bruising, but stated, This was extensive [bruising], even for a blood thinner. NP A stated upon evaluation, R1 appeared to have extreme fear in her eyes, and stated over the weekend facility staff had been really rough with her while using a mechanical lift. NP A stated R1 asked to be transferred to the ER for further work-up due to significant pain in her left leg. NP A stated, I felt it [the situation] to be extremely serious. I feel like it was a very big deal, not only was the patient hurt, but administration also brushed it under the rug.On 8/17/26 at 10:27 AM, a phone interview was conducted with Family Member B regarding R1's care at the facility. FM B stated R1 conveyed a nursing aide was in a hurry with a mechanical lift and the whole left side of her thigh, her entire crotch, her stomach, was totally bruised. It was all red and purple. The whole area was bruised from that lift. She had so much pain from it, that's why they had to send her to the hospital. FM B stated upon discharge from the ER, R1 requested a transfer to a different facility stating, Those injuries caused her a hospital run. it was unnecessary. FM B agreed to forward photographs of R1's bruising to this Surveyor.On 8/21/26 at 3:02 PM, this Surveyor observed photographs of R1 which revealed significant purple and yellow bruising to the left groin and left inner thigh to the level of the knee. R1's pelvis was covered by a brief due to privacy concerns and was not observed.On 8/17/26 at 11:05 AM, a phone interview was conducted with R1 regarding the significant bruising to her stomach, pelvis, and left leg. R1 stated, I was in the shower room, they shoved that thing [mechanical lift sling] up under my legs. I said it hurt, I asked them to stop, and they kept shoving and shoving it under my legs and butt. A couple days later, I noticed there was bruising up and down my leg. When asked who placed the sling, R1 was able to verify it was nursing aides but could not offer a name. R1 endorsed significant pain in her left leg before requesting to be transferred to the ER.On 8/17/26 at 12:35 PM a phone interview was conducted with RN L regarding R1's bruising. RN L stated although she wasn't the nurse who initially discovered the bruise, R1 at one point told her that, Three girls [staff members] had roughed her up.On 8/17/26 at 1:06 PM, an interview was conducted with Certified Nursing Assistant (CNA) E who confirmed R1 required a total body mechanical lift to transfer. CNA E recollected she had observed purple bruising along R1's groin and reported it to RN M who stated she had been notified and, a shower aide was rough with her. Review of a physical therapy treatment encounter note written by Physical Therapist (PT) G, dated 7/13/25, read, in part: .discussed new bruises on LLE [left lower extremity] with pt [patient] and with interdisciplinary team, educated pt to advocate for herself. On 8/17/26 at 1:59 PM, a phone interview was conducted with PT G regarding the encounter note written on 7/13/26. PT G recalled R1 was hesitant to participate in therapy that day due to pain and was really concerned with the bruises, where they were located, and how they got there. PT G stated, The bruises were pretty intense; they were pretty closed to the pelvic area and halfway down her inner thigh. PT G stated R1 thought it was from the mechanical lift sling and an issue in the shower. PT G stated given the significance and location of the bruises, she notified her Regional Therapy Director and the Nursing Home Administrator (NHA) who indicated she, already had a plan. When asked if a person could sustain a bruising pattern like R1 by correctly using a mechanical lift sling, PT G said, No. When asked if her answer changed it the person was taking a blood thinner, PT G stated, No.On 8/17/27 at 1:38 PM, an interview was conducted with Physical Therapy Assistant (PTA) F who verified she observed bruising to R1's left inner leg and groin and small bruise on her upper right thigh during the therapy session on 7/14/26. PTA F stated R1 told her the bruising was from a mechanical lift sling. PTA F explained she reported the bruise and allegation to the Director of Nursing (DON) who stated she was already aware of the incident.On 8/18/26 at 9:10 AM, an interview was conducted with Registered Nurse (RN) M who verified she was alerted by a CNA of the bruising to R1's left leg. RN M stated initially, R1 did not vocalize what happened to her but later stated one of the CNAs were rough with her. RN M stated she completed a skin incident report and notified the DON of the allegation. Review of a document titled, Skin Integrity Events, created by RN M on 7/12/26 read, in part: .Type of injury.bruise. rt [right] side of pubis has small bruise. Activity During Skin Alteration Occurrence: unknown.Further review revealed the event was closed by the DON on 7/13/26 at 9:41 AM. On 8/17/26 at 4:16 PM, an interview was conducted with the DON who endorsed bruising to R1's left inner thigh and right outer thigh was reported to her by RN M. The DON stated a skin incident report was completed and the next day the bruising was spreading. The DON said a provider re-evaluated R1 and because she was complaining of increased pain, she was sent out to the ER for further evaluation. When asked if there was an investigation to determine the origin of the bruising, the DON stated, There was no reason. She's alert and oriented and could tell me what happened. She said she didn't know how she got the bruise. Even the NP said it was spontaneous ecchymosis. When asked if witness statements from staff were collected, the DON replied, I talked to staff. When queried as to whether the witness statements were documented, the DON responded, I probably didn't.On 8/17/26 at 4:33 PM, an interview was conducted with the NHA who was asked if a formal investigation was conducted to determine the cause of R1's extensive bruising. The NHA replied, It's assumed the bruise was from the sling, either the strap was too tight, or it was bothering her in some way . I talked to the CNAs and nurses. When asked if the investigation was documented, the NHA referred the question to the DON.Review of the facility policy titled, Corporate Compliance Policy Manual, dated 8/2/21, read, in part: .When a report of a suspected violation.is brought to the attention of the Compliance Officer, the following steps shall be followed: .B. Investigation & Report. the Compliance Officer will investigate the suspected violation or questionable conduct. A report regarding such inquiry shall be prepared. The report, at a minimum, shall address: 1) the allegation that has been made; 2) the specific steps and/or methods used in investigating the matter (such as people interviewed, records reviewed, analyses performed, etc.); 3) specific findings and/or results of the investigation; and 4) a proposed plan of action (such as disciplinary action, policy or procedure changes, in-service training regarding existing policy and/or procedure, or other suggested actions) to prevent future non-compliance.

Based on interview and record review, the facility failed to ensure Certified Nurse Aide (CNA) training of no less than 12 hours per year was completed for three of five CNAs reviewed for nurse aide training hours.Findings include:During an interview on 6/10/26 at 7:37 a.m., the Business Office Manager (BOM) reported, The 12 hours of training in a year is based on the CNAs hire date. The BOM acknowledged the facility used online training.Review of facility documents provided by the Nursing Home Administrator (NHA) revealed the following:CNA H was hired on 1/18/22 with 3.87 hours of training from 1/18/25 - 1/18/26.CNA I was hired on 7/25/19 with 8.75 hours of training from 7/25/24 -7/25/25.CNA J was hired on 6/29/23 with 3.25 hours of training from 6/29/24-6/29/25.During an interview on 6/10/25 at 9:26 a.m., the NHA reported, There were educational issues.we have CNAs that did not receive their 12 hours of training in a year.

Based on observation, interview, and record review the facility failed to ensure the provision of adequate supplies, care and services to meet the personal hygiene needs of 1 Resident (#4) of 12 residents reviewed for Activities of Daily Living. This deficient practice resulted in resident dissatisfaction with the lack of assistance with personal hygiene and showers and has the potential to affect all residents who required staff assistance and clean linens for the completion of personal hygiene. Findings include:Review of R4's Minimum Data Set (MDS) assessment, dated 3/20/26, revealed R4 was re-admitted to the facility on [DATE], with active diagnoses that included the following, in part: renal failure, diabetes mellitus, hyperlipidemia (high cholesterol), anxiety disorder, depression, and psychotic disorder. R4 Scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), reflective of intact cognition.During an interview on 6/8/26 at 6:40 p.m., when asked if R4 received showers as scheduled, R4 speaking loudly and with apparent frustration said that they did not get washed up that day, 6/8/26, because staff said there were no towels or washcloths to wash up all the facility residents. R4 continued to report they were supposed to get a shower the previous Friday, and they didn't. When asked if they had refused the shower, R4 said they had not refused the shower.During an interview and observation on 6/8/26 at approximately 7:00 p.m., two confidential Staff members were asked to view the clean linen room with this Surveyor. Observed, with the count verified by one of the confidential Staff were 15 white, cotton washcloths,16 white bath towels, 12 fitted sheets, 5 flat sheets, 3 pull sheets, and 17 pillowcases. Staff both confirmed there were not adequate linens to meet the needs of all the residents. One Confidential Staff said they, themselves, routinely did laundry at night so they would have linens for the residents. The same confidential Staff said they had cut up facility towels to have washcloths for residents. When asked when the last time they had cut up the towels, the same confidential Staff said it was that day. When asked if other staff cut up towels, the same confidential Staff stated, We all do (on night shift). The same confidential Staff said they had not seen the blue/grey microfiber cloths in the linen room until the previous day and said they did not know what they were for.Observation of the clean and dirty laundry rooms on 6/8/26 at approximately 7:15 p.m., with Staff T and U, found clean laundry in two large dryers. The dryers were cold, and the laundry was compressed down to fill approximately 1/2 of the dryer bins. The dirty laundry contained one white cotton washcloth, and no other towels/washcloths. All dirty laundry appeared to have been washed and dried and left to sit overnight in the two dryers. Staff U said laundry was only done in the facility by laundry staff from 6:00 a.m. until 2:00 p.m., when laundry staff left for the day.Observation of the clean and dirty laundry rooms with another confidential Staff on 6/9/26 at 6:15 a.m., found the same laundry observed in the dryers the previous evening (6/8/26) was fluffed this morning. The confidential Staff confirmed the facility had been having difficulty maintaining enough washcloths and towels for resident care and acknowledged staff were cutting up facility towels to make washcloths for the residents. The confidential Staff said two days ago (approximately 6/6/26), blue microfiber cloths (resembling a cleaning cloth/dishcloth) were placed in the clean linen room for staff to use and confirmed residents were not always getting their clean ups because there may not have been adequate supplies to do the wash ups.Observation of the clean linen storage, in the presence of Staff Q on 6/9/26 at approximately 6:20 a.m., revealed the following linen counts:Clean linen room: 16 white towels, 0 white hand towels and 0 white (cotton) washcloths.100 Hall linen cart: 7 white towels and 6 (cotton) washcloths.200 Hall linen cart: 0 white towels and 0 (cotton) washcloths.300 Hall linen cart: 5 white towels and 0 (cotton) washcloths.Review of R4's Alteration to ADLs (Activities of Daily Living) Care Plan, retained from the Electronic Medical Record (EMR) on 6/9/26 at 3:28 p.m., revealed the following, in part: Approach Date of 5/14/24, Bathing choice is showers in the morning on Fridays only.Review of R4's CNA (Certified Nurse Aide) Shower Sheet(s) listing, retained on 6/9/26 at 10:38 a.m., from within the EMR, did not include a shower sheet for 6/5/26.Review of the Shower Sheets, maintained in a binder at the nurses' station on R4's hall, on 6/10/26 at 12:49 p.m., revealed a shower sheet was not present for a 6/5/26 shower completion.During an interview on 6/9/26 at 7:45 a.m., when asked if they were aware facility towels were being cut up to use as washcloths for facility residents, the Nursing Home Administrator (NHA) said she was not aware. The NHA acknowledged the limited [number] of towels and washcloths had been an issue for the last month. The NHA said washcloths had been disappearing. Review of the Activities of Daily Living (ADLs)/Maintain Abilities policy, reviewed 1/2025, revealed the following, in part: It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person centered, and honor and support each resident's preferences, choices, values and beliefs. 3. The facility will provide care and services for the following activities of daily living: a. Hygiene -bathing, dressing, grooming, and oral care . 4. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .

Based on observation, interview and record review the facility failed to ensure the temperature of the medication storage refrigerator was maintained at acceptable temperatures. This deficient practice resulted the exposure of resident medications to temperatures outside of acceptable storage ranges and the potential for reduced efficacy of resident medications. Findings include:During observation of the facility's medication storage room on 6/10/26 at approximately 8:50 a.m., in the presence of Registered Nurse (RN) G, the medication refrigerator was unlocked and the contents observed. No refrigerator medication log was found in the medication room. RN G looked in the medication refrigerator for a thermometer without results. This Surveyor located the thermometer on the second shelf toward the back of the refrigerator, between stored medications. The thermometer was difficult to read but appeared to show a temperature of 34 degrees Fahrenheit (F.), moving higher as held up to 36 degrees. RN G pulled the thermometer out of the refrigerator into the room air, reading a temperature of 38 degrees F. No temperature log for the medication storage refrigerator was found inside the locked medication room. The Refrigerator logs for the past six months were requested. RN G looked though several binders at the nurses' station and asked another nurse where the refrigerator temperature logs were kept in the building. The binder was obtained and only June 2026 refrigerator temperature logs were present in the binder, with temperatures monitored once daily. The medication refrigerator temperature logs for January 2026 through May 2026 were unable to be located prior to survey completion. On 6/10/26 9:22 a.m., RN C provided the [Corporation Name] LTC (Long Term Care) Facility Pharmacy Services and Procedures Manual policy 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles, revision Date 1/1/13, which revealed in part: Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges. Facility staff should monitor the temperature of vaccines twice a day. 11.1 Room Temperature: 59-77 degrees F., Refrigeration 36-46 degrees F . On 6/10/26 at 10:23 a.m., Review of the Maintenance of Medication Storage Areas policy, dated 4/2020, revealed the following, in part: . Refrigerators used for medication storage must have a thermometer monitoring ideal temps 35-46 degrees F. (unless otherwise specified.) Adjust refrigerator setting until thermometer registered is appropriate . Refrigerators with vaccines stored in them require monitoring and recording of temperature 2x a day. On 6/10/26 at 10:44 a.m., Consultant Pharmacist V was asked regarding the [Corporation Name] Medication Storage Policy provided by the facility, dated 2013. Consultant Pharmacist V stated, That is old. Lately we have just been using the CDC (Centers for Disease Control) refrigerator storage policy that says twice a day for refrigerators that contain vaccine. Consultant Pharmacist V was asked to provide a copy of the policy/form regarding appropriate medication storage within the facility, and it was provided via email to this Surveyor. 06/10/2026 11:05 AM Observation of the medication administration room storage fridge with RN G, found the refrigerator to be at a temperature of 32 degrees F. RN G was given the thermometer to read, and agreed the thermometer read 32 degree F, The thermometer was located on the same second shelf of the medication refrigeration as the first detailed observation detailed above. When asked what the concern would be with the medication storage refrigerator at a temperature of 32 degrees F., RN G stated, It is too low. RN G confirmed that when a refrigerator is only checked once a day there is no way to know the time of excursion for medications outside of the recommended medication storage temperature.On 6/10/26 at approximately 11:10 a.m., Assistant Director of Nursing (ADON)/RN A entered the medication room and said she was going to turn the refrigerator up. ADON A was asked to provide a list of all medications stored in the refrigerator at this time, following the temperature measured at 32 degrees F. by RN G and this Surveyor. During an interview on 6/10/2026 at 11:15 a.m., the Nursing Home Administrator (NHA) was informed regarding the medication administration room storage refrigerator found with a temperature of 32 degrees F.During an interview on 6/10/26 at 11:40 a.m., ADON A provided a handwritten list of the medications/biologicals/vaccine located within the medication storage refrigerator, which included the following:Three [Consultant Pharmacy] Back-Up Boxes (which included insulins and other medications per ADON A).[Name Brand] intravenous antibiotic.[Name Brand] Nebulizer solution.Pneumococcal [Name Brand] vaccine.Fast-acting and Long-acting insulin.Dulaglutide (diabetic medication) injection.Review of the Instructions for Use for the dulaglutide injection, [Name Brand] long-acting insulin, fast-acting insulin, and pneumococcal vaccine included the following storage instructions, respectively, which included the following, in part:Store your Pen in the refrigerator between 36 F to 46 F (2 C to 8 C). Do not freeze your Pen. If the Pen has been frozen, throw the Pen away and use a new Pen.Store your unused Pen in the refrigerator between 36 F to 46 F (2 C to 8 C). Do not freeze. Do not use if [Name Brand Long-Acting Insulin) has been Frozen.Keep new pens in the refrigerator between 36 F to 46 F (2 C to 8 C). Do not freeze your [Name Brand fast-acting] insulin. Do not use [Name Brand fast-acting insulin] if it has been frozen.Upon receipt, store refrigerated at 2 C to 8 C (36 F to 46 C) ,,, Do not freeze. Discard if the vaccine has been frozen

Based on observation, interview and record review the facility failed to provide palatable food, served at a safe an appetizing temperature, for 8 Confidential Residents of 12 residents reviewed for food palatability. This deficient practice resulted in resident dissatisfaction with being served cold food, and the potential for foodborne illness with potentially hazardous foods served at an unsafe temperature. Findings include: During initial kitchen tour observations on 6/8/26 at approximately 5:25 PM, dietary staff were observed serving food from the steam table. Temperature checks revealed the following: *Hamburgers measured at 119 degrees F (degrees Fahrenheit) on the top of pan and 131 degrees F on the bottom of the pan.*French fries measured 122 degrees F On 6/8/2026 at 6:08 PM, One confidential Resident was observed in her room moving the frenchfries and hamburger around on her plate with a fork. This confidential Resident stated she was moving her food around because it was cold and she didn't want to eat it since it was cold. During a confidential group meeting on 6/9/26 at 2:07 p.m., one of the confidential Residents reported, We need a microwave in our rooms, so we can warm our food up. The food is always cold here. During an observation of dinner in the main dining room on 6/8/26 at 5:20 p.m., one of the confidential Residents was sitting at the same table with this Surveyor and stated, Everything is cold. When asked if their hamburger was cold, they again stated, Everything is cold. The hamburger the French fries, the coffee - they are all cold. The confidential Resident handed this Surveyor a French fry to feel how cold the French fries were. The French fry was cold, greasy and limp to the touch. When the confidential Resident was asked for their meal tray card, they refused and said they didn't want anyone to get in trouble. During an observation in the kitchen on 6/8/26 at approximately 5:35 p.m., Dietary Manager (DM) E was observed removing the tray of French fries from the tray line and placing them in the oven for re-heating. This Surveyor requested the temperature of the French fries placed back in the oven. DM E opened the oven, pulled the French fry tray partially out of the oven and placed the instant read thermometer in the middle of the French fries, The instant read thermometer measured the temperature of the French fries, partially in the oven at 122 degrees Fahrenheit. During interviews in the dining room on 6/8/26 between 5:20 p.m. and 5:31 p.m., four confidential Residents all said their hamburger and french-fries were served to them cold. When two of these confidential Residents were asked about the palatability of their food, both, respectively, said the food was not cold, but it was not hot either. It was room temperature. Review of the Tray and Dining Room Meal Service policy, revised 4/21, revealed the following, in part: POLICY: The Dietary Department will provide accurate, efficient, and consistent meal service . PROCEDURE . 4. Food is to be tasted, and temperatures taken prior to meal service. Any item that does not meet the minimum requirement > (greater than) 135 degrees for hot items, and < (less than) 41 degrees for cold items should be removed and brought to the correct temperature. This may cause a tray line delay, however, resident safety first and foremost . 6. Food is to be on the steam table no longer than 30 minutes before resident meal service. Cold or frozen foods should remain in the refrigerator/freezer until needed. Milk will be stored in an ice bath during meal service .

Based on observation, interview, and record review, the facility failed to ensure that hot and cold food items were maintained at safe temperatures during meal service to prevent the risk of foodborne illness for residents. Findings include:During the dinner meal service observation on 6/8/26 at approximately 5:25 PM, dietary staff were observed serving food from the steam table. Temperature checks revealed the following: Hamburgers measured at 119 F (degrees Fahrenheit) on the top of pan and 131 F on the bottom of the pan.French fries measured 122 FBoth items were below the required minimum hot holding temperature of 135 F. Additionally, during the same observation, cold food items were noted to be above safe temperature ranges:Pickle spears measured 63.5 FGlass of milk, not stored in ice bath measured 47.2 FGlass of lemonade measured 44.8 FCup of vanilla pudding measured 50.8 FCup of strawberries measured 44 FAll exceeding the recommended maximum cold holding temperature of 41 F. On 6/8/26 at approximately 5:35 PM, during an interview, Dietary Staff member Q confirmed food temperatures had not been monitored at the steam table.On 6/8/26 as approximately 6:00 PM, Dietary Manager E stated staff are expected to check and document food temperatures before and during meal service to ensure compliance with food safety standards.According to the 2022 FDA Food Code section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57C (135F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54C (130F) or above; or (2) At 5C (41F) or less. Review of the facility's policy titled Tray and Dining Room Meal Service indicated .Any item that does not meet he minimum requirement >135 degrees for hot items and <41 degrees for cold items should be removed and brought to correct temperature.Cold or frozen foods should remain in the refrigerator/freezer until needed. Milk will be stored in an ice bath during meal service .

Based on observation and interview, the facility failed to protect the privacy of medical records for one Resident (#21) of one resident reviewed for privacy of medical records.Findings include:Resident #21 (R21)On 6/9/26 at 1:36 p.m., a medication cart was observed near the nurse's station with a facility laptop open. R21's personal health information was observed on the screen with no facility staff present near the medication cart.During a interview on 6/10/26 at 1:50 p.m., Nursing Home Administrator (NHA) reported, I often go around closing laptop screens due to the same issue.it is a problem.Review of policy titled Resident Rights last updated 9/22, read in part Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to: privacy and confidentiality.

628Based on interview and record review the facility failed to:Provide a bed hold notice for one Resident (#1) of two residents reviewed for hospitalization andSend a copy of the residents written notice of transfer to the Office of the State Long term Care Ombudsman for two Resident's (#1 & #46) of two residents reviewed for hospitalization.Findings include: Resident #46 (R46) During review of R46's EMR, a progress note was documented on 3/28/26 that stated, .Resident was sent out via EMS for slurred speech and change in condition. The Nursing Home Administrator had stated at during an interview on 6/9/26 at 1:12 p.m., that she was unaware of the requirement to notify the Ombudsman of discharges. The NHA was unable to provide an Ombudsman list from March to verify that R46 was on it. Resident #1 (R1) was transferred to the hospital Emergency Department (ED) on 1/5/26. There was no documentation in the Electronic Medical Records (EMR) indicating the resident/responsible party were provided a bed hold notice. There was no documentation in the EMR that the ombudsman was provided with a notice of transfer. Review of an email communication from the Long-Term Care Ombudsman on 6/9/26 at 11:42 a.m., revealed the ombudsman had not received a list of discharges from the facility. During an interview on 6/9/26 at 1:12 p.m., the Nursing Home Administrator (NHA) reported, The facility had not been sending the ombudsman a list of discharges.I didn't know I was supposed to send the ombudsman a list.we do not send a resident or the resident representative a bed hold notice upon transfer to the hospital. During an interview on 6/10/26 at 8:15 a.m., Registered Nurse (RN) G reported, When a resident is sent out to the hospital, we do not give the resident or resident representative a copy of the bed hold notice.they have that information on admission but, we do not provide the bed hold policy or notice upon discharge to the hospital . Review of a policy titled Bed hold last reviewed 1/22, read in part .This policy applies to all residents regardless of payment source and will be provided to the resident or the residents representation at the time of admission and again with any emergency transfer from the community [facility].

Based on observation, interview, and record review, the facility failed to implement revision to care plans to address necessary care and services provided for two Residents (#4 & #1) of two residents reviewed for care plan revisions. Findings include: Resident #4 (R4) Review of R4's Minimum Data Set (MDS) assessment, dated 3/20/26, revealed R4 was re-admitted to the facility on [DATE], with active diagnoses that included the following, in part: renal failure, diabetes mellitus, and hyperlipidemia (high cholesterol). R4 Scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), reflective of intact cognition. R4 was documented as receiving a therapeutic diet while a resident in the facility. During an interview on 6/8/26 at 6:40 p.m., when asked about their satisfaction with food in the facility, R4 said not enough food was being served, and noted that she received one hamburger patty for dinner that evening, served with a bun and French fries. R4 had a diagnosis of diabetes and said she does not eat bread or fries and only had one hamburger patty that she consumed. Review of R4's Nutritional Care Plan revealed the following, in part: Approach Date (for all interventions listed below) dated 2/9/2021. Diet as ordered. Honor food preferences within acceptable dietary limits for [R4's] quality of life concerns . Medications as ordered. Monitor FAR (Food Acceptance Record) . Observe tolerance to diet, make adjustments PRN (as needed). Offer substitutions if consumes < (less than) 50% (percent) of meal. RD to review PRN. During an interview on 6/10/26 at 12:55 p.m., Dietary Manager (DM) E was asked about R4's prescribed diet. DM E looked at R4's lunch dietary tray card and said R4's diet was a regular diet with extra protein. The tray card was documented with Regular, ExPro. DM E stated, I didn't know [R4] was supposed to get double protein. I will change that right now. DM E acknowledged R4 did not get double protein on her lunch tray which consisted of spaghetti with meat sauce, garlic bread and zucchini, and agreed that because the diet was not documented as Diet Regular/Double Protein/Thin liquids, R4' had not received double protein as ordered for approximately 2 months. Review of R4's Physician Order, dated 3/30/26, revealed the following: Diet regular/double protein, thin liquids. The order was signed by a physician on 4/5/26 and was also found in the Electronic Medical Record (EMR) listing of physician orders. This newly prescribed dietary order (as of 3/30/26) was not added to R4's care plan to provide resident-specific instructions and interventions as appropriate for the resident's care needs. Review of the Tray and Dining Room Meal Service policy, revised 4/21, revealed the following, in part: Policy: The Dietary Department will provide accurate, efficient, and consistent meal service.Trays will be check for accuracy at each meal. Resident#1 (R1) Review of R1's MDS dated [DATE], revealed admission to the facility on [DATE] with diagnoses that included hip fracture. R1 scored 3 of 15 on the BIMS assessment reflective of severe cognitive impairment. Review of document titled Safety Events—Fall events revealed, Event Date: 1/5/26.Evaluation Notes: Resident took herself to the bathroom and she was coming back to sit in the wheelchair.she stated that she tripped and fell on her right hip.resident was complaining of severe hip pain and stated I thing I broke my hip.the nurse called EMS.hospital called and resident does have a fractured right hip. Review of R1's care plan did not reveal any interventions or revisions from the fall. During an interview on 6/10/26 at 8:58 a.m., RN/MDS C reported, There is no revision or interventions to R1's care plan following the fall that occurred on 1/5/26. During an interview on 6/10/26 at 1:50 p.m., the Nursing Home Administrator (NHA) acknowledged the care plan should be reviewed/revised with interventions following a fall with major injury. Review of policy titled. Resident Incident/Accident Reporting Protocol last reviewed 1/25, read in part .Following an incident/accident event, the charge nurse shall.ensure immediate interventions are in place to prevent re-occurrence.during an investigation, the administrator, DON [Director of Nursing], or designee shall.review all documentation or materials related to the event, review at the next AM morning meeting with the Interdisciplinary Team (IDT) on a daily basis for review.and further possible interventions to precent reoccurrence of incidents.The plan of care will be updated to reflect what interventions were put into place to prevent reoccurrence of incidents.

Based on interview and record review the facility failed to implement a restorative nursing program to maintain or improve Range of Motion (ROM) for two Residents (#26 and #42) of two residents reviewed for range of motion.Findings include:Resident #26 (R26)Review of R26's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 4/21/26. R26 scored 15 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of intact cognition.During an interview on 6/8/26 at 6:46 p.m., R26 reported, I am having difficulty using my hand and feeding myself. I am having difficulty moving or using my hand and am losing strength in my hand.there is no one in restorative therapy helping me with range of motion or improving my strength in my hand.Resident #42 (R42)Review of 42's MDS assessment dated [DATE], revealed admission to the facility on 5/1/26. R42 scored a 8 of 15 on the BIMS assessment reflective of moderate cognitive impairment.During an interview on 6/8/26 at approximately 6:30 p.m., R42 reported, I am having problems with losing strength in my hands and my hands feel weak. I do not work with a restorative nursing program at the facility.During an interview on 6/9/26 at 12:02 p.m., Registered Nurse (RN) M reported, The Director of Nursing (DON) is in charge of the restorative therapy program however, there is no formalized program for restorative therapy, there is no charting regarding restorative therapy notes, and there is no restorative aide.During an interview on 6/9/26 at 12:42 p.m., Physical Therapy Assistant (PTA) O reported, I have never met with the DON regarding the restorative therapy program.I am not aware of a restorative therapy program at this facility.During an interview on 6/9/26 at 1:05 p.m., the Nursing Home Administrator (NHA) reported The DON is supposed to be in charge of the restorative nursing program and there is no one implementing the program at this time .Review of policy titled Overview and Philosophy Restorative Nursing read in part, .Restorative nursing is utilizing the skill and expertise of each discipline to plan, implement, and facility all individual pathways for returning the individual to their highest, practicable, physical, mental, and psychological functional level of well-being .reaching an individual's highest possible level can mean maintain a current level and instituting a program to assure an individual will not diminish.restorative nursing is a planned, systematic program that builds on positive goals from impairment deficits.maintaining at a certain level, preventing deterioration.restorative nursing focuses on restoring or compensating for skills lost through disuse or changes in physiology.restorative nursing seeks to maximize and prolong abilities with specific, measurable objectives.

Based on interview and record review the facility failed to meet the increased protein needs of one Resident (#4) out of one resident reviewed for their daily nutritional needs. Findings include:Review of R4's Minimum Data Set (MDS) assessment, dated 3/20/26, revealed R4 was re-admitted to the facility on [DATE], with active diagnoses that included the following, in part: diabetes mellitus. R4 Scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), reflective of intact cognition. R4 was documented as receiving a therapeutic diet while a resident in the facility.During an interview on 6/8/26 at 6:40 p.m., when asked about their satisfaction with food in the facility, R4 said not enough food was being served, and noted that she received one hamburger patty for dinner that evening, served with a bun and French fries. R4 said she was diabetic, does not eat bread or fries, and was offered only one hamburger patty which she consumed for dinner that evening.Review of R4's Nutritional Care Plan revealed the following, in part: Approach Date, 2/9/21, Diet as Ordered.Review of R4's Physician Order, dated 3/30/26, revealed the following: Diet regular/double protein, thin liquids. The order was signed by a physician on 4/5/26 and was also found in the Electronic Medical Record (EMR) listing of physician orders. Review of the Tray and Dining Room Meal Service policy, revised 4/21, revealed the following, in part: Policy: The Dietary Department will provide accurate, efficient, and consistent meal service.Trays will be check for accuracy at each meal.On 6/10/26 at approximately 12:30 p.m., R4 was observed eating her lunch tray which included spaghetti with meat sauce, garlic bread and zucchini. R3 was only eating the spaghetti meat sauce and said she would not be eating the pasta or the garlic bread. The spaghetti sauce did not appear to be a double serving of protein.During an interview on 6/10/26 at 1255 p.m., Dietary Manager (DM) E was asked about R4's prescribed diet. DM E looked at R4's lunch dietary tray card and said R4's had a regular diet with extra protein. The tray card was documented with Regular, ExPro. DM E stated, I didn't know [R4] was supposed to get double protein. DM E acknowledged R4 did not get double protein on her lunch tray because the diet was not documented as Diet Regular/Double Protein/Thin liquids on the meal tray card, DM E also acknowledged R4 had not received double protein as ordered for approximately 2 months.

Based on interview and record review, the facility failed to ensure the resident/resident representative understood the purpose of binding arbitration agreements (an out of court alternate form of dispute resolution) for two Residents ( #43 & #22 ) of three residents reviewed for arbitration.Findings include:Resident #43 (R43)Review of R43's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 4/8/26. Section B: [Hearing Speech and Vision] of the MDS revealed R43 understands with clear comprehension and makes herself understood.Review of document titled [name of facility] Agreement to Resolve Legal Disputes Through Arbitration revealed R43 signed the document on 4/9/26.During an interview on 6/10/26 at 6:52 a.m., R43 reported, I know what binding arbitration is and I don't believe in it. I feel right is right and wrong is wrong and a person should be able to hold people accountable. I have not signed any arbitration here, at least I don't remember signing anything. When I was first admitted to the facility they gave me a bunch of paperwork to sign. All the person did was flip pages and tell me to sign here and sign there.they didn't explain anything. I didn't have time to review the paperwork like I would have liked to and normally would. I trusted them. I just had surgery and there was a lot on my mind. I had just come into a new place and I didn't know anyone, I needed rehab so I could go home, and I was in a lot of pain. I really thought they would have explained what I was signing, but I felt rushed and thought I had to sign it all to be at the facility.During an interview on 6/10/26 at 7:35 a.m., Business Office Manager (BOM) B reported, All the residents or their representatives have signed the binding arbitration agreement and not one person has refused to sign.Resident #22 (R22)Review of R22's MDS assessment dated [DATE], revealed admission to the facility on 4/26/26. Section B of the MDS revealed R22 understands with clear comprehension and makes herself understood.Review of document titled [name of facility] Agreement to Resolve Legal Disputes Through Arbitration revealed R22 signed the document on 4/27/26.During an interview on 6/10/26 at 7:50 a.m., R22 reported, I don't remember much when I first came to the facility.I remember signing papers, but I have no idea what I was signing. I just had a heart attack and remembering things at that time was not a priority. I do not recall signing anything regarding arbitration.During an interview on 6/10/26 at 1:50 p.m., the Nursing Home Administrator (NHA) reported, I have asked BOM B to explain the arbitration agreement and ensure the residents understand what they are signing.the residents should not feel pressured to sign and understand what they are agreeing to regarding arbitration . Review of policy titled Binding Arbitration Agreement Policy last reviewed/revised 3/2026, read in part . When explaining the arbitration agreement, the facility shall: a. Explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or a requirement to continue to receive care at, this facility. B. explain to the resident and his or her representative in a form and manner that he or she understands.

This deficient practice pertains to Facility Reported Incident (FRI) 3014540.Based on observation, interview, and record review, the facility failed to prevent, detect, and respond to an elopement for one Resident (#30) of four residents reviewed for elopement.Findings include:Resident #30 (R30)Review of the FRI submitted to the State Agency (SA) on 5/3/26 at 8:05 PM, included an investigation report which read, in part: Staff reported [R30] left facility out west hall door. [R30] was assisted willingly back into the building.[R30] wearing sweatpants, grippy socks, and a shirt. Weather at time sunny 55 degrees.[R30].resides on the west hall. He [R30] is independently ambulatory without the need of assistive devices and routinely ambulates around his room and the facility as he desires. On the afternoon of 5.3.26, [R30] exited the west hall exit door and ambulated outside. [R30] was assisted willingly back inside the building, and when asked, he stated he, just wanted to go outside.A new BIMs [brief interview for mental status] assessment was completed following this incident and showed a significant decline in cognitive status.Witness statement from Licensed Practical Nurse (LPN) C was reviewed by this Surveyor as she was unavailable for interview during the survey. LPN C wrote, At 6:32 PM, [R30] was at [NAME] Hall doors. I was going to the bathroom.At 6:40 PM, Staff notified me that [R30] got out. Staff reported to me that only the alarm panel went off.Witness statement from Certified Nurse Aide (CNA) G was reviewed by this Surveyor as she was unavailable for interview during the survey. CNA G wrote, At 6:20-6:30 PM, I heard someone from nurses' station saying, 'turn off the alarm'. I heard no alarm. Pushed code. Alarm turned off according to coworker. At 6:30-6:35 PM, I looked out the door and did not see anyone. I did not go out and look around outside. I looked out window. We tested the door multiple times, and it did not alarm with the loud exit alarm.Witness statement from CNA E was reviewed by this Surveyor as she was unavailable for interview during the survey. CNA E wrote, At 6:30 PM, I was not in the building when the alarm went off so I did not hear any alarms. I was getting oxygen for another resident.Witness statement from CNA H was reviewed by this Surveyor as she was unavailable for interview during the survey. CNA H wrote, At 6:15 PM, I saw [R30] in Lakeside looking out the window. At 6:20 PM, I returned to East Hall. At 6:35 PM, I was directed by nurse to grab chair and assist [R30] into building. I never heard an alarm.On 5/4/26, the NHA and LPN F went to the [NAME] Hall exit door to perform a door simulation test and the following was discovered: LPN 'F' stated that the door was malfunctioning on 5/3/26 which allowed [R30] to exit without alerting staff by sounding overheard. LPN 'F' and NHA attempted to open door. Alarm did go off. LPN 'F' then showed NHA that the key portion of the door was wobbling and able to be moved out from the door bar. Once LPN 'F' toggled the key spot NHA was able to walk in and out of the [NAME] Hall door with no alarm. Alarm was malfunctioning. Due to door alarm malfunctioning [R30] was able to get out the door without staff being aware.Review of R30's electronic medical record (EMR) revealed the following progress note written on 5/3/26 at 8:28 PM: [R30] was brought back to facility from neighbor who noted [R30] outside on grass down the hill from building around 1840 [6:40 PM] she stated.Review of R30's care plan, dated 2/27/26, unveiled in part Problem: [Resident name] experiences wandering (moves with no rational purpose, seemingly oblivious to needs or safety). Goal: [R30] will not injury/harm self-secondary to wandering. Approach: Remove [R30] from other resident's rooms and unsafe situations.During an interview on 5/26/26 at 11:50 AM, with the NHA, who was asked what her expectations were of staff if the door alarms went off and replied, I would expect staff to respond appropriately, go outside the exit doors and look around, ensure all residents are accounted for, and not just go and reset the alarm. The NHA was asked if R30 had a wander guard on and replied, We don't use them here.Review of CNA G disciplinary action, dated 5/4/26, read in part .understands she should have checked outside perimeter. It was found that door was not functioning properly.On 5/26/26 at 12:00 PM, an interview was conducted with the Maintenance Director A who was asked how often the exit doors are tested and who is responsible for the testing, and replied, I test the exit doors Monday through Friday and housekeeping is responsible for the testing during the weekends. A request was made for the testing logs and the work orders for the exit doors.Review of the exit door testing logs for the year 2026, revealed an X by each day of each month and did not indicate who performed the testing. On the backside of the exit door testing log for the year 2026 the following was noted:As of 5/3/26 when elopement extra daily checks were done to make sure door was working as it should.5/5/26 Gentleman from Total Fire Protection here to fix latch mechanism.5/18/26 Discovered on my audit check something wrong with it again. Total Fire Protection called again.5/19/26 Total Fire hear at 8:00 AM to check. Determined it is working as it should. Ordering new crash bar to prevent further issues.Review of the work orders for exit doors indicated repairs made on 5/5/26 and 5/12/26.On 5/26/26 at 12:27 PM, an interview was conducted with Housekeeper I who was asked if she tested the exit doors on the weekend of 5/2/26 - 5/3/26 and replied, No. I did not know I was supposed to. Housekeeper I was asked how R30 was behaving on 5/3/26 and replied, He was really agitated and was touching all kinds of things like the fire extinguisher and keypads to doors. Usually, we just walk with him, and the nurse instructed me to keep an eye on him.During an interview on 5/3/26 at 12:34 PM, with Housekeeper J who was asked if she was aware she was responsible for checking exit doors during the weekend and stated, I don't check the door alarms. Never check door alarms. [R30] kinda just like gets into things. He was a little character.On 5/26/26 at 12:50 PM, an interview was conducted with CNA K, who was asked about R30's behaviors and replied, He was very busy. Always wandering around.During an interview on 5/26/26 at 12:55 PM, with CNA H was asked about R30's behaviors, and stated, He would move around and was busy. I had to get him after he got out and I asked him how he was doing and he told me he had a nice walk, but it was hard on his feet. He just had gripper socks on and no shoes. Someone brought him back in a white car. I don't know who it was, some lady.On 5/26/26 at 1:40 PM, the NHA confirmed R30 would wander around the building from hall to hall, in her office, and the Director of Nursing's. The NHA stated, The CNA just adding the code in to shut the alarm off and not actually step outside to see if a resident eloped is one problem and the door not being checked by housekeeping on the weekends is another.At 2:15 PM on 5/26/26, a phone interview was conducted with LPN F who was working at the time R30 eloped from the facility and stated, The other nurse working was assigned to [R30]. I was assigned to the other end of the building. [R30] walked to Lakeside room and then came back near the sink by the nurses' station and just stood there. I got a message from the NHA because she had a few questions for me around 6:15 PM and I left the floor to go back to the conference room so I could call her. I was sitting in the conference room for about 10 to 15 minutes. I was looking out the window and saw this black SUV pull up and a lady came out and I heard the doorbell ring. I could see she had him [R30] in the passenger's seat. We never got her name. She said she had been driving and seen him in the wooded area behind the house down in front of the facility. She stopped to ask him if he was alright and noted he was alright but confused so she put him in her car and took him back to the facility. After we got him back in and secured, I went to check the door. I pressed the door open and the door flung open without an alarm. I messed around with the lock then I pressed on it, and it was not secure it was jiggling and then I hit it back in and then my key worked. I do not know how long it was not working.During the SA investigation on 5/26/26, it was concluded R30 was approximately 0.2 miles from the facility and outside for approximately 10-15 minutes before a neighbor intervened.Review of policy titled, Elopement Prevention and Management Program, dated 1/2025, read in part Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in according with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.Policy Explanation and Compliance Guidelines: 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner.

Based on observation, interview, and record review, the facility failed to monitor fluids as ordered for one Resident (R6) of two residents reviewed for fluid concerns. This deficient practice resulted in the potential for fluid imbalance. Findings include: Resident #6 (R6) The medical record revealed an admitted [DATE] and a diagnosis list including dementia, stroke, and hyponatremia (a condition where the blood sodium is too low and can trigger cell swelling causing health issues ranging from mild to life threatening.) The medical record included a physician order dated 5/14/24 which read Fluid restriction of 1.5 liters daily secondary to hyponatremia. On 4/8/25 at 12:34 PM during a tour of the dining room, R6 was observed eating lunch. The tray card indicated a diet of Regular, NAS (No Added Salt) 1500 cc (cubic centimeters) Restr (Restriction - indicating a fluid restricted diet of 1.5 liters.) When the resident was asked if she limited her fluids. The resident replied she did not. On 4/10/25 at 8:31 AM, R6 was observed in the dining room eating breakfast. Again, the tray card indicated a 1500cc fluid restriction with instructions to serve 360 cc or 2 x 6 oz (two six ounce) drinks. R6 was served 180 cc tea, 180 cc apple juice, and 120 cc milk to total 480 cc, exceeding the planned amount. During an interview on 4/10/25 at approximately 8:45 AM, Certified Dietary Manager (CDM) G stated the nursing department provided beverages with meals in the dining room and had served R6 that morning. The medical record for R6 from 3/10/25 to 4/10/25, revealed no fluids were documented as consumed in the vital section of the chart. The Care Plan for R6 included a problem with a Start Date: 05/14/2024 which listed Potential for fluid imbalance, fluctuating weights and edema r/t (related to) ordered fluid restrictions. Approaches for this care plan problem included: - Start Date: 03/04/2025 Diet as ordered - Fluid restrictions as ordered. If applicable, educate (R6) on importance/reason of fluid restrictions in attempt to promote compliance and understanding. The care plan did not indicate an individualized plan for R6 related to fluid distribution. The Fluid Restriction Worksheet presented by the facility for R6, was dated as calculated on 5/14/24. This worksheet indicated 1500 cc of fluid was planned each day with 1080 cc distributed from the dietary department and 360 cc from the nursing department (for beverages at bedside and to be taken with medications.) The worksheet planned 60 cc per day as variance. During an interview on 4/10/25 at 8:21 AM, Certified Nurse Aide (CNA) D stated, We do not document fluids anymore. During an interview on 4/10/25 at 8:27 AM, Licensed Practical Nurse (LPN) C stated, We know who is on fluid restriction and give fluids with meds but we do not have any documentation (to note the amount of fluids given). During an interview on 4/10/25 at approximately 11:40 AM, the Director of Nursing (DON) stated the facility did not document amounts of fluids given or have a process to total fluids given as ordered by the physician. The DON acknowledged the physician had ordered a fluid restriction and fluid intake should be documented, totaled and analyzed for those residents requiring fluids be limited. The fluid restriction policy was requested. A policy titled Standards of Practices dated as revised 5/2018 included a section on Nutrition and hydration. The fluid restriction section of the policy read . 3. Staff will be aware of those residents on fluid restrictions or who have special swallowing requirements. No other fluid restriction procedures or policies were presented.

This deficiency pertains to MI00148756. Based on interview and record review, the facility failed to prevent misappropriation of narcotic medication for one Resident (#1) of five residents reviewed for misappropriation. Findings include: Resident #1 (R1) Review of R1's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including malignant cancer of the colon and rectum. Review of R1's most recent Minimum Data Set (MDS) assessment, dated 12/12/24, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition. R1 signed with hospice services on 8/6/24. Review of R1's EMR physician orders revealed the following pharmacy order, initiated 9/11/24: Hydrocodone acetaminophen (opiate [narcotic] medication mixed with Tylenol) - Schedule II tablet; 10-325 mg [milligram]; 1 tab; oral, Four Times A Day. Review of R1's Medication Administration Record [MAR] revealed they were scheduled to receive a dose of hydrocodone at 2:00 AM, 8:00 AM, 2:00 PM, and 8:00 PM. Review of the FRI read, in part: On 11/27/2024 at approximately 5:58 a.m., DON [Director of Nursing] received a phone call from [Registered Nurse (RN) A] .reporting that the mandatory med [medication] count .was off by one . When this was discovered, the night nurse [Licensed Practical Nurse (LPN) D] wrote on the med sheet, in front of [RN A] and stated she gave [R1] his Norco [Hydrocodone-acetaminophen brand name] at 5:00 am .she stated she forgot to write it down. DON told [RN A] to make sure [LPN D] stayed until she got to facility to do med count with them. [RN A] reported that [LPN D] would not stay and that she had left . we confirmed with the resident .that he did not receive a 5:00 am Norco, but did get his 2:00 am [dose]. This is a scheduled medication to be given every 6 hours, so was not due to receive again until 8:00 am . On 12/18/24 at 10:59 AM, an interview was conducted with RN A who verified she was the oncoming day shift nurse on 11/27/24. RN A stated she and LPN D were reconciling the Controlled Substance Proof of Use form and medication cart around 6:00 AM on 11/27/24 when she noticed R1 had only two remaining hydrocodone pills in the medication cart, yet the Controlled Substance Proof of Use form indicated R1 should have had three remaining pills. RN A stated after the discrepancy was noticed, LPN D stated she forgot to record an administration on the Controlled Substance Proof of Use form. RN A stated she witnessed LPN D retroactively timestamp the form to 5:02 AM. RN A stated she immediately notified the DON of the discrepancy and expressed concerns R1 could have been overmedicated as the medication was not scheduled to be given again until 8:00 AM. On 12/18/24 at 11:13 AM, an interview was conducted with the DON regarding the medication discrepancy on the morning of 11/27/24. The DON stated she received a call from RN A who reported LPN D altered the Controlled Substance Proof of Use form to match the medication cart. The DON stated she immediately called LPN D who had already left the facility and asked her to return so an official investigation could be conducted. The DON stated LPN D declined to come back to the facility claiming she was, too tired. The DON stated she interviewed R1 who was adamant he never received any medication at 5:00 AM, refuting LPN D's claims of administering this medication to R1 at that time. The DON explained the typical administration process of a narcotic is to record the use on the Controlled Substance Proof of Use form as soon as the medication is pulled from the cart. The DON continued after administration, it is then documented in the respective resident's electronic MAR. On 12/18/24 at 10:51 AM, an interview was conducted with R1 regarding medication administration between 11/26/24 - 11/27/24. R1 verified he received a dose of hydrocodone on 11/26/24 at 8:00 PM and on 11/27/24 at 2:00 AM. R1 declined receiving a dose of a hydrocodone on 11/27/24 at 5:00 AM and stated, I'm only scheduled to receive it every 6 hours. Review of an Incident Report from local law enforcement, dated 12/18/24, read, in part: .officer advised [LPN D] that it appeared she stole the pill from [R1] and hoped that no one noticed and tried to cover up what she did after she was confronted . While speaking to [LPN D], Officer did not believe that [LPN D] was telling the truth . On 12/18/24 at 1:46 PM, an interview was conducted with the Nursing Home Administrator (NHA) who verified the facility substantiated the misappropriation of R1's prescription medication and subsequently terminated LPN D. Review of the facility policy titled, Abuse Prevention Program Policy & Procedure, reviewed 1/2024, read, in part: .[Facility Name] has prevention programs in which policies and procedures safeguard our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation . Review of the facility policy titled, Controlled Substances Standards of Practice, reviewed 1/2024, read, in part: .Nurses removing controlled substance from the narcotic storage require documentation on the Proof-of-Use Sheet the amount removed using a full last name signature. Nurse documentation of inventory balance on Proof-of Use sheet MUST be made as soon as the controlled substance is removed from the package/cart. Avoid waiting until the end of med pass or end of shift. Once the nurse completes the administration, then the nurse is to document on the MAR paper record or E-MAR electronic record .Note: If documentation is not provided on MAR or E-Mar, medication will be considered not given. MAR or E-Mar is record of administration NOT the proof-of-use sheet

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety potentially resulting in a food borne illness among any or all 42 residents. Findings include: On [DATE] at approximately 1:03 p.m., three individual take-out containers lacking resident names or dates were observed in the refrigerator located in the activity room. Upon opening the individual containers, the following was observed: 1) A small Styrofoam cup with lid containing what appeared to be a milk shake with mold growing on top of the substances. 2) Two packages of hot dogs, expired on [DATE] and [DATE], hot dog buns that expired on [DATE] and the first name of a resident. 3) A large Styrofoam take out container containing crab Rangoon with no label or date. A Record of Refrigeration Temperatures log for [DATE] was observed in a drawer to the left of the refrigerator. No temperatures were recorded from [DATE] through [DATE]. On [DATE] at approximately 2:00 p.m. the Nursing Home Administrator (NHA) was asked to view the resident refrigerator. The NHA reported that she did not note any expired or unlabeled foods, and the refrigerator must have been cleaned after the observations were made on [DATE]. On [DATE] at approximately 12:00 p.m., the NHA produced the previously blank Record of Refrigeration Temperature log for [DATE] with temperature values recorded from [DATE] through [DATE]. The NHA was provided with evidence of falsification of data. When asked what department was responsible for the cleaning and maintenance of the resident refrigerator, the NHA stated that it was the dietary's responsibility. A review of the Properly labeling and Dating Food Brought in by Visitors form posted on [DATE] read, in part, Patient Name .R: (received date) date brought into facility .): Date food item opened .X: Expiration Date or best used by date marked on original manufacture packaging .please see Nurse for black marker for labeling package . Review of the facility's Foods Brought In To Resident policy dated ,d+[DATE] read, in part, 1) Food brought into the facility by a family/Resident Representative/Visitor or by vendor must be checked by the nurse to assure that the food is not in conflict with the resident's ordered or prescribed diet .Refrigerated Cooked Food items will automatically be disposed after 3 days (counting day of food brought in, as day #1) .All opened packages must have open date, and use by date clearly marked .Any suspicious or obviously contaminated food or beverage will be thrown out immediately upon discovery. Foods found without dates will also be discarded .Cooked food items will be labeled with the resident's name and date of delivery .

Based on observation, interview, and record review, the facility failed in implement enhanced barrier precautions (EBP) for seven Residents (R3, R7, R17, R23, R29, R33, and R36) of twelve sampled residents reviewed for infection control practices. Findings include: Resident #3 (R3) On 5/6/24 at 12:05 PM, an observation was made of R3's sitting in her room. R3 was observed to have an indwelling urinary catheter. R3's room door lacked any indication she was on EBP and lacked a cart for personal protective equipment (PPE) outside of her room. Further observations of the facility's halls and resident rooms revealed the lack of any residents being identified as having EBP or PPE carts. Review of R3's physician order, dated 4/14/24, read in part, Catheter care per shift . Resident #7 (R7) Review of R7's physician order, dated 3/1/24, read in part, Flush peg tube . Resident #17 (R17) Review of R17's physician order, dated 5/3/24, read in part, .Wound: cleanse with wound cleaner. Pat dry. Lightly pack .every day . Resident #23 (R23) Review of R23's physician order, dated 4/1/24, read in part, Catheter Care every shift . Review of R23's physician order, dated 4/23/24, read in part, Flush residents PICC [peripherally inserted central line] .after running the antibiotic . Resident #29 (R29) Review of R29's physician order, dated 12/14/23, read in part, Cleanse area around PEG tube with wound cleanser . Review of R29's physician order, dated 4/7/24, read in part, Cleanse wound to coccyx with wound cleanser .change daily and as needed . Resident #33 (R33) Review of R33's physician order, dated 1/31/23, read in part, Cleanse G-tube site with normal saline .at bedtime . Review of R33's physician order, dated 3/3/23, read in part, Flush PEG tube with water . Resident #36 (R36) Review of R36's physician order, dated 5/2/24, read in part, Right Breast Areola: Cleanse with wound cleaner .cover with .absorbant (sic) gauze On 5/6/24 at 1:30 PM, a policy for EBP was requested from the Director of Nursing (DON). On 5/6/24 at 2:40 PM, an interview was conducted with the DON and was asked if any of the current resident population should be on EBP and replied, I think maybe one, but I would need to check the list. On 5/7/24 at 2:20 PM, an interview was conducted with the DON and when asked why residents with an indwelling catheter, wound, or feeding tube lacked EBP signage and PPE carts with supplies she replied, I dropped the ball on that. That is all on me. After the COVID outbreak we just put all the PPE away because we didn't need it and one by one it was gone that was about a month ago. Review of physician orders for R3, R7, R17, R23, R29, R33, and R36 lacked any orders for EBP. Review of care plans for R3, R7, R17, R23, R29, R33, and R36 lacked any focus, goal, or interventions related to EBP and providing cares. Review of policy titled, Enhanced Barrier Precautions Policy and Procedure, dated 4/5/24, read in part, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .2. Initiation of Enhanced Barrier Precautions . b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds .and/or indwelling medical devices .3. Implementation of Enhanced Barrier Precautions - a. Make gowns and gloves available immediately near or outside of the resident's room .

Based on observation, interview and record review, the facility failed to implement interventions to address range of motion (ROM) for one Resident (R33) of two residents reviewed for limited range of motion. This deficient practice resulted in the potential for extreme pain, discomfort, and worsening of contractures. Findings include: Review of R33's Electronic Medical Record (EMR) revealed an admitted [DATE] and diagnoses including epilepsy, dementia with agitation, seizure disorder, weakness, convulsions, and cognitive communication deficit. Her 3/18/24 Quarterly Minimum Data Set (MDS) assessment revealed she was unable to complete the Brief Interview for Mental Status (BIMS) score and was marked with severely impaired cognition. Review of MDS Section GG dated 3/18/24, revealed R33 had functional limitations secondary to rand of motion deficits to both sides of her upper and lower extremity. In Section O of her 3/18/24 MDS, she was noted to have received zero days of treatment in a Restorative Nursing Program which included range of motion (passive and active, splint, or brace assistance. On 5/6/24 at approximately 10:55 a.m., R33 was observed sitting in a Geri chair in her room. R33 was nonverbal during this interaction, but it was observed that her right and left hands were contracted with her fingers folding into her palm. R33's right hand was on her chest. There were no splints or pads in place. On 5/7/24 at approximately 10:00 a.m., R33 was observed sleeping in her Geri chair. Her fingers remained folded into her palm, with no protectors or padding in place. On 5/8/24 at approximately 10:07 a.m., R33 was observed in her Geri chair during church service. Her fingers remained folded into her palm, with no protectors or padding in place. An interview was conducted with the Director of Nursing (DON) and Registered Nurse (RN) F on 5/8/24 at approximately 11:10 a.m. When asked if R33 had always had bilateral hand contractures, RN F stated that she believed she did. When asked if R33 was supposed to have a splint or device in her hands to prevent discomfort or worsening of her contractures, RN F stated that she has seen R33 wear devices in the past but was unable to state when she last saw them. The DON confirmed RN F's statement and confirmed there were no physician orders in R33's EMR to wear any device on her hands. An interview was conducted with Therapy Director/Staff O on 5/8/24 at 12:10 p.m. who stated R33 was last seen by therapy in June of 2023, and it was recommended to use palm protectors in both hands as tolerated to help with her contractures. Staff O confirmed that staff were educated on how to apply the palm protectors for R33 but was unable to tell if the palm protectors were being used or documented as R33 was no longer receiving therapy services. Review of R33's Care Plans read, in part, Encourage bilateral palm protectors.

Based on observation, interview, and record review, the facility failed to ensure persistent nausea and vomiting was treated consistently and under the coordinated supervision of the physician, dietary, and nursing department for one Resident (#26) out of 5 Residents reviewed for quality of care based on comprehensive assessment. This deficient practice resulted in significant weight loss as well as functional and psychosocial decline. Findings include: On 1/26/21 at 10:49 a.m., Resident #26 was observed lying on her back in her bed tremoring and gripping on to an emesis (vomit) basin. A review of Resident #26's record revealed she admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of her 9/22/20 Admission Minimum Data Set (MDS) assessment revealed she scored 15/15 on the Brief Interview for Mental Status (BIMS) assessment, indicating intact cognition. This MDS also revealed she scored a 0 on the PHQ-9 assessment for depression, and used the extensive assistance of one staff to walk in her room. A review of the 1/17/21 Quarterly MDS revealed her BIMS score declined to a 13/15, her PHQ9 (Patient Health Questionnaire) assessment increased to 3 (signs of depression), and she was marked as not having walked in her room at all during the assessment period. A review of a skin assessment dated [DATE] revealed, No areas of skin impairment. Review of a 1/24/21 skin assessment revealed, Coccyx remains red, indicating potential breakdown and pressure ulcer development. A review of Resident #26's weight record revealed she weighed 213.2 lbs on 11/30/20 and 179 lbs on 12/30/20 (-34.2 pounds or 16 % loss in 1 month). A three month review revealed she lost 40.6 pounds since 10/26/20 (-18% body weight in 3 months). A review of Resident #26's 9/28/20 Initial Nutritional Assessment conducted by the Certified Dietary Manager (CDM) J revealed, . was admitted on full liquid diet due to nausea and vomiting . FAR (food acceptance record) shows average of 50-75% intake . poc (plan of care) initiated . A review of the 1/122/21 Quarterly Dietary Review revealed, .average meal intake: 0-24% . Average po (by mouth) supplements intake: 0-24% . Current weight 1/19/21 175.4# FAR is very poor, fluid intake is very poor as well. Refuses most meals. Has requested mashed potatoes to all meals, rarely eats them . Loss of 43# or 19.9% in 123 (days) is considered significant. Loss likely r/t (related to) nausea with frequent emesis, recently COVID positive with severely decreased appetite, current supplement is house (supplement) 60 cc BID (twice per day) and adaptive equipment of swivel spoon and 2 handled cup. Will continue to monitor weight, labs, and FAR as available . A review of the January 2021 Medication Administration Record [REDACTED]. There was also an order [REDACTED].#26 had complaints of nausea on 1/17, 1/18, 1/20, and 1/22 yet no prn [MEDICATION NAME] or [MEDICATION NAME] was documented as given on those days. A review of Resident #26's December 2020 MAR indicated [REDACTED]. A review of Resident #26's November 2020 MAR indicated [REDACTED]. A review of Resident #26's physician notes revealed the following: 9/23/20 Reevaluate diabetic regimen and patients diet related to recurrent nausea (and) vomiting . patient states her nausea and vomiting has resolved. We will advance her diet to mechanical soft . 10/15/20 Readmission after hospitalization for dehydration and altered mental status . was found to have acute kidney injury . was given IV (intraveneous) rehydration . get weights 3 times a week . offer fluids and monitor intake and output . 10/23/20 Nausea . is seen today for nausea. Patient states she was feeling sick this morning however she feels better at this time. Patient has intermittent nausea since admission . 10/26/20 . I did discuss with her next steps in treatment including a possible GI (gastrointestinal) referral, hospice and comfort care, for continuing with current treatment that has not been improving her nausea 11/3/20 . seen today for her nausea. Patients nausea is persistent . patient states that she just constantly feels nauseated . GI referral has been made however according to scheduling the GI specialists are backed up therefore an appointment cannot be accomdated quickly . start [MEDICATION NAME] 4 mg q 6 and increase TUMS to BID . 11/17/20 .Patient has been having a difficult time in the last month with having increased episodes of nausea and vomiting . over the last week patient's nausea and vomiting has improved as she was started on [MEDICATION NAME] for dizziness as well as [MEDICATION NAME] . 12/23/20 . no significant weight changes . denies constipation, nausea, vomiting . denies nausea currently however had episode of nausea with vomiting this morning . 1/19/21 . being seen for routine 30 day appointment . she had no nausea, vomiting . her appetite has been adequate . appetite is satisfactory. No significant weight change . No nausea, vomiting . well nourished . 1/25/21 . no significant weight changes .denies constipation, positive for nausea . nausea and vomiting . continues in spite of treatment. Will await family decision. 1/25/21 . Patient has had persistent nausea since she admitted to this facility. She has been treated with [MEDICATION NAME] as well as [MEDICATION NAME] which temporarily has relieved however returned quickly. Patient has minimal appetite continues to decline . On 1/26/21 at 12:05 p.m., Certified Nurse Aide (CNA) L was observed bringing a meal tray to Resident #26 and putting it on the overbed table. Resident #26 made no move to eat or drink any of her meal. On 1/26/21 at 1:15 p.m., Resident #26 was observed in bed and had not touched her meal tray. On 1/26/21 at 1:17 p.m., CNA L was observed in the hallway after exiting the room of Resident #26, and when asked about Resident #26 she stated, She doesn't feel well . She only eats about 10% usually. When asked if Resident #26 was often not feeling well and unable to eat her meal, CNA L stated, Yes, this is normal for her. She's nauseous. On 1/27/21 at 9:06 a.m., Resident #26 was lying in her bed on her back, gripping on the emesis basin. On 1/27/21 at 10:07 a.m., Resident #26 was still lying on her back in her room with her emesis basin beside her. On 1/27/21 at 11:47 a.m., Resident #26 was observed still lying on her back in her bed holding her emesis basin. On 1/27/21 at 12:13 p.m., Registered Nurse (RN) A was asked if Resident #26 had any orders for antiemetic or anti-nausea medication. RN A stated, Yeah she's nauseated. I'll go see if she has any [MEDICATION NAME]. I'm new to her (not familiar with this Resident). On 1/27/21 at 12:14 p.m. CNA M was observed entering Resident #26's room with a bowl of mashed potatoes. Resident #26 did not make a move to eat or drink anything. CNA M upon exiting the room was asked about Resident #26 not eating and stated, .it's really hard (to get her to eat). Sometimes it helps when we try to feed her . On 1/27/21 at 12:19 p.m., RN A was observed coming out of the medication storage room, and stated, Yep, she (Resident #26) has an order for [REDACTED]. On 1/27/21 at 2:00 p.m., an interview was conducted with the Dietary Manager (DM) I. When asked if she had become a Certified Dietary Manager (CDM) yet, DM I stated, I finished the coursework. But as soon as I have the money I will schedule the test. When asked about Resident #26 and her nutritional status and weight loss, DM I stated, I know we tried pro heal (brand name) and house supplement. I think a lot of her weight loss was from when she was in the hospital. She is super nauseous. When asked if she had something in place to treat the nausea, DM I stated, I'd have to check the chart. When asked how much of the current supplement Resident #26 was actually consuming, DM I stated, The nurses should be charting that. I don't know how she is doing with that. On 1/27/21 at 1:51 p.m., an interview was conducted with RN H regarding Resident #26's nausea and weight loss. RN H stated, Since she has been her she has had a lot of gastral issues. We've used [MEDICATION NAME] (motion sickness medication) and [MEDICATION NAME] prn, but it didn't really help. I talked to (Nurse Practioner (NP) F) and she's said last week she talked to her (Resident #26's) daughter because she is not able to get the CT (computer tomography scan - ordered by the GI doctor) because her kidney function is declining. On 1/27/21 at 2:08 p.m., a follow-up interview was conducted with RN H who stated, The family wanted a GI (gastrointestinal) consult before they decided about hospice. She had an appointment on December 9th (2020), but she got COVID so we had to cancel. On 1/27/21 at 2:39 p.m., Resident #26 was observed sitting up in bed. She was no longer holding her emesis basin. When asked how she was doing, Resident #26 stated, I'm ok. When asked if she had been experiencing nausea, Resident #26 stated, Yes. All the time. When asked if the nurses gave her a medication to treat it, Resident #26 stated, Sometimes. When asked if it relieved the nausea when they did give a medication for it, Resident #26 stated, Yes. Because I can't eat when I feel like that (nauseous). On 1/27/21 at 2:42 p.m., RN A was asked about Resident #26 and stated, She's feeling better now. She even took some jello. She said she'd work on keeping that down and we could try more food later. It ([MEDICATION NAME]) is ordered q 6 (every 6 hours) so I'm going to tell the oncoming nurse to try to give her the next dose. On 1/28/21 at 2:14 p.m., a phone interview was conducted with Registered Dietitian (RD) G. When asked if she had communicated to the Physician Resident #26's significant weight loss, RD G stated, I didn't communicate anything. I expect it to be the nurses (who communicate with the Physician). When asked if she had reviewed Resident #26's lack of oral intake, her nausea, and the infrequent use of the [MEDICATION NAME] with nursing or the Physician, RD G stated, I didn't know the extent of her nausea. I guess from the nursing perspective I would have ordered it ([MEDICATION NAME]) routinely if I was aware. When asked what interventions to prevent the weight loss had been provided for Resident #26, RD G reported she had been receiving the house supplement twice per day, and they had increased it to three times per day recently. When asked whether Resident #26 was consuming the supplement, RD G stated, I don't see any of the documentation of whether she accepts it or not. On 1/28/21 at 4:35 p.m., a phone interview was conducted with NP F regarding Resident #26's nausea. NP F stated, We sent her to a GI specialist. I talked to the family quite a while ago about hospice, but they wanted her to have the GI consult. I sent her, even with the delay because of COVID. I heard they wanted a CT scan but she can't because her kidney function is declining. When asked why the [MEDICATION NAME] was discontinued after 7 days despite it being effective back in November 2020, NP F stated, We switched it to [MEDICATION NAME]. They (administration) asked me to switch it. They thought it would be more effective. When informed that the prn [MEDICATION NAME] had only been given a total of 4 times in the month of January 2021 per the MAR indicated [REDACTED]. When asked if aware of Resident #26's significant weight loss of 34.2 pounds in one month, NP F stated, No. I would expect that they (nursing) would tell me that. On 2/1/21 at 1:13 p.m., an interview was conducted with Licensed Practical Nurse (LPN) P who was currently working on the unit with Resident #26. When asked about her current status, LPN P stated, Today we scheduled her [MEDICATION NAME]. We also discontinued her [MEDICATION NAME] and the [MEDICATION NAME], because it can cause symptoms of anorexia (lack of loss of appetite for food). When asked how they normally dispensed prn medication to her, LPN P stated, You have to ask her. You have to ask her how she's feeling, and when she says she's nauseous you have to ask her if she wants the medication. She's not a resident who will ask you. I really have to take my time giving her her meds. There are underlying issues, and unfortunately they couldn't be taken care of as fast as they should have been, mostly due to COVID.

This citation pertains to MI# 34 Based on interview and record review, the facility failed to check blood sugar level in a known diabetic with a significant change of condition in 1 (#101) of 5 sampled residents resulting in Resident #101 having a decreased level of consciousness and being unresponsive to stimuli and was transferred to the hospital with a critical elevated blood sugar over 600. Findings Include: Record review of facility SBAR (Situation, Background, Assessment, Recommendation) program binder on 9/26/14 revealed a 'Physical Assessment' guideline dated 2/2013, which noted: "The following protocols must be followed prior to contacting the physician for transport orders. All facilities will utilize the SBAR communication process and the adopted Interact communication tools. #3.) Care Paths for decision making related to dehydration, Urinary Tract Infection [MEDICAL CONDITION], mental status change.........critical care paths will be placed at each nursing station for reference. Under the procedure section of the guideline #1.) Complete a head to toe assessment. (B.) Change in level of consciousness: ....complete an Accu-check (finger stick blood sugar check). Step one: signs and symptoms of changes noted diabetes- any diabetic with altered metal status, or an acute infection with glucose over 300 or less than 70 need immediate notifications to physician. Review of the 'Physician Notification Protocol' under consciousness, altered recommended (3.) Blood sugar if diabetic and urine clarity and color.......any signs or symptoms of infection/illness including dehydration....." Record review of facility care paths for 'Acute Mental Status Change', 'Change in Behavior', 'Dehydration', and 'Urinary Tract Infection' all include finger stick glucose (blood sugar) for a diabetic as a vital sign at the top of the pathway flow protocol. Record review of Resident #101's Minimum Data Set ((MDS) dated [DATE] revealed an [AGE] year old female with severely impaired cognitive abilities never/rarely making decisions. There were no noted behavior symptoms or rejection of care. Urinary assessment noted frequent incontinence. Medical [DIAGNOSES REDACTED]. Record review of Resident #101's nursing progress notes dated 9/21/14 at 12:52 PM revealed 'Resident up in wheelchair at the beginning of this shift (starts at 6:00 AM) resident sleeping with head down. This writer encouraged resident to lift up head. Asked resident several questions with no verbal responses. Resident did accept medications in liquid with cuing and support. Advised staff to lay resident in bed. During assessment resident continued to make no verbal or physical responses. Lung sounds clear, abdomen soft and non-distended, bowel sounds active, pulse rapid 101, blood pressure 110/62, resident afebrile 97.1 with rapid shallow respirations through the mouth noted at 36 per minute. Oxygen saturation 96% on room air..............' There was no documentation of a blood sugar/finger stick check for a known diabetic with a change of condition as stated in their policy. Record review of Resident #101's SBAR communication form dated 9/21/14 by Licensed Practical Nurse (LPN) "D" revealed the change in condition, symptoms, or signs of unresponsiveness started on 9/21/14 at 7:30 AM and the nurse noted a history of diabetes. Vital signs included blood pressure, pulse, respirations, temperature and weight. There was no blood sugar check noted. The LPN "D" noted a decrease in consciousness and unresponsiveness. The LPN "D" noted Resident #101 to have decreased level of consciousness, unresponsive to stimuli and increased weakness and rapid respirations. An interview on 9/26/14 at 11:50 AM with Licensed Practical Nurse "D" revealed that on 9/21/14 when she came to work at 6:00 AM, Resident #101 was up in her wheelchair and dressed for the day with her head tilted forward more than usual. Between 6:30 to 6:45 AM. LPN "D" stated that she got her medication pass started and when she got to Resident #101, she crushed the resident's medication and put in to the two-cal supplement and that it took her 30 minutes to get the resident to drink the liquid. LPN "D" stated that usually Resident #101 took her medications in the two-cal liquid in five minutes or so. LPN "D" stated that Resident #101 made very little eye contact and was difficult to arouse, so she had the Certified Nurse Assistants (CNA) lay the resident down. LPN "D" stated that Resident #101 did not eat breakfast, just the medications in the supplement. The LPN "D" stated that she assessed Resident #101 around 8:30 AM and that there was an elevated pulse, and resident was not responding to any stimuli or to touch, and stated, "Like she was in a deep sleep, lethargic". LPN further added that's how she was in the wheelchair and when the resident was laid down, it became worse. LPN "D" stated that she did not check a blood sugar level on Resident #101 because she did not smell anything fruity. An interview on 9/26/14 at 12:10 PM with Registered Nurse (RN) "E" revealed that LPN "D" had asked her to assess Resident #101 because of a change of condition from when she did medication pass. RN "E" stated that she assessed Resident #101 and wrote the Discharge & Transfer form dated 9/21/4 around 10:30 AM, which did not note a blood sugar check. RN "E" stated that she did not check a blood sugar level because there was no odor or smells from the resident. RN "E" stated that Resident #101 did not respond to verbal stimuli or squeeze her fingers. Record review of Resident #101's Emergency Medical Services (EMS) documentation dated 9/21/14 noted onset time of 8:00 AM of unresponsiveness. EMS noted as protocol, take the blood sugar and that one was not done prior to their care. EMS noted taking a blood sugar level with a reading of "High" on glucometer. Record review of Resident #101's emergency room record dated 9/21/14 at 12:04 PM noted glucose over 500 and lab drawn glucose at 12:10 PM of 686. (Normal range is 70-99) Hospital HbA1C (long range blood sugar level) drawn on 9/22/14 was 8.1 (normal range 3.6- 6.8). Record review of the American Diabetes Association ' Hyperosmolar Hyperglycemic Nonketoti[DIAGNOSES REDACTED]' edited 12/2013, (HHNS) is a serious condition frequently seen in older persons with diabetes. Warning signs included blood sugar level over 600, dry parched mouth, warm dry skin that does not sweat, sleepiness or confusion....HHNS only occurs when diabetes is uncontrolled. If HHNS continues severe dehydration will lead to coma and death. (# )

This citation pertains to MI# 34 Based on interview and record review, the facility failed to address specific to monitoring for a change in mental status in 1 (#101) from 5 sampled residents resulting in Resident #101 having a decreased level of consciousness and being unresponsive to stimuli, being hospitalized for [REDACTED]. Findings: Record review of 'Diabetic Hyperglycemic Hyperosmolar Syndrome' by the U.S. National Library of Medicine NIH National Institutes of Health, 6/2012, revealed is a condition of extremely high blood sugar, extreme lack of water (dehydration) and decreased consciousness. Record review of the American Diabetes Association ' Hyperosmolar Hyperglycemic Nonketoti[DIAGNOSES REDACTED]' edited 12/2013, (HHNS) is a serious condition frequently seen in older persons with diabetes. Warning signs included blood sugar level over 600, dry parched mouth, warm dry skin that does not sweat, sleepiness or confusion....HHNS only occurs when diabetes is uncontrolled. If HHNS continues severe dehydration will lead to coma and death. Record review of facility 'Dehydration' policy dated 1/2008, revealed risk factors including refusal of fluids, infection, dependence on staff for provisions of fluids, limited fluid intake, lacking of thirst. Individual assessment clinical signs dry skin or mucous membranes, concentrated urine, poor skin turgor, new on set increased confusion..... Record review of facility SBAR (Situation, Background, Assessment, Recommendation) program binder on 9/26/14 revealed a 'Physical Assessment' guideline dated 2/2013, which noted: "The following protocols must be followed prior to contacting the physician for transport orders. All facilities will utilize the SBAR communication process and the adopted Interact communication tools. #3.) Care Paths for decision making related to dehydration, Urinary Tract Infection [MEDICAL CONDITION], mental status change.........critical care paths will be placed at each nursing station for reference. Under the procedure section of the guideline #1.) Complete a head to toe assessment. (B.) Change in level of consciousness: ....complete an Accu-check (finger stick blood sugar check). Step one: signs and symptoms of changes noted diabetes- any diabetic with altered metal status, or an acute infection with glucose over 300 or less than 70 need immediate notifications to physician. Review of the 'Physician Notification Protocol' under consciousness, altered recommended (3.) Blood sugar if diabetic and urine clarity and color.......any signs or symptoms of infection/illness including dehydration....." Record review of Resident #101's Minimum Data Set ((MDS) dated [DATE] revealed an [AGE] year old female with severely impaired cognitive abilities never/rarely making decisions. There were no noted behavior symptoms or rejection of care by Resident #101. Urinary assessment noted frequent incontinence. Medical [DIAGNOSES REDACTED]. Record review of Resident #101's care plan 'Alteration in ADL (Activity of Daily living)' related to care deficit related to Alzheimer dementia, very limited mobility, non-ambulatory, adult failure to thrive, range of motion deficits bilateral upper/lower extremities, generalized weakness, hospice resident, dated 11/12/13. Approaches included reporting any deterioration in status to physician. Hyper/hypo glycemia care plan dated 7/31/13 related to [DIAGNOSES REDACTED]. Record review of care plan dated 8/7/2013, 'Nutrition/hydration' risk related to Alzheimer ' s disease, diabetes, failure to thrive, mechanically altered diet, poor oral intake, little or no interest in food.....approaches included monitoring food acceptance record (FAR), observe for dry mucous membranes, dry skin, poor turgor. Review of the 'Cognitive' care plan dated 7/31/13 revealed the resident #101 had cognitive deficits, impaired decision making skills and processing skills. In an interview on 9/26/14 at 2:15 PM with Certified Nurse Assistant (CNA) "G" who worked full time revealed that on 9/21/14 she came into work at 6:00 AM and Resident #101 was already up in her wheelchair leaning forward and very sleepy. CNA "G" stated that she also worked the day prior (9/20/14) and that at the end of her shift that day Resident #101 was more tired than usual. On 9/21/14 CNA "G" stated that Resident #101 was leaning more forward than usual in her wheelchair. She took vital signs and Licensed Practical Nurse "D" told her lay the resident down. CNA "G" stated that Resident #101 was toileted and that CNA "H" had to help hold Resident #101 up because the resident would not help at all and did not resist as usual. CNA "G" thought the resident was tired and that her respirations were rapid. CNA "G" stated that Resident #101 could feed herself, but that she would not eat. CNA "G" stated that bedside drinking cups/pitchers are changed/freshened at shift change and that Resident #101 would not drink the bedside water (22 oz. cups). CNA "G" stated that Resident #101 would not drink or ask for water and that the Resident #101 only drank the milk at meals. These would be recorded on the food acceptance record. Record review of Resident #101's 'Daily Food Acceptance Record' for the month of September 2014 revealed that the resident refused or accepted, " Little drink at meals and refused bedtime snacks". It was unclear whether this pattern of minimally drinking and refusing snacks were addressed. An interview on 9/29/14 at 8:25 AM with Licensed Practical Nurse (LPN) "C" who was the infection control person, revealed that urinary tract infection assessment required 3 criteria: change in mental status or change in behaviors, indicate pain , change in character of urine or foul odor of urine. LPN "C" stated that a resident with dementia would have urinary frequency, change urine color, foul odor and a change in mental status. Record review of Resident #101's MDS dated [DATE] revealed an [AGE] year old female with severely impaired cognitive abilities never/rarely making decisions. There were no noted behavior symptoms or rejection of care issues. Urinary assessment noted frequent incontinence. Pain assessment revealed that the resident was unable to answer or indicate pain. The facility Director of Nursing (DON) "B" on 9/26/14 at 1:00 PM stated that there were no "Stop and Watch" early warning tool sheets for Resident #101 on 9/20/14 or 9/21/14 from the CNA's. DON "B" stated that Resident #101 was a diabetic. On May 5, 2014 Resident #101 had her insulin stopped by the physician due to low blood sugars and finger stick blood sugar checks went from daily to weekly. Record review of facility SBAR and the Discharge & Transfer forms dated 9/21/14 did not have a skin turgor assessment nor a mucous membrane assessment. The last skin turgor assessment the facility was able to provide was dated 9/19/14. Record review of Resident #101's emergency room notes dated 9/21/14 at 12:20 PM revealed the resident on physical exam to be obtunded (unresponsive) with dry mucous membranes with abnormal labs. Resident #101 was started on intravenous fluids. Clinical impressions noted hyperosmolar [MEDICAL CONDITION] coma, dehydration, urinary tract infection, [MEDICAL CONDITION]. Resident #101 was admitted to the hospital for treatment. Record review of hospital 'History and Physical' dated 9/21/14 for Resident #101 revealed the resident to be obtunded with labs of BUN 80, glucose of 686 and positive urine analysis. The form noted the resident received 3 liters of intravenous fluids in the emergency room for dehydration. Record review of Resident #101's hospital discharge summary documentation dated 9/24/14 revealed discharge [DIAGNOSES REDACTED]. (# )

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION WHILE EATING A SANDWICH TO ONE COGNITIVELY IMPAIRED RESIDENT (#101) WHO WAS KNOWN BY THE FACILITY TO BE AT RISK FOR ASPIRATION DUE TO IMPULSIVE BEHAVIORS WITH MEALS AND WHO HAD DYSPHAGIA (DIFFICULTY WITH SWALLOWING), OF FIVE RESIDENTS REVIEWED FOR NEEDING ASSISTANCE DURING EATING, OUT OF A TOTAL RESIDENT POPULATION OF 59. THIS FAILURE RESULTED IN RESIDENT #101 REQUIRING THE FACILITY TO PERFORM THE HEIMLICH MANEUVER WHICH PLACED RESIDENT #101 IN IMMEDIATE JEOPARDY TO HIS HEALTH AND SAFETY. RESIDENT #101 died on [DATE] AT 10:45 P.M. FINDINGS INCLUDE: THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON [DATE] AT 3:00 P.M. THE IMMEDIATE JEOPARDY BEGAN ON [DATE] AT APPROXIMATELY 8:00 P.M., WHEN CERTIFIED NURSE AIDE (CNA) "A" FOUND RESIDENT #101 SLUMPED OVER AND CHOKING AFTER HE, CNA "A", HAD GIVEN RESIDENT #101 HALF OF A PEANUT BUTTER AND JELLY SANDWICH TO EAT AND LEFT HIM UNATTENDED TO ANSWER A CALL LIGHT FOR RESIDENT #107. AT THE TIME OF RESIDENT #101'S CHOKING EPISODE, CNA "A" WAS NOT TO HAVE LEFT RESIDENT #101 UNATTENDED PER PHYSICIAN ORDER TO PROVIDE HIM WITH ONE TO ONE (1:1) SUPERVISION. THROUGH THE ABBREVIATED SURVEY INTERVIEW PROCESS FROM [DATE] TO [DATE], IT WAS DETERMINED, PRIOR TO THE INCIDENT, DIRECT CARE STAFF WERE CONCERNED WITH THE POSSIBILITY OF RESIDENT #101 CHOKING, DUE TO HIS FAST EATING, TAKING LARGE BITES OF FOOD, SHOVELING FOOD INTO HIS MOUTH AND A PREVIOUS CHOKING EPISODE. THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON [DATE] AT 3:45 P.M. ON [DATE] AT 4:35 P.M., THE IMMEDIATE JEOPARDY WAS REMOVED WHEN THIS SURVEYOR VERIFIED THE FOLLOWING: - THE POLICY REGARDING RESIDENTS WITH A [DIAGNOSES REDACTED]. FOR VERIFICATION, THE SURVEYOR REVIEWED THE [DATE] REVISED FACILITY POLICY TITLED, "DYSPHAGIA". - ON [DATE], THE REGISTERED DIETITIAN (RD) "Z" REVIEWED THE SPEECH THERAPY RECOMMENDATIONS FOR ALL RESIDENTS diagnosed with [REDACTED]. THE SURVEYOR VERIFIED THE REVIEW AND ASSESSMENT PROCESS BY REVIEWING THE CLINICAL CHARTS OF FIVE SAMPLED RESIDENTS WITH [DIAGNOSES REDACTED].M. AND 12:30 P.M. - ON [DATE], ALL THE NURSES AND CNAS WERE TRAINED ON THE NEW "DYSPHAGIA" POLICY. THIS WAS VERIFIED BY STAFF INTERVIEWS, REVIEWING TRAINING AGENDAS AND STAFF SIGN-IN SHEETS. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE CONTINUES AT A PATTERN LEVEL WITH POTENTIAL FOR MORE THAN MINIMAL HARM DUE TO THE FACILITY'S NEED TO: - ASSESS ALL RESIDENTS TO DETERMINE IF THEY HAVE BEEN EVALUATED FOR SWALLOWING CAPABILITIES AND ARE RECEIVING THE APPROPRIATE MEAL/SNACK ASSISTANCE WHEN NEEDED. - ENSURE ALL RESIDENT CARE PLANS INCLUDE ALL PERTINENT INTERVENTIONS REGARDING SWALLOWING INCLUDING THE TYPE OF STAFF ASSISTANCE NEEDED AND SPECIFIC INTERVENTIONS TO PREVENT CHOKING. - DEMONSTRATE THE STAFF RESPONSIBLE FOR DEVELOPING RESIDENT CARE PLANNING FOR EATING ASSISTANCE ARE COMPETENT IN DETERMINING CARE PLAN INTERVENTIONS FOR ANY SWALLOWING ISSUES AND PREVENTION OF CHOKING. - DEMONSTRATE ALL STAFF HAVE BEEN TRAINED IN THE IMPORTANCE OF SHARING CRITICAL INFORMATION REGARDING THE DINING/EATING NEEDS OF THE RESIDENTS. FINDINGS INCLUDE: THE REVIEW OF THE FACILITY'S [DATE] INCIDENT INVESTIGATION INFORMATION INCLUDING HOSPITAL DOCUMENTS, SHOWED ON [DATE] AT APPROXIMATELY 8:00 P.M., RESIDENT #101 WAS IN HIS WHEELCHAIR IN THE RESIDENT HALLWAY, BEING 1:1 SUPERVISED BY CNA "A". THE FACILITY'S INFORMATION DOCUMENTED RESIDENT #101 HAD FINISHED A HALF OF PEANUT BUTTER AND JELLY SANDWICH AND WAS GIVEN THE SECOND HALF. THE FACILITY'S INVESTIGATION INFORMATION FURTHER SHOWED, CNA "A" THEN ANSWERED RESIDENT #107'S CALL LIGHT AND LEFT RESIDENT #101 UNSUPERVISED WHILE EATING THE REMAINING HALF OF SANDWICH. WHEN CNA "A" LEFT RESIDENT #107'S ROOM AND FOUND RESIDENT #101 SLUMPED OVER AND NON-RESPONDENT, PER THE FACILITY'S INVESTIGATION INFORMATION, CNA "A" IMMEDIATELY CALLED FOR ASSISTANCE FROM REGISTERED NURSE (RN) "Q", WHO THEN PERFORMED THE HEIMLICH MANEUVER. RN "Q" WAS ABLE TO HAVE RESIDENT #101 SPIT/COUGH OUT THE PORTION OF THE PEANUT BUTTER AND JELLY SANDWICH HE HAD ATTEMPTED TO EAT. THE REPORT INFORMATION SHOWED RESIDENT #101 HAD THEN RESPONDED PER HIS NORMAL CONDITION WITH "ONLY SLIGHT RATTLING LUNG SOUNDS". THE [DATE] HOSPITAL DOCUMENTS SHOWED THE AMBULANCE WAS SUMMONED TO THE FACILITY VIA A 911 CALL AND RESIDENT #101 WAS TRANSPORTED TO THE HOSPITAL AND expired on [DATE] AT 10:45 P.M. RESIDENT #101'S CLINICAL CHART FACE SHEET DOCUMENTED HE WAS [AGE] years OLD AND HAD RESIDED AT THE FACILITY SINCE [DATE]. HIS [DIAGNOSES REDACTED]. RESIDENT #101'S [DATE] AND [DATE] MINIMUM DATA SET (MDS) ASSESSMENTS SHOWED HIS COGNITION WAS SEVERELY IMPAIRED BUT HE USUALLY COULD UNDERSTAND WHAT WAS SAID TO HIM AND USUALLY COULD BE UNDERSTOOD WHEN HE TALKED. THE [DATE] CARE PLAN SHOWED HE USED A WHEELCHAIR WITH STAFF ASSISTANCE TO MOVE THROUGH THE FACILITY. THE CARE PLAN SHOWED, DUE TO POOR SAFETY AWARENESS, CONFUSION, USE OF ANTIPSYCHOTIC DRUGS, SOME INTERMITTENT DIZZINESS FROM AN "ADRENAL MASS", AND ATTEMPTS TO STAND AND TRANSFER INDEPENDENTLY, CHAIR AND BED ALARMS WERE BEING USED. THE [DATE] "CARE GUIDE" PORTION OF RESIDENT #101'S CARE PLAN DOCUMENTED HE ATE IN THE ASSISTED DINING ROOM WITH "SET UP" ONLY. NURSES NOTES DATED [DATE] AT 6:46 A.M., SHOWED RESIDENT #101 HAD BEEN EATING A PEANUT BUTTER SANDWICH, "AND WAS NOW HAVING DIFFICULTY BREATHING... RESIDENT (#101) WAS ABLE TO DRINK WATER AND PASS THE PEANUT BUTTER DOWN... ORDERED CXR (CHEST X-RAY) AND SWALLOW STUDY..." THE [DATE] TO [DATE] SPEECH "THERAPIST PROGRESS REPORT AND DISCHARGE SUMMARY" DOCUMENT SHOWED SPEECH AND LANGUAGE PATHOLOGIST (SLP) "Y" CONDUCTED 3 MEAL OBSERVATIONS AT 3 DIFFERENT TIMES OF DAY. THE SPEECH THERAPY REPORT DOCUMENTED "...NO SIGNS OF PENETRATION OR ASPIRATION OBSERVED OVER 3 MEALS AT 3 DIFFERENT TIMES OF DAY. PATIENT IS NOW discharged FROM SKILLED ST (SPEECH THERAPY)... DIET LEVEL MECHANICAL SOFT... PRECAUTIONS: ...ASPIRATION RISK DUE TO IMPULSIVE BEHAVIORS WITH MEALS... DISCHARGE TO SNF (SKILLED NURSING FACILITY) WITH INDEPENDENT DINING." THE NURSES NOTES FOR [DATE] TO [DATE], DOCUMENTED RESIDENT #101'S BEHAVIORS OF AGITATION, REFUSING ASSISTANCE, CONTINUOUS ATTEMPTS OF INDEPENDENT STANDING AND AMBULATING. THE PHYSICIAN'S [DATE] AND [DATE] NOTES DOCUMENTED RESIDENT #101'S INCREASED "RESTLESSNESS" AND ASSESSMENT OF RESIDENT #101'S PAIN INCLUDING A CHANGE IN RESIDENT #101'S PAIN MEDICATION, BELIEVING PAIN MAY BE CAUSING THE INCREASED AGITATION AND RESTLESSNESS. A [DATE] PHYSICIAN ORDER SHOWED RESIDENT #101 WAS TO RECEIVE 1:1 SUPERVISION FROM STAFF AS NEEDED "UNTIL RESIDENT'S (#101) PAIN IS CONTROLLED..." SLP "Y" WAS INTERVIEWED ON [DATE] AT 7:45 A.M. SHE SAID THE "THERAPIST REPORT AND DISCHARGE SUMMARY" DATED [DATE], FOR RESIDENT #101 WAS CORRECT. WHEN ASKED WHY RESIDENT #101 WOULD BE CONSIDERED INDEPENDENT WITH DINING EVEN THOUGH THE SPEECH THERAPY REPORT DOCUMENTED THE PRECAUTION OF ASPIRATION RISK FOR RESIDENT #101 DUE TO "IMPULSIVE BEHAVIORS WITH MEALS", SLP "Y" STATED, HER (SLP "Y") RESPONSIBILITY WAS TO DETERMINE IF RESIDENT #101 HAD ISSUES WITH SWALLOWING AND HE DID NOT BASED ON HER OBSERVATIONS OF THE 3 DIFFERENT MEALS. SLP "Y" WAS ASKED IF BASED ON HER SWALLOWING EVALUATION, RESIDENT #101 COULD EAT INDEPENDENTLY AND ALONE IN HIS ROOM IF HE WANTED TO. SHE SAID, "YES." WHEN SLP "Y" WAS ASKED WHY RESIDENT #101 WAS PUT ON A MECHANICAL SOFT DIET, SHE EMPHASIZED, "NOT BECAUSE OF ANY SWALLOWING ISSUES AND NOT BECAUSE HE DIDN'T HAVE TEETH... THE ONLY REASON HE WAS ON A MECHANICAL SOFT DIET WAS BECAUSE OF HIS MENTAL ISSUES AND SOMETIMES BEING CONFUSED..." SLP "Y" SAID RESIDENT #101 ATE IN THE ASSISTED DINING ROOM NOT FOR ASSISTANCE WITH EATING BUT BECAUSE OF HIS DISRUPTIVE BEHAVIORS. CNA "A" WAS INTERVIEWED ON [DATE] AT 1:45 P.M. HE SAID HE WAS THE STAFF ASSIGNED TO BE 1:1 WITH RESIDENT #101 WHEN THE [DATE] INCIDENT OCCURRED. CNA "A" SAID, "I WASN'T EVEN GONE A MINUTE, ALL (RESIDENT #107) WANTED WAS A CUP OF COFFEE. I CAME OUT OF HIS (RESIDENT #107) ROOM AND (RESIDENT #101) WAS SLUMPED OVER AND HIS COLOR WASN'T GOOD... I IMMEDIATELY CALLED THE NURSE AND WE DID THE HEIMLICH... HE SPIT OUT THE SANDWICH AND (RESIDENT #101) DID AN ASSISTED PIVOT TRANSFER ON TO THE GURNEY AND SEEMED TO BE HIMSELF." WHEN CNA "A" WAS ASKED IF RESIDENT #101 HAD A GLASS OF WATER OR OTHER LIQUID WHEN HE WAS EATING THE SECOND SANDWICH HALF, CNA "A" SAID, "NO, WE DON'T GIVE HIM SOMETHING TO DRINK UNTIL AFTER HE EATS..." ON [DATE] AT 1:30 P.M., RN "Q" WAS INTERVIEWED. SHE STATED SHE WAS THE NURSE WHO RESPONDED IMMEDIATELY TO CNA "A'S" REQUEST FOR A NURSE. RN "Q" EXPLAINED, SHE PERFORMED THE HEIMLICH MANEUVER ON RESIDENT #101 AND "HE RESPONDED BY SPITTING OUT A FAIRLY LARGE PIECE OF MUSHED PEANUT BUTTER AND JELLY SANDWICH..." SHE STATED, "IT WAS MORE THAN A QUARTER PIECE OF THE HALF..." RN "Q" SAID SHE DID NOT THINK RESIDENT #101 REQUIRED SUPERVISION WHILE EATING, BUT DID SAY WHEN A RESIDENT WAS ON 1:1 SUPERVISION, IT MEANT YOU DID NOT LEAVE THE RESIDENT UNATTENDED. LPN "K" WAS INTERVIEWED BY PHONE ON [DATE] AT 11 A.M. SHE STATED SHE WAS THE NURSE ON DUTY FOR RESIDENT #101 AT THE TIME OF THE INCIDENT. LPN "K" STATED AT THE TIME OF THE INCIDENT, RESIDENT #101 WAS ON 1:1 SUPERVISION AND CNA "A" WAS THE STAFF ASSIGNED. LPN "K" EXPLAINED, SHE WOULD HAVE BEEN THE NURSE THAT WOULD HAVE REMOVED THE 1:1 SUPERVISION. BUT, AT THE TIME OF THE INCIDENT, RESIDENT #101 WAS ON THE 1:1 SUPERVISION WITH CNA "A". LPN "Q" SAID, THE 1:1 SUPERVISION MEANT CNA "A", "EVEN THOUGH HE WASN'T GONE LONG," SHOULD NOT HAVE LEFT RESIDENT #101 TO ANSWER RESIDENT #107'S CALL LIGHT. INDIVIDUAL INTERVIEWS WERE CONDUCTED WITH CNA "B", RESTORATIVE CNA "C", CNA "D", CNA "E", CNA "F" AND CNA "G" ON [DATE] AT 2:10 P.M., 12:55 P.M., 2 P.M., 2:45 P.M., 2:40 P.M. AND 2:30 P.M. ALL 6 OF 6 STAFF INTERVIEWED SAID THEY HAD ASSISTED RESIDENT #101 AS HE ATE IN THE ASSISTED DINING ROOM AND THEY HAD TO MONITOR HIS EATING BECAUSE HE "WAS A VERY FAST EATER", "HE INHALED HIS FOOD", AND "HE SHOVELED HIS FOOD AND DRANK VERY FAST." CNA "B" STATED SHE HAD BEEN ASSIGNED ON OCCASIONS TO 1:1 SUPERVISION WITH RESIDENT #101. SHE SAID, "I COULDN'T BELIEVE IT WHEN I HEARD THAT SOMEONE HAD GIVEN HIM A HALF OF PEANUT BUTTER AND JELLY SANDWICH WITHOUT CUTTING IT IN SMALL PIECES... IF HE WAS UPSET OR RESTLESS, AND HE NEVER GAVE YOU ANY WARNING, HE WOULD SHOVE THE WHOLE HALF IN HIS MOUTH IF YOU LET HIM... I ALWAYS CUT THE SANDWICH IN VERY SMALL PIECES... IF YOU CUED HIM TO TAKE ONE (BITE) AT A TIME, HE DID FINE... HE LOVED HIS PEANUT BUTTER AND JELLY SANDWICHES, HE LOVED BANANAS TOO BUT YOU ALWAYS HAD TO MAKE SURE YOU CUT THINGS UP IN SMALL PIECES..." CNA "E" STATED, "(RESIDENT #101) COULD JUST NEVER SIT STILL AND WHEN HE GOT RESTLESS, HE ATE VERY FAST... SOMETIMES I WOULD THINK HE WAS STARTING TO CHOKE, BUT HE WOULD COUGH, CLEAR HIS THROAT AND CONTINUE... WE DID WATCH HIM CLOSELY WHEN HE ATE BECAUSE WE WERE AFRAID HE MIGHT CHOKE..." DURING THE INTERVIEWS WITH THE ABOVE STAFF, THEY WERE ASKED IF RESIDENT #101'S EATING HABITS WERE WRITTEN IN HIS CARE PLAN OR IN THE CNA CARE GUIDES. THE 6 STAFF SAID "NO" THEY DID NOT THINK SO. CNA "B" SAID, "NO, THAT WOULD BE NICE, BUT WE AIDES JUST KNOW BECAUSE WE WORK WITH HIM..." THE INTERVIEWED STAFF WERE ASKED IF THEY HAD TOLD THE NURSING STAFF ABOUT RESIDENT #101'S EATING HABITS. CNA "B" EXPLAINED, "...I FIGURED THE NURSES KNEW HE WAS ON 1:1 SUPERVISION, THEY ASSIGNED US TO HIM... WE (CNAS) KNOW HE WAS PUT ON 1:1 SUPERVISION BECAUSE OF HIS SPONTANEOUS BEHAVIOR CHANGES AND RESTLESSNESS, BUT I THOUGHT (RESIDENT #101'S) EATING HABITS WERE PROBABLY ANOTHER REASON HE WAS PUT ON 1:1 SUPERVISION, BECAUSE WHEN HE GOT RESTLESS WAS WHEN HE WOULD SHOVEL AND EAT FASTER... I NEVER TOLD THE NURSES. HOW COULD THEY NOT KNOW...?" CNA "D" EXPLAINED, "NOW THAT YOU'RE ASKING THE QUESTIONS, WE (CNAS) SHOULD'VE TOLD NURSING STAFF TO MAKE SURE THEY WERE AWARE OF US (CNAS) MAKING SURE (RESIDENT #101) WAS TAKING SMALL BITES OF FOOD AND CUEING HIM TO SLOW DOWN SO HE WOULDN'T CHOKE..." INTERVIEWS WERE CONDUCTED WITH LPN "O" AND LPN "R" ON [DATE] AT 1:50 P.M. AND 10:10 A.M. RESPECTIVELY. A PHONE INTERVIEW WAS CONDUCTED WITH LPN "R". THE CERTIFIED DIETARY MANAGER (CDM) "P" WAS INTERVIEWED ON [DATE] AT 9:05 A.M. THE 3 STAFF INTERVIEWED ALL STATED NOT BEING AWARE OF RESIDENT #101 SHOVELING HIS FOOD OR THAT THE CNAS WERE MAKING SURE HIS FOOD WAS CUT IN SMALL PIECES. CDM "P" SAID SHE HAD NOT OBSERVED RESIDENT #101 EATING FAST AND SHOVELING HIS FOOD. DURING A [DATE], 2:05 P.M. INTERVIEW WITH CNA "A", HE WAS ASKED IF HE WAS AWARE OF RESIDENT #101'S TENDENCIES TO EAT FAST, SHOVEL HIS FOOD AND NEEDING A SANDWICH CUT UP INTO SMALL PIECES. CNA "A" STATED HE DID NOT WORK IN THE ASSISTED DINING ROOM WITH RESIDENT #101 AND WAS NEVER TOLD OF RESIDENT #101'S EATING HABITS OR THE CUTTING OF HIS FOOD. HE SAID, "THAT WOULD'VE BEEN NICE TO KNOW..." THE ADMINISTRATOR WAS INTERVIEWED ON [DATE] AT 3 P.M. SHE SAID, AFTER THE CHOKING INCIDENT ON [DATE], SLP "Y" HAD COMPLETED AN EVALUATION OF RESIDENT #101'S CAPABILITY FOR SWALLOWING AND DETERMINED HE NEEDED NO ASSISTANCE OR SUPERVISION WHEN EATING. THE ADMINISTRATOR EMPHASIZED, "(RESIDENT #101) WAS NOT EATING IN THE ASSISTED DINING ROOM BECAUSE HE NEEDED SUPERVISION WHILE EATING... HE WAS ONLY IN THAT DINING ROOM BECAUSE OF HIS BEHAVIORS..." SHE SAID, "WHEN (CNA "A") WAS SUPERVISING (RESIDENT #101), HE WAS NOT SUPERVISING HIM WITH EATING, JUST BEHAVIORS..." THE ADMINISTRATOR WAS ASKED IF SHE WAS AWARE OF THE CNAS' ("B", "C", "D", "E", "F" AND "G") INFORMATION REGARDING RESIDENT #101'S EATING HABITS, WHEN HE BECAME SPONTANEOUSLY RESTLESS, OF SHOVELING FOOD, EATING VERY FAST AND NEEDING HIS FOOD CUT UP INTO SMALL PIECES; FOODS INCLUDING PEANUT BUTTER AND JELLY SANDWICHES AND BANANAS. THE ADMINISTRATOR SAID, SHE WAS NOT AWARE OF THAT KIND OF ASSISTANCE BEING GIVEN TO RESIDENT #101. ( )