Every finding on record at La Grande Post Acute Rehab

Based on observation, interview and record review it was determined the facility failed to ensure kitchen equipment was clean and sanitary, and dishes were adequately cleaned for 1 of 1 kitchen reviewed. This placed residents at risk of illness and contaminated food. Findings include: The facility's Sanitation Policy dated 10/2008 indicated the following:- Utensils, counters, shelves, and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks, and chipped areas. The facility's Dishwashing Policy dated 10/2/20 indicated the following:- The person assigned to dishwashing should allow all items to air dry prior to storage.1. Observations of the facility's dishwashing process on 7/20/26 from 10:42 AM through 1:11 PM, revealed Staff 9 (Dietary Aide) complete the following:- Put away multiple, visibly wet, serving utensils, cooking pans, and steam table pans away with visible drips of water.- Rinse a steam table pan, which had residual food scraps after being run through the dish washer, and put it away without rewashing or allowing the pan to dry.On 7/20/26 at 1:11 PM Staff 9 confirmed she put the dishes away wet and had not rewashed the pan with food debris. Staff 9 stated she should have rewashed the pan and allowed the dishes to dry before putting them away.On 7/20/26 at 1:23 PM Staff 5 (Dietary Manager) stated the expectation was to rewash dishes that come out of the dishwasher with food debris or was visibly dirty and allow dishes to dry before they were put away due to the risk of developing bacteria.On 7/22/26 at 8:45 AM Staff 18 (Registered Dietician) stated dishes put away wet pose a risk of bacteria development. 2. Observation of the facility's kitchen on 7/19/26 and 7/20/26 between the hours of 10:42 AM and 1:30 PM, revealed the following:- The stainless steel, three-compartment sink had white calcification coating approximately 75% of the sinks' surface, including the sides and faucets. Meat (ground) was observed thawing in a container placed in the sink with cold water running into the container.- The countertops were observed with multiple missing portions of the surface material, one approximately fourteen by one inch and another approximately three by one inch, both of which revealed a wood material with a coating of dark colored, and scrapable material. The area was sticky upon touching.- A slotted steam table pan was observed in the steam table with opaque white stains and two small, slivered, light brown colored stick-like material in the upper left corner. Insulated plate warmer bases were stacked in this pan.- Multiple counter surfaces in and around the kitchen were covered with dust and debris.- Behind the steam table was dust particles and food on the floor and adjacent to the steam table there were dust particles and food splatters on the cabinet and floors?On 7/20/26 at 1:11 PM Staff 9 stated a cleaning list was posted, and she followed the instructions which included daily cleaning of wiping down surfaces and the sink. On 7/20/26 at 1:23 PM Staff 5 (Dietary Manager) and on 7/22/26 at 8:45 AM Staff 18 (Registered Dietician) with Staff 5 were shown the areas of observed concerns. Staff 5 confirmed the areas were unclean but should have been cleaned daily. Staff 5 and Staff 18 stated the white calcification in the sink and damage to the countertops could not be adequately sanitized and were at risk of growing bacteria that could cause foodborne illnesses, especially because meat is thawed in the sinks.

Based on interview and record review it was determined the facility failed to ensure resident records were complete and accurately documented for 1 of 5 sampled residents (#17) reviewed for unnecessary medications. This placed residents at risk for inaccurate health records. Findings include:Resident 17 was admitted to the facility in 3/2024 with diagnoses including a stroke with right side weakness/paralysis and hypertension (high blood pressure). Physician orders dated 5/7/26, 5/8/26 and 6/2/26 indicated Resident 17 was prescribed the following medications: -Cholecalciferol (vitamin D3 supplement) one time a day. -Cranberry oral tablet (supplement) one time a day. -Spironolactone (diuretic) one time a day. -Ascorbic Acid (vitamin C supplement) one time a day. -Multivitamins (supplement) one time a day. -Senna (bowel care) two times a day. -Phenazopyridine (bladder numbing medication) three times a day. A review of Resident 17's 6/1/26 through 7/20/26 MAR indicated medications were not consistently being administered; the MAR was marked 5 indicating medications were being held and to see progress note for details. Medications were not administered and no progress notes were found in Resident 17's health record for the following medications, on the following days: -Cholecalciferol 6/10/26, 7/1/26 and 7/3/26. -Cranberry oral tablet 6/5/26, 6/6/26, 6/10/26, 6/11/26, 6/12/26, 6/24/26, 7/1/26, 7/2/26 and 7/3/26. -Spironolactone 6/3/26, 6/4/26 and 6/5/26. -Ascorbic Acid 6/10/26, 6/11/26, 6/12/26, 6/24/26, 7/1/26 and 7/3/26. -Multivitamins 6/10/26, 6/11/26, 6/24/26, 7/1/26, 7/2/26 and 7/3/26. -Senna 7/3/26 and 7/17/26.-Phenazopyridine 7/17/26. On 7/21/26 at 10:36 AM and 7/23/26 at 8:47 AM, Staff 20 (CMA) stated she held Resident 17's medications on various days for different reasons including the resident being tired, medications drooling from her/his mouth or the resident choking on medications. She reported at times she held some medications so more important medications could be given. Staff 20 reviewed Resident 17's 6/1/26 through 7/20/26 MAR and confirmed she held several of the resident's medications on multiple days. Staff 20 stated she always communicated to the charge nurse any time Resident 17's medications were held and either her or the charge nurse was supposed to write a progress note to explain the reason the resident's medications were held. Staff 20 confirmed there were no progress notes written on the days reviewed. On 7/23/26 at 9:35 AM, Staff 19 (LPN) stated Staff 20 routinely communicated with her when Resident 17's medications were not administered. Staff 19 confirmed there were no progress notes written to explain the reason why Resident 17 was not administered medications on multiple days. Staff 19 stated either she or Staff 20 should write a progress note with a rationale as to why a resident's medication was not administered. On 7/23/26 at 1:42 PM, Staff 2 (DNS) stated she reviewed Resident 17's 6/1/26 through 7/20/26 MAR and health record and confirmed there were many days when medications were not administered and no progress note to explain why. Staff 2 stated in order for Resident 17's health record to be complete and accurate, a progress note needed to be written to provide a rationale as to why Resident 17's medications were not administered.

Based on interview and record review it was determined the facility failed to implement antibiotic stewardship practices for 1 of 1 sampled resident (#5) reviewed for antibiotics. This placed residents at risk for adverse medication effects, inappropriate antibiotic use and potential for development of antibiotic resistance. Findings include: The facility's Antibiotic Stewardship Policy dated 3/2018 instructs the facility to collaborate with providers regarding resident clinical status and current treatment and document clinical rationale to support the use of antibiotics. Resident 5 was readmitted to the facility in 1/2025 with diagnoses including UTI.The 5/24/26 Annual MDS indicated Resident 5 was cognitively intact and was taking an antibiotic.The hospital clinical records dated 1/6/25 revealed Resident 5 was discharged from the hospital with a low dose chronic suppressive therapy using Bactrim (an antibiotic) daily due to four UTIs in four months. A pharmacy recommendation dated 4/27/26 indicated the pharmacist advised the prescriber of the requirement for periodic assessment of prophylactic antimicrobial therapy to minimize the development of potential resistance to the prescribed daily use of Bactrim (an antibiotic). The pharmacist requested the prescriber to verify if the antibiotic order needed to be continued indefinitely and for the provider to provide a brief risk verses benefit assessment to justify the continuation. The prescriber marked yes to continuing the antibiotic but did not include a written justification for the continuance of the medication. Review of the 7/2026 physician orders revealed an order for Bactrim DS Oral Tablet 800-160 MG 0.5 tablet daily.Review of the 7/2026 MAR revealed the antibiotic had been administered daily as ordered. On 7/23/26 at 12:30 PM Staff 14 (Nurse Practitioner) stated he had not been the original prescriber of the antibiotic but continued the medication because the hospital felt it was necessary. Staff 14 stated he had not evaluated the ongoing use and had not documented any justification for continuing the antibiotic.On 7/23/26 at 1:45 PM Staff 3 (Infection Preventionist/RNCM) stated she was unsure why the antibiotic was ordered prophylactically (a preventative measure). She stated she had not reviewed the need to continue the daily Bactrim and acknowledged she should have. On 7/23/26 at 2:00 PM Staff 2 (DNS) stated she thought Staff 14 had provided justification for the ongoing use of the Bactrim however no additional information was provided.

Based on interview and record review it was determined the facility failed to have a process in place to ensure resident rights to execute an advance directive and periodically follow up on preferences for 2 of 2 sampled residents (#s 7 and 19) reviewed for advance directives. Findings include: The facility's advance directive policy dated 1/2025 included the following:- During the admission process, if it is determined that the resident does not have an advance directive and wishes to formulate one, assistance is provided using state specific advance directive forms.- During the development of the initial comprehensive assessment and care plan, quarterly, annually, when significant changes in condition occur, or at the resident's request, discussion and documentation of the resident's choices regarding future health care occurs. A review of the advance directive is included in the discussion. 1. Resident 7 was admitted to the facility 2/2026 with a diagnosis of end stage renal disease. Resident 7's 5/18/26 5-Day Medicare MDS revealed the resident was cognitively intact.A review of Resident 7's clinical record revealed no evidence of an advance directive being discussed or offered to the resident.On 7/19/26 at 4:08 PM, Resident 7 stated she/he didn't know what an advance directive was and was uncertain if staff had ever talked to her/him about one. Resident 7 stated she/he was interested in completing an advance directive to ensure her/his choices and preferences were known and would be honored.On 7/22/26 at 9:43 AM, Staff 4 (Social Services Director) stated he did not offer, explain, or assist residents with completing an advance directive. Staff 4 stated it was the responsibility of Staff 3 (RNCM) to assist residents with advance directives. On 7/22/26 at 10:04 AM, Staff 3 (RNCM) stated she did not do anything with advance directives, but encouraged residents to go over an advance directive with their physicians.On 7/22/26 at 2:22 PM, Staff 1 (Administrator) acknowledged advance directives were not being offered or discussed with residents. Staff 1 stated he expected Staff 4 (Social Services Director) to discuss advance directives upon admission and during quarterly care conferences. 2. Resident 19 was admitted to the facility in 8/2023 with a diagnosis of chronic obstructive pulmonary disease.Resident 19's 5/10/26 Quarterly MDS revealed the resident had moderate cognitive impairment. On 7/20/26 at 8:18 AM, Resident 19 stated she/he didn't know what an advance directive was and was uncertain if staff had ever talked to her/him about one. Resident 19 stated it would be beneficial to have an advance directive and expressed a desire to complete one to ensure treatment preferences were known. On 7/22/26 at 9:43 AM, Staff 4 (Social Services Director) stated he did not offer, explain, or assist residents with completing an advance directive. Staff 4 stated it was the responsibility of Staff 3 (RNCM) to assist residents with advance directives.On 7/22/26 at 10:04 AM, Staff 3 (RNCM) stated she did not do anything with advance directives, but encouraged residents to go over an advance directive with their physicians.On 7/22/26 at 2:22 PM, Staff 1 (Administrator) acknowledged advance directives were not being offered or discussed with residents. Staff 1 stated he expected Staff 4 (Social Services Director) to discuss advance directives upon admission and during quarterly care conferences.

Based on interview and record review it was determined the facility failed to ensure residents with Serious Mental Illness (SMI) diagnoses had PASRR (pre-admission screening/resident review) level II referrals for 1 of 1 resident (# 5) reviewed for PASRR level II screening. This placed residents at risk for unmet mental health needs. Findings include:Resident 5 was admitted to the facility in 5/2024 with diagnoses including anxiety. The diagnosis of PTSD (Post-Traumatic Stress Disorder) was added in 1/2025.The 5/24/26 Annual MDS indicated Resident 5 was cognitively intact and had current active diagnoses of depression, anxiety and PTSD, and PASRR level II screening was marked as not needed. Review of Resident 5's clinical records revealed the following:- The 1/6/25 PASRR level I screening was completed prior to Resident 5's 1/6/25 readmission to the facility and was marked 'no SMI'.- Resident 5 was diagnosed with PTSD on 1/8/25, major depressive disorder on 2/11/25, and adjustment disorder on 11/10/25. No evidence was found that a PASRR level II referral had been submitted after these diagnoses were added.A progress note dated 1/8/26 indicated Resident 5 had a verbal altercation with another resident, where Resident 5 chased the other resident down the hallway, threatening to harm the other resident, because the other resident had given her/him the finger. Review of Resident 5's 6/3/26 care plan revealed the resident had behaviors requiring intervention and psychotropic medication use. The behaviors listed included accusing others, expressing frustration and anger towards others, agitation, and cursing others. On 7/21/26 at 9:56 AM Staff 28 (CNA), 10:21 AM Staff 17 (CNA), 7:00 PM Staff 7 (CNA), 7:29 PM Staff 27 (Agency RN), and on 7/22/26 at 9:47 AM Staff 19 (RN) stated Resident 5 demonstrated behaviors such as verbal aggression towards others, targeting timid individuals especially those of the same gender, and becoming agitated with change or when things did not go her/his way. Staff 7 stated she also observed Resident 5 exhibiting trauma responses to loud noises and nightmares about war. On 7/21/26 at 1:51 PM Staff 4 (Social Services Director) stated he was unaware of what diagnoses were considered SMI and stated his understanding was a PASRR level II was required for a resident with developmental delays or significant cognitive decline. Staff 4 was not aware residents exhibiting SMI in the nursing home setting required PASRR II referrals. Staff 4 confirmed Resident 5 had a PTSD diagnosis and exhibited behaviors, including verbal aggression, perseveration, possessiveness over specific spaces. He confirmed Resident 5 did not have a PASRR level II referral or screening. Staff 4 stated he was still new to the SSD position, and required more training regarding SMI and PASRR level II referrals.0n 7/23/26 at 2:00 PM Staff 1 (Administrator) indicated if the PASRR level 1 screen did not indicate SMI, the resident did not need a PASRR level II screen. After review of diagnoses that were considered SMI, potential for the PASRR level 1 to be marked incorrectly, and the PASRR level II requirements, Staff 1 acknowledged if Resident 5 had PTSD and was exhibiting behaviors and trauma responses a PASRR level II referral may be needed.

Based on interview and record review it was determined the facility failed to provide care and service related to hospice and comfort care and follow physician orders for 2 of 6 sampled residents (#s17 and 33) reviewed for change of condition and medications. This placed residents at risk for unmanaged symptoms, decreased comfort during end-of-life care and adverse side effects. Findings include: 1. Resident 33 was admitted to the facility in 5/2024 with diagnoses including bladder neck obstruction (a blockage or narrowing where the bladder empties into the tube that carries urine out of the body), dementia and palliative care (care focused on relieving symptoms and improving comfort rather than curing illness) and was admitted to hospice services on 10/20/25. Record review indicated the resident had an indwelling urinary catheter for urinary retention and documentation revealed the following: On 5/10/26 night shift (10:00 PM to 6:00 AM) the resident's medical record documented no urinary output. On 5/11/26 day shift (6:00 AM to 2:00 PM) the resident's medical record documented no urinary output. On 5/11/26 evening shift (2:00 PM to 10:00 PM) there was no documentation of the resident's urinary output. There was no documentation found in the resident's medical record of any assessment or interventions, including bladder scan, catheter evaluation, or replacement despite the absence of urinary output. Review of Resident 33's medical record indicated medical transport to the hospital was requested by the family on 5/11/26 at 11:07 PM. Resident 33 was admitted to the hospital on [DATE] with urinary retention. The resident's hospital admission records stated the resident's catheter was found out of place, and 1250 ml of concentrated and odorous urine was drained from the resident's bladder. The catheter was removed and replaced with a new indwelling urinary catheter. On 7/20/26 at 10:35 AM Witness 1 (Family Member) stated they visited Resident 33 several times on 5/11/26 and consistently observed no urine in the collection bag. They reported the resident appeared uncomfortable throughout the day, staff noted earlier vomiting, and hospice was contacted. Witness 1stated the resident's discomfort persisted, and by approximately 10:30 PM, with continued absence of urinary output they requested the resident be sent to the hospital. On 7/23/26 at 8:34 AM Staff 24 (CNA) stated they cared for the resident on the 5/11/26 day shift, noted little to no urinary output, did not recall the resident being uncomfortable. Staff 24 stated they left early and did not document or report the concern. On 7/23/26 at 1:40 PM Staff 10 (CNA) stated they observed little to no urinary output during multiple rounds on the 5/10/26 night shift, reported it to the charge nurse each time, and documented it in the medical record. Staff 10 indicated they did not recall the resident being uncomfortable or having discomfort. On 7/20/26 at 4:12 PM Staff 16 (LPN) described the facility process requiring CNAs to report and document no urinary output, which generated an electronic alert. Nurses were expected to assess bladder status, catheter patency, and notify hospice if applicable. On 7/21/26 at 1:58 PM Staff 13 (Hospice RN) stated they saw Resident 33 on 5/11/26 for a hospice visit due to the resident's vomiting. Staff 13 stated Resident 33 was sick and Witness 1 was concerned. Staff 13 stated they believed they asked facility staff when the resident's urinary collection bag was last emptied but did not remember the response. Staff 13 stated they observed scant urine in the resident's urinary collection bag but did not have concerns regarding the catheter's function and did not examine or palpate Resident 33's bladder. On 7/22/26 and 7/23/26 attempts were made to reach Staff 11 (LPN) and Staff 25 (RN), both night shift nurses but were unsuccessful. On 7/23/26 at 12:47 PM Staff 14 (Nurse Practitioner) stated if a resident had no urinary output for over eight to16 hours, should receive a bladder scan and likely straight catheterization should be performed. Staff 14 stated that while every bladder is different, a volume of 350-400 ml would cause pressure and discomfort, and 1250 ml of urine in the bladder would be uncomfortable. On 7/23/26 at 9:27 AM, Staff 3 (RNCM) stated they expected CNAs to report absent urinary output but were unaware nurses received electronic alerts. Staff 3, who worked the 5/11/26 day shift and requested a hospice nurse due to vomiting, stated they were unaware the resident had no urinary output. Staff 3 acknowledged there was no documentation of urinary output or bladder/catheter assessments on 5/10/26 or 5/11/26 and stated the assessments should have been completed. On 7/23/26 at 9:50 AM, Staff 2 (DNS) stated CNAs were expected to document and report absent urinary output, which also generated an electronic alert to the nurse. Staff 2 said nurses should then assess the bladder, perform a bladder scan, and check catheter patency. Staff 2 acknowledged these assessments were not documented for Resident 33 and stated they should have been completed. 2. Resident 17 was admitted to the facility in 3/2024 with diagnoses including a stroke with right side weakness/paralysis and hypertension (high blood pressure). Resident 17's 5/27/26 physician order instructed staff to administer lisinopril (a medication to treat high blood pressure) in the morning due to hypertension. A review of Resident 17's 6/1/26 through 7/1/26 MARs indicated the resident's lisinopril was not administered on the following dates: -6/3/26, -6/4/26,-6/9/26,-6/13/26 and -7/1/26. On 7/21/26 at 10:36 AM, Staff 20 (CMA) stated she did not administer Resident 17's lisinopril on 6/3/26, 6/4/26, 6/9/26 and 7/1/26 because she thought the lisinopril was supposed to be held when the resident's systolic blood pressure (top number in a blood pressure reading) was less than 100. Staff 20 reviewed Resident 17's physician order and confirmed there were no instructions to hold the resident's lisinopril for systolic blood pressure less than 100. On 7/22/26 at 2:43 PM, Staff 3 (RNCM) reviewed Resident 17's physician order for lisinopril and confirmed there were no instructions to hold the resident's lisinopril if systolic blood pressure was less than 100. Staff 3 stated she expected the resident's lisinopril to be administered per physician orders and if there were concerns with low blood pressure, the physician should have been contacted to determine if parameters were needed.

Based on interview and record review it was determined the facility failed to provide adequate catheter care for 1 of 1 sampled residents (#33) reviewed for catheter care. This placed residents at risk for inadequate catheter management and related complications. Findings include:Resident 33 was admitted to the facility in 5/2024 with diagnoses including chronic kidney disease, bladder neck obstruction (a blockage or narrowing where the bladder empties into the tube that carries urine out of the body).Resident 33's 10/30/25 care plan indicated the resident's indwelling urinary catheter was to be replaced every four to six weeks and as needed.Resident 33's 3/24/26 Physician Orders specified the resident's indwelling urinary catheter was to be replaced every four to six weeks and as needed by hospice or the facility for urinary retention.Review of Resident 33's medical record indicated the following: -The 3/25/26 hospice visit note indicated the resident's catheter was changed.-The resident was due to have a catheter change no later than 5/6/26.-There was no documentation in Resident 33's medical record her/his catheter was changed after 3/25/26. On 5/11/2026 Resident 33 was hospitalized with urinary retention. The resident's indwelling catheter was found to be displaced and was replaced by hospital staff. The resident had 1250 ml of retained urine drained from the bladder at the time of hospitalization. On 7/23/26 at 9:37 AM Staff 3 (RNCM) stated they expected nursing staff to follow physician orders. Staff 3 acknowledged Resident 33's physician orders and care plan for indwelling urinary catheter change frequency had not been followed and should have been followed.

Based on observation, interview and record review it was determined the facility failed to ensure recommendations from dialysis were followed up on and ensure residents' medications were scheduled to avoid missed doses for 1 of 1 sampled resident (#7) reviewed for dialysis. This placed residents at risk for delayed treatment. Findings include: Resident 7 was admitted to the facility in 3/2026 with diagnoses including End-Stage Renal Disease (ESRD) and dependence on renal dialysis.The 5/18/26 5-Day MDS indicated Resident 7 was cognitively intact and received dialysis treatments.a. Resident 7's 7/2026 physician's order revealed the following orders:- The resident left the facility at 11:00 AM three days per week (Monday, Wednesday, and Friday) for dialysis treatments.- Four capsules of Zenpep Oral Capsule Delayed Release Particles 5000-24000 UNIT were ordered to be given to the resident three times a day with meals for the resident's Exocrine Pancreatic Insufficiency (a lack of digestive enzymes to break down food and nutrient absorption).- Two tablets of Sevelamer Carbonate Oral Tablet 800 MG were ordered to be given to the resident three times a day with meals for high phosphorus.Review of Resident 7's 7/2026 MAR revealed the ordered Zenpep and Sevelamer Carbonate were not administered due to the resident being out of the facility on the following days and time:- 7/1/26 12:00 PM - 7/6/26 12:00 PM- 7/8/26 12:00 PM- 7/13/26 12:00 PMReview of Resident 7's clinical record revealed no evidence the facility attempted to augment the medication administration or dialysis time or send the medication with the resident to ensure the medication was administered as ordered. Staff 20 (CMA) stated Resident 7 had not been given the ordered lunchtime Zenpep and Sevelamer Carbonate on days she/he went to dialysis because the two medications were scheduled to be given at 12:00 PM but the resident left for dialysis at 11:00 AM.Staff 3 (RNCM) acknowledged Resident 7's Zenpep and Sevelamer Carbonate were ordered to be administered at 12:00 PM and the resident left for dialysis three days per week at 11:00 AM. Staff 3 confirmed the two medications had not been administered to the resident on dialysis days because the medications would have been washed out during the dialysis process and confirmed no attempts had not been made to change the administration schedules or dialysis times, and the facility did not obtain an order to hold the medications but should have.b. Resident 7's clinical records revealed the following recommendations from dialysis:- The 6/29/26 Dialysis Transfer form revealed a recommendation of a fluid restriction of two liters or less.- The 7/15/26 Dialysis Transfer form revealed a recommendation to maintain fluid restriction at two liters per 24 hours due to gains and fluid pulled had exceeded what they could safely pull.- A 7/15/26 progress note revealed the dialysis clinic called the facility and requested an order change from the primary provider to increase Sevelamer Carbonate from two tablets to three tablets with meals, and an additional two tablets PRN with a large snack.- The 7/17/26 Dialysis Transfer form revealed a change in medical or mental status that included fluid restrictions of 2000 cc per day. Review of Resident 7's physician orders on 7/21/26 revealed there were no current or past orders for fluid restrictions or a requested change to the Sevelamer Carbonate order was made. Resident 7's clinical records revealed no evidence the requested changes were followed up on. On 7/22/26 at 8:47 AM Staff 19 (LPN) confirmed she received the call from the dialysis clinic on 7/15/26 and reviewed the dialysis transfer form the same day. Staff 19 stated she notified Staff 3 (RNCM) and Staff 14 (Nurse Practitioner) by secure messaging on 7/15/26 but had not seen a response back and confirmed no changes were made to the Sevelamer Carbonate order and fluid restrictions were not in the orders. On 7/22/26 at 10:24 AM Staff 3 stated nurses were responsible for reviewing the dialysis transfer forms and then enter the recommendations into the resident's physician's orders. She confirmed she was the nurse who reviewed the 6/29/26 dialysis transfer form but had not followed up on or entered the fluid restriction recommendation into Resident 7's orders. Staff 3 also confirmed Resident 7's record did not reflect the other dialysis clinic recommendations received on 7/15/26 and 7/17/26 were followed up on and no orders were active for fluid restrictions or changes to Sevelamer Carbonate order.

F699: Based on observation, interview and record review it was determined the facility failed to ensure residents who were trauma survivors received trauma-informed care for 1 of 1 sampled resident (#5) reviewed for trauma-informed care. This placed residents at risk for re-traumatization and a decrease in their quality of life. Findings include: The facility's Social Services admission and History policy dated 11/2016 instructed the facility to develop a plan of care to mitigate triggers that may increase potential re-traumatization of residents with a history of trauma.Resident 5 was first admitted to the facility in 5/2024 with diagnoses including anxiety. The diagnosis of PTSD (Post-Traumatic Stress Disorder, mental condition with intense emotional and/or physical reaction after a traumatic event or experience) was added in 1/2025.The 5/24/26 Annual MDS indicated Resident 5 was cognitively intact and had current active diagnoses of depression, anxiety and PTSD. No behaviors or mood concerns were marked as occurring during the assessment review period.Review of Resident 5's clinical records revealed the following:- The resident was diagnosed with the following diagnoses during her/his stay: PTSD on 1/8/25, major depressive disorder on 2/11/25, and adjustment disorder on 11/10/25.- The Social Service admission and History dated 6/15/24 revealed the resident worked as a paramedic, as well as in an emergency department, and was a military veteran. - The 1/6/25 Trauma Informed Care form indicated Resident 5 reported she/he was abused by a stepparent and had a friend who threw things around.- Staff 4 (Social Services) completed Resident 5's 1/7/26 Trauma Informed Care form which revealed Resident 5 did not want to talk about her/his trauma with Staff 4.Resident 5's 6/3/26 care plan revealed there was no observed trauma specific focus. PTSD was observed as a contributing diagnosis for being at risk for nutrition/hydration deficits, ADL self-care performance deficits, and impaired psychosocial well-being, but not what the trauma response was, how PTSD impacted these care areas or interventions to prevent or address trauma responses. On 7/19/26 at 1:25 PM Resident 5 acknowledge she/he had PTSD and other mood related diagnoses but declined to discuss them or his trauma.On 7/21/26 at 9:56 AM Staff 28 (CNA) stated she would know about and how to address a resident's trauma through the care plan and word of mouth. Resident 5 but did not like to talk about the time she/he served in the military. Staff 28 suspected the resident had trauma associated with the military but did not recall seeing anything in the care plan. On 7/21/25 at 10:21 AM Staff 17 (CNA) stated she used the care plan and reports from others to know about a resident's trauma but did not recall seeing anything in Resident 5's care plan specific to trauma. Staff 17 stated she suspected Resident 5 had experienced trauma due to the resident not wanting to talk about being a military veteran and her/his experience as a paramedic but was unsure of the specific trauma or specific trauma related triggers. On 7/21/26 at 7:00 PM Staff 7 (CNA) stated she did not recall specific trauma but had observed possible trauma response. She stated Resident 5 had told her she/he had nightmares about being in the army after the resident had awoken a few times sweating and startled. Staff 7 stated she once saw Resident 5 jump out of her/his wheelchair when someone dropped something that created an explosion-like sound. Staff 7 stated Resident 5 told her that noises that sound like explosions sometimes caused her/him to startle. Staff 7 stated she reported sharing her observations with other nursing staff. She stated she would use the care plan and report from nurses to guide her with trauma care.On 7/21/26 at 1:51 PM Staff 4 stated Resident 5 had PTSD but was unaware of the resident's trauma or known trauma related triggers. He confirmed he had not reviewed the 1/6/25 trauma informed care assessment. Staff 4 stated the resident declined to talk about trauma but suspected the resident had past traumas associated with her/his military experience and losing her/his spouse. Staff 4 stated he was unaware of the reported loud noise trigger and nightmares. He stated he had not added a trauma care plan because he was assuming the resident's traumas but acknowledged he should have care planned the resident's PTSD diagnosis and desire not to discuss the trauma.

Based on interview and record review it was determined the facility failed to ensure residents were free from unnecessary hypoglycemic medications for 1 of 5 sampled residents (#3) reviewed for unnecessary medications. This placed residents at risk for complications related to low blood sugars. Findings include:Resident 3 was admitted to the facility in 10/2021 with diagnoses including diabetes, chronic kidney disease and Alzheimer's/dementia. Resident 3's 5/22/26 physician orders indicated the resident received insulin glargine (long-acting insulin) one time a day. The insulin glargine was to be held if Resident 3's blood sugar readings were less than 100. Resident 3's 7/1/2026 through 7/20/26 MAR indicated the resident received insulin glargine when her/his blood sugar readings were less than 100 on the following days: -7/1/26 with blood sugar reading of 97,-7/8/26 with blood sugar reading of 89 and-7/16/26 with blood sugar reading of 86. On 7/22/26 at 9:24 AM, Staff 19 (LPN) reviewed Resident 3's 7/2026 MAR and confirmed she administered the resident's insulin glargine when her/his blood sugars were less than 100 on 7/8/26 and 7/16/26. Staff 19 stated Resident 3's blood sugars were on the low side for a while and was unsure why she administered the resident's insulin glargine when her/his blood sugars were less than 100. On 7/22/26 at 2:14 PM, Staff 3 (RNCM) stated Resident 3's blood sugars were running low, even after adjusting her/his night-time insulin and the resident should not have received insulin glargine on 7/1/26, 7/8/26 and 7/16/26 when her/his blood sugars were that low.

Based on interview and record review, it was determined the facility failed to ensure appropriate catheter care and treatment was provided in accordance with professional standards of care for 1 of 3 sampled residents (#3) reviewed for catheters. This placed residents at risk for improper catheter care. Findings include:Resident 3 admitted to the facility in 11/2025 with diagnosis including indwelling urethral catheter.Resident 3's 11/2/25 Physician Order indicated to change foley catheter every 4 weeks using an 18 French catheter one time a day.Resident 3's 11/11/25 progress notes revealed the following:-At 6:36 PM Staff 13 (RN) charted she changed Resident 3's foley catheter.-At 8:30 PM Resident 3 requested Staff 12 (RN) to flush her/his catheter. -At 10:40 PM Staff 12 rechecked Resident 3 and observed no urine drainage over the past two hours. Resident 3 had consumed over 400 cc of water since 8:30 PM. The current foley catheter was a size 20 French. On 2/3/26 at 2:59 PM, Staff 12 stated when she attempted to adjust Resident 3's catheter at his/her request due to discomfort, she noticed it was larger than what was ordered by the physician.On 2/3/26 at 3:49 PM, Staff 13 stated she changed Resident 13's catheter using a 20 French because she could not find a size 18 French catheter in the facility. She stated she did not notify anyone at the facility or the provider.On 2/4/26 at 7:58 AM, Staff 3 (DNS) stated physician orders should be followed and acknowledged Staff 13 used the wrong size catheter on Resident 3.The deficient practice was identified as Past Noncompliance based on the following:On 11/12/25, the deficient practice was identified by the facility and was corrected when the facility identified the risk for urethral injury post foley catheter change. The Plan of Correction included: 1. Resident 3 was sent to the ED for evaluation, foley replaced and IV ABX given, and was transported back after ED visit, 2. Other residents who require an indwelling catheter were identified to have the potential risk of a negative outcome if the insertion procedure is not followed per protocol, 3. DNS trained licensed nurses on female catheter insertion and will require two nurses for each catheter insertion for at least 90 days, 4. For shifts with just one nurse, the on-call nurse will be called, 5. Audits by the DNS or Designee will be conducted for each catheter change to ensure that proper procedure was followed, urine return was noted prior to balloon inflation and that urine is draining post insertion, 6. One to one remediation will be done for any negative outcomes, and 7. Any negative findings will be brought to QAPI and reviewed monthly for three months or until resolved.

Based on interview and record review it was determined the facility failed to implement the plan of care for 1 of 3 sampled residents (#2) reviewed for care plans. This placed residents at risk of abuse. Findings include: Resident 2 was admitted to the facility in 5/2024, with diagnoses including stroke. Resident 2's Quarterly MDS dated [DATE] revealed a BIMS score of 13 which indicated she/he was cognitively intact. Resident 2's care plan, revised 2/3/25, indicated she/he had disinhibited sexual behaviors related to touching residents of the opposite gender. Interventions included Resident 2 was to be in line of sight of staff and was not to dine with opposite gender residents. On 4/2/25 at 2:12 PM, Resident 1 stated she/he recalled the incident from 3/25/25. She/he revealed Resident 2 had touched her/his genital area over the clothing on that date. Resident 1 stated Resident 2 was taken away from the dining room by a nurse immediately after the incident. On 4/2/25 at 2:17 PM, Staff 5 (CNA) stated she was Resident 2's assigned CNA on 3/25/25 and was aware Resident 2 had a history of touching other residents inappropriately. Staff 5 stated she was assigned to the dining room for lunch duty and had left the dining room to return another resident to their room and left Resident 2 alone with other residents in the dining room. Staff 5 stated she was gone only for a minute but acknowledged Resident 2 moved very quickly in her/his wheelchair, stating she/he was 20 feet away (from Resident 1), it was that quick. On 4/2/25 at 5:00 PM, Staff 1 (Administrator) acknowledged the facility did not follow Resident 2's care plan related to supervision in the dining room and Resident 2 would be on one to one supervision during waking hours until a more appropriate placement was found.

Based on interview and record review it was determined the facility failed to protect the resident's right to be free from sexual abuse by a resident for 1 of 3 (#1) sampled residents reviewed for abuse. This placed residents at risk for abuse. Findings include: The facility's Investigation of Alleged Sexual Abuse policy, updated 10/2022, defined sexual abuse as non consensual sexual contact of any type with a resident, which included unwanted intimate touching of any kind, especially the breast or perineal area. Resident 1 was admitted to the facility in 8/2024, with diagnoses including multiple sclerosis. Resident 1's Quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated she/he was cognitively intact. Resident 2 was admitted to the facility in 5/2024 with diagnoses including stroke. Resident 2's Quarterly MDS dated [DATE] revealed a BIMS score of 13 which indicated she/he was cognitively intact. On 2/25/25, the facility submitted a FRI to the State Survey Agency which revealed Resident 2 was observed with her/his hand in the genital area of Resident 1, who was seated in her/his wheelchair in the facility's dining hall. Resident 2 was immediately taken to her/his room and Staff 1 (Administrator) initiated an investigation. On 4/2/25 at 2:12 PM, Resident 1 stated she/he recalled the incident from 3/25/25. She/he revealed Resident 2 had touched her/his genital area over the clothing on that date. Resident 1 stated Resident 2 was taken away from the dining room by a nurse immediately after the incident. She/he denied that she/he was afraid of Resident 2, confirmed she/he had seen Resident 2 since the incident and there was always staff present with Resident 2 in the dining room or hallways. Resident 1 confirmed she/he felt safe and wanted to remain living in the facility. On 4/2/25 at 2:17 PM, Staff 5 (CNA) was observed to provide 1:1 supervision for Resident 2. She stated she was Resident 2's assigned CNA on 3/25/25 and was aware Resident 2 had a history of touching other residents inappropriately. Staff 5 stated she was assigned to the dining room for lunch duty and had left the dining room to return another resident to their room. When she came back to the dining room, Resident 2 had already been taken out of the dining room. Staff 5 stated she was gone only for a minute but acknowledged Resident 2 moved very quickly in her/his wheelchair, stating she/he was 20 feet away (from Resident 1), it was that quick. On 4/2/25 at 2:56 PM, Staff 3 (Dietary Manager) stated he was working in the kitchen on 3/25/25 and was told by the cook something was going on in the dining room. Staff 3 walked into the dining room and observed Resident 2 sitting in her/his wheelchair next to Resident 1, who was seated in her/his wheelchair facing the kitchen. Staff 3 stated Witness 3 (facility resident) was yelling and told him Resident 2 had her/his hand all the way up Resident 1's thigh. Staff 4 (LPN) had entered the room the same time as Staff 3 and removed Resident 2 from the dining room. Staff 3 then spoke to Resident 1, who stated she/he was okay. Staff 3 stated there were no other CNA or staff in the dining room when the incident occurred. On 4/2/25 at 3:22 PM, Witness 3 (facility resident) stated she was in the dining room on 3/25/25 and it was just her, Resident 1 and Resident 2. She decided to stay in the dining room with Resident 1 and was seated at a different table. Witness 3 observed Resident 2 go to Resident 1's table and talked to her/him, then leaned toward Resident 1, who told Resident 2 to leave her/him alone. Resident 2 then moved closer in to Resident 1 and Witness 3 observed her/him put her/his hand up Resident 1's pants leg. Witness 3 stated Resident 1 then said no, no, go away to Resident 2, who still had her/his hand on Resident 1's upper leg area. Witness 3 started yelling at Resident 2 to stop and for help and stated staff immediately came to the dining room. Witness 3 stated a CNA had been assisting Resident 1 with eating but had left to take someone to their room when the incident occurred. On 4/2/25 at 3:52 PM, Staff 4 (LPN) stated she worked on 3/25/25 day shift, was at the nurse's station and heard yelling from the dining room. She ran down to the dining room and observed Resident 2 facing the kitchen doors seated right next to Resident 1. Staff 4 did not observe any physical contact and stated she could tell Resident 1 was distressed by her/his voice and facial expression. She stated another resident in the dining room was yelling. She noted Resident 2 was cognitively intact and had a smirk on her/his face when she came into the dining room. She stated she told Resident 2 she was going to take her/him to their room and the resident was agreeable. Resident 2 was observed in her/his room on 4/2/25 at 2:08 PM and 3:45 PM. Resident 2 was unavailable for an interview. On 4/2/25 at 5:00 PM, Staff 1 (Administrator) was advised of the investigative findings. He stated Resident 2 would remain on one to one supervision during waking hours until a more appropriate placement was found.

Based on observation, interview and record review it was determined the facility failed to maintain hygienic conditions in the facility's walk-in freezer and failed to store food in a hygienic manner in the freezer and dry storage rooms to maintain freshness and prevent the spread of food-borne illness in 1 of 1 kitchen reviewed for food storage. This placed residents at risk of food-borne illness and cross contamination. Findings include: The facility's October 2017 Food Storage policy indicated: -Food storage areas are to be kept clean at all times; -Dry bulk foods are to be stored in seamless plastic or metal bins with tight-fitting lids; and -Items stored in the freezer are to be kept on shelving above the floor. On 2/10/25 at 12:02 PM, during the initial tour of the facility's kitchen, the following was observed in the walk-in freezer: -A discarded frozen snack cup on the floor under the shelving; -A cardboard case of chocolate health shake cartons stored on the floor; -Discarded plastic wrappers scattered on the floor under and between the shelving units; -A plastic-lined cardboard case of frozen peas and chopped carrots stored with the lid unsealed and open; and -A partial hamburger patty on the floor between the shelving units. In the dry-storage room, the following was observed: -A plastic-lined cardboard box of parboiled rice with the lid unsealed and open. On 2/10/25 at 12:09 PM, Staff 10 (Dietary Manager) acknowledged the food in freezer was not stored properly and the freezer was not cleaned appropiately. Staff 10 stated the dry storage foods were to be stored in closed containers. During a follow-up tour of the facility's kitchen on 2/12/25 at 10:34 AM, a cardboard box of saltine crackers was observed to be stored on the floor of the food storage closet adjacent to the rear kitchen door. Staff 10 acknowledged the storage location of the crackers and stated no food items should be stored on the floor even if they were in boxes. On 2/13/25 at 2:45 PM, Staff 1 (Administrator) stated he expected food to be stored in a sanitary manner with residents' safety in mind.

Based on observation, interview and record review it was determined the facility failed to ensure a system of accurate reconciliation to account for controlled drugs for 1 of 2 sampled medications carts reviewed for medication storage. This placed residents at risk for misappropriation and misplacement of controlled drugs. Findings include: The facility's 1/2023 Storage of Medication and Controlled Medication Storage Policy & Procedure specified the following: - Medications included in the Drug Enforcement Administration Classifications as controlled substances were subject to special handling, storage, disposal and record keeping. A controlled medication accountability record is prepared when receiving inventory of a schedule 2 medication. At each shift change, a physical inventory of all schedule 2 medication was conducted and was documented on the controlled substances accountability record. Resident 15 was admitted to the facility in 8/2024 with diagnoses including amyotrophic lateral sclerosis (a neurological disorder). Resident 15's 2/2025 Physician Orders did not include Morphine (an opioid medication classified as a controlled drug with high potential for abuse and addiction). On 2/11/25 at 12:54 PM, Staff 5 (CMA) and the state surveyor reviewed the narcotic compartment, located inside the medication cart used to store controlled drugs (drugs regulated by the government due to their potential for abuse and addiction). The narcotic compartment contained four bubble pack cards with Resident 15's name and dated 1/31/25. Each card contained 60 half tablets of Morphine 15 mg. Staff 5 stated the Morphine was not entered into and documented on the facility's accountability record. Staff 5 stated Resident 15 did not have a physician order for Morphine, she reported this information to Staff 2 (DNS) and other agency nurses and was waiting on direction for what to do with the drugs. On 2/11/25 at 1:02 PM, Staff 2 stated the proper process for receipt, tracking and reconciliation of controlled drugs was to enter the drug information into the facility's accountability record immediately upon delivery. Staff 2 stated staff who administered medications and utilized the medication carts were expected to count and reconcile the controlled drugs every shift by comparing the bubble pack drug cards to the documentation in the accountability record. At 1:06 PM Staff 2 observed the four bubble packs of Morphine, stated she was unaware they were in the narcotic compartment and indicated the Morphine should have been entered into and documented on the facility's accountability record to ensure the drugs were tracked.

StaBased on observation, interview and record review it was determined the facility failed to ensure drugs and biologicals were secure for 1 of 1 treatment cart and stored under proper temperatures for 1 of 1 medication refrigerator reviewed for medication storage. This placed residents at risk for misappropriation and reduced medication efficacy. Findings include: The facility's 1/2023 Storage of Medication and Controlled Medication Storage Policy & Procedure specified the following: - Medications and biologicals were stored properly to support safe effective drug administration. - Medications requiring refrigeration or temperatures between 36 degrees F and 46 degrees F were kept in a refrigerator with a thermometer to allow temperature monitoring. Do not freeze insulin, if insulin has been frozen, do not use. The CDC's 6/18/24 Storage and Handling of Immunobiologics website, https://www.cdc.gov/vaccines/hcp/imz-best-practices/storage-handling-immunobiologics.html#cdc_report_pub_study_section_2-storage-temperature, specified vaccines licensed for refrigerator storage should be stored at 2 C-8 C (36 F-46 F) and an out-of-range temperature reading should prompt immediate action. The CDC's 7/31/24 Provider's Role: Importance of Vaccine Administration and Vaccine Storage & Handling website, https://www.cdc.gov/vaccines/hcp/storage-handling/providers-role.html specified to carefully select and use the proper vaccine storage units to store vaccines and have a properly calibrated thermometer or temperature recording device inside each storage compartment. a. On 2/11/25 at 11:05 AM, the treatment cart adjacent to the nursing station was unlocked and unattended. At 11:09 AM, Staff 6 (Nursing Student) and Staff 7 (Nursing Student) approached the cart, disinfected the glucometer (device used to obtain blood sugar level), obtained supplies from the top drawer, left the treatment cart and walked down the hallway. The treatment cart was left unlocked and unattended and accessible to staff and residents in the area. On 2/11/25 at 11:12 AM, Staff 6 and Staff 7 returned to the cart. Staff 6 acknowledged the cart was left unlocked and stated the treatment cart should have been locked when unattended. The contents of the cart included various types of insulin, needles, scissors and medicated creams, ointments and powders. On 2/12/25 at 1:29 PM, Staff 1 (Administrator) and Staff 3 (Divisional Director of Clinical Operations) were notified the treatment cart was left unlocked and unattended with the contents accessible to unauthorized staff and residents. Staff 3 acknowledged the treatment cart should have been locked when unattended. b. On 2/11/25 at 11:00 AM, Staff 5 (CMA) and the state surveyor reviewed the medication room refrigerator. Upon review, there was no thermometer found inside the refrigerator. When asked how the temperature of the refrigerator was monitored, Staff 5 stated she removed a thermometer from an adjacent empty refrigerator and placed the thermometer into the medication refrigerator for about 20 minutes. Staff 5 retrieved the thermometer from the empty refrigerator and placed it into the medication refrigerator. On 2/11/25 at 11:30 AM, Staff 5 and the state surveyor observed the medication refrigerator thermometer at 26 degrees F. On 2/11/25 at 11:54 AM, Staff 5 and the state surveyor observed the medication refrigerator thermometer at 20 degrees F. On 2/11/25 at 12:00 PM, Staff 2 (DNS) was asked about the process to monitor medication refrigerator temperatures and stated it was the CMA's responsibility. Staff 2 was notified of the out-of-range medication refrigerator temperatures and stated she would recheck it. On 2/11/25 at 12:53 PM, Staff 5 and the state surveyor observed the medication refrigerator thermometer at 26 degrees F. On 2/11/25 at 3:38 PM, Staff 5 and the state surveyor observed the medication refrigerator thermometer at 26 degrees F. Staff 5 stated she would continue to adjust the refrigerator temperature until the end of her shift. The contents of the medication refrigerator included: - insulin - lorazepam liquid (anti-anxiety medication) - Ozempic (used to manage type 2 diabetes) - denosumab (used to treat bone loss) - tuberculin (used to diagnose tuberculosis) - latanoprost eye drops (used to treat eye pressure) - Trulicity (used to treat type 2 diabetes) - estradiol patches (used to treat menopause symptoms) - influenza vaccine - formoterol fumarate inhalation solution (used to treat lung disease) - liquid urine controls box - Covid 19 vaccines - respiratory synctial virus vaccine On 2/12/25 at 8:02 AM, Staff 5 and the state surveyor observed the medication refrigerator thermometer at 32 degrees F. Staff 5 stated she checked the medication refrigerator temperatures until midnight on 2/11/25 and stated the temperatures were all over the place and was even in the 50's. On 2/12/25 at 9:10 AM, Staff 9 (Pharmacist) stated the recommended temperature range for refrigerated drugs and biologicals was between 35 degrees F and 45 degrees F. Staff 9 was notified of the out-of-range temperatures and provided with the list of drugs and biologicals observed inside the refrigerator. Staff 9 stated it was determined the refrigerated drugs were compromised by the fluctuating and potentially freezing temperatures and would need to be removed from the refrigerator and destroyed. Staff 9 stated it was best practice to maintain a thermometer inside the refrigerator to accurately monitor the temperatures. On 2/12/25 at 1:29 PM, Staff 1 (Administrator) and Staff 3 (Divisional Director of Clinical Operations) were notified of the findings of this investigation. Staff 1 and Staff 3 acknowledged the refrigerator temperatures were out-of-range for an extended period of time and the drugs' and biologicals' efficacy was compromised.

Based on observation, interview and record review it was determined the facility failed to accommodate residents with wheelchair arm rests in safe and proper cleanable order for 1 of 2 sampled residents (#86) reviewed for environment. This placed residents at risk for lack of a clean, safe homelike environment and personal equipment in disrepair. Findings include: On 2/10/25 at 3:28 PM, Resident 86's left wheelchair arm rest was observed with the black surface covering torn and cracked with exposed uncleanable cloth foam. The surface was in disrepair and uncleanable. Record review of the facilities maintenance log dated 12/5/24 to 2/10/25 revealed no reports of Resident 86's or any resident's wheelchair arm rests in poor condition. On 2/11/25 at 12:26 PM Staff 13 (CNA) stated if a resident's wheelchair equipment needed repairs, the staff were to write the concerns in the maintenance log. On 2/11/25 at 1:42 PM, Staff 14 (Maintenance Director) stated staff were to write in the maintenance log when a resident's wheelchair needed repair. Staff 14 confirmed no reports were documented in the maintenance log to repair Resident 86's wheelchair arm rests. Staff 14 confirmed Resident 86's wheelchair arm rests were in poor condition and needed replaced. On 2/11/24 at 1:50 PM Staff 1 (Executive Director) confirmed Resident 86's wheelchair arm rests were in poor condition and not cleanable. Staff 1 stated he expected residents to have safe and cleanable wheelchairs.

Based on interview and record review it was determined the facility failed to implement an antibiotic stewardship program for 1 of 1 facilities reviewed for infection control. This placed residents at risk for unnecessary and/or prolonged use of antibiotic medications. Findings include: A review of safety with infection control was performed which included a review of the facilities antibiotic stewardship program. There was no indication of the existence of an antibiotic stewardship program. On 2/13/25 at 12:02 PM, 12:51 PM, and 1:11 PM Staff 3 (Divisional Director of Clinical Operations) stated Staff 2 (DNS) was the current Infection Preventionist, but Staff 2 was out of the facility. Staff 3 stated she was unaware of the existance of an antibiotic stewardship program in the facility. Staff 3 stated four current residents received antibiotics but was unable to verify if the residents were being monitored appropriately for the continued use of an antibiotic. Staff 3 stated Staff 2, Staff 9 (Phamacist), the Executive Director, and the Medical Director should be involved in a monthly review of antibiotic use and confirmed these meeting had not occurred.

Based on interview and record review it was determined the facility failed to follow bowel care physician orders for 1 of 5 sampled residents (#10) reviewed for medications. This placed residents at risk for constipation care needs. Findings include: The facility's Bowel Protocol Policy, updated 2018, revealed each resident was placed on a daily bowel monitoring program. The licensed nurse reviewed the bowel monitoring daily. If a resident did not have a bowel movement for three days, the nurse was to administer the physician ordered bowel program or the facility specific PRN medication bowel program. Resident 10 was admitted to the facility in 5/2024 with a diagnoses including pain. Resident 10's 12/1/24 Quarterly MDS indicated she/he was cognitively intact. Resident 10's 1/2025 Physician Orders directed staff to administer the following bowel care medications PRN for constipation: - Senna Oral Tablet; every 24 hours as needed. - Miralax Oral Powder; every 24 hours as needed. - Milk of Magnesia (MOM) Oral Suspension; if resident does not have a bowel movement for three days. - Bisacodyl Suppository; if no results from MOM, administer per physician order on next shift. - Fleet Enema; if no results from supplement, give the next shift. - Sodium Phosphates Rectal Enema; as needed daily. Review of Resident 10's 1/10/25 through 1/31/25 bowel records revealed she/he did not have a bowel movement on the following dates: 16, 17, 18, 19, 20 and 24, 25, 26, 27 and 28. Review of Resident 10's 1/2025 MAR revealed no PRN bowel care medications for constipation were administered on the 16, 17, 18, 19, 20 and 24, 25, 26, 27 and 28 dates. On 2/10/25 at 12:41 PM, Resident 10 expressed she/he experienced long periods of time without a bowel movement and staff had not addressed the constipation. On 2/13/25 at 10:52 AM, Staff 3 (RN/ Divisional Director of Clinical Operations) confirmed Resident 10 did not have PRN medications administered per the facility protocol for bowel care. Staff 3 acknowledged she would expect bowel care protocol to be followed.

Based on interview and record review it was determined the facility failed to inform residents of the risks and benefits of psychotropic medication use for 2 of 5 sampled residents (#s 7 and 10) reviewed for medications. This placed residents at risk for being uniformed of psychotropic medication. Findings include: 1. Resident 10 was admitted to the facility in 5/2024 with the diagnoses including anxiety. The 5/25/24 Physician Orders revealed an order for Duloxetine (antianxiety) to be administered daily. Resident 10's medical record revealed no evidence of the risk and benefit information for Duloxetine was reviewed with her/him prior to 10/9/24. On 2/13/25 at 11:52 AM, Staff 3 (RN/Divisional Director of Clinical Operations) confirmed Resident 10 was administered Duloxetine from 5/25/24 to 10/9/24. Staff 3 acknowledged Resident 10 was not provided risk and benefit information related to the use of Duloxetine until 10/9/25. Staff 3 stated she would expect the risk and benefit information provided prior to the administration of Duloxetine. 50928 2. Resident 7 was admitted to the facility in 10/2021 with diagnoses including Alzheimer's disease and bipolar disorder (a mental health disorder affecting a person's mood, emotions, and ability to function). The 2/12/25 Physician Orders revealed an order for lurasidone (anti-psychotic) and escitalopram (antidepressant) daily. Review of Resident 7's medical record revealed no documentation to indicate the resident was informed in advance of the risks and benefits of lurasidone or escitalopram. On 2/12/25 3:06 PM, Staff 2 (DNS) acknowledged Resident 7 was not informed of the risks and benefits of lurasidone and escitalopram.

Based on observation, interview and record review, it was determined the facility failed to ensure residents were free from accident hazards for 1 of 3 sampled residents (#3) reviewed for accidents. As a result, Resident 3 received a second degree burn. Findings include: Resident 3 was admitted to the facility in 10/2019 with [DIAGNOSES REDACTED]. A 2/8/20 Progress Note written by Staff 7 (RN) indicated Resident 3 was found face down on the floor on top of a fall mat in her/his room. The resident had scooted her/himself over to the wall with the baseboard heater in contact with her/his right abdomen. Staff immediately pulled the resident away from the baseboard heater. Resident 3 denied any pain or injury. There was a visible burn to the resident's abdomen with a fluid filled blister that measured 8.5 inches by 5 inches. The blister ruptured while the resident was back in bed and being cared for. A large amount of golden fluid came out where the blister split. Non-adhesive dressing applied while Witness 6 (Hospice RN) was contacted. The resident was able to perform all range of motion extremities and denied pain or discomfort. The facility's 2/8/20 Event Investigation Report indicated Staff 7 (RN) was called to Resident 3's room to find her/him face down on the floor. Fall mats were on each side of the bed. The resident had scooted her/himself over the baseboard heater. Resident 3's right abdomen was in contact with the baseboard heater. The resident was immediately pulled away from the baseboard heater and transferred back to her/his bed. Vital signs were taken and the resident was able to move all extremities at her/his baseline. Resident 3 sustained a 8.5 inches by 5 inches burn with fluid filled blister. The hospice nurse was contacted after Staff 7 placed non-adhesive gauze onto the burn area. The resident reported attempting to get out of bed after seeing a women in her/his room and was trying to get to her. The Fall Risk Care Plan (reviewed 1/29/20) included the following interventions, the resident's bed was to be in the lowest position; fall mat on both sides of the bed and non-skid socks. The Skin Breakdown Care Plan (reviewed 1/29/20) indicated on 2/8/20, the resident had a second degree burn on her/his abdomen On 2/19/20 at 3:48 PM, baseboard heater temperatures were checked in random resident rooms including the room Resident 3 had resided in (room [ROOM NUMBER]). The top of the baseboard heaters which were located directly below the windows in resident rooms 10, 19, 28 and 33 were noted to be hot to touch. On 2/19/20 at 4:08 PM, baseboard heater temperatures were checked with Staff 6 (Maintenance Director) in random resident rooms. Using a facility laser thermometer, Staff 6 initially pointed the laser thermometer at the front side of the baseboard heaters near the air release vent. When asked to point the thermometer at the top of the baseboard heaters, Staff 6 recorded the temperature at the top of the baseboard heater in room [ROOM NUMBER] to be 127 degrees and room [ROOM NUMBER] to be 124 degrees. There was currently no resident in room [ROOM NUMBER] near the baseboard heater and the resident in room [ROOM NUMBER] near the baseboard heater was not able to get out of bed on her/his own. When asked about the facility baseboard heaters and how they were monitored, Staff 6 stated the facility had a baseboard heater protocol he followed. Baseboard heater checks were completed on a monthly basis using a laser thermometer and documented. The protocol indicated if any of the baseboard heaters were over 150 degrees, he would shut off the heater and problem solve. Staff 6 then stated the monthly audits have not had any temps in excess of 150 degrees and he had not received any reports of the baseboard heaters being too hot. The facility's 7/2008 Baseboard Heater Protocol indicated the Executive Director (ED) and Maintenance Supervisor (MS) were responsible for regulating the thermostat to maintain a safe temperature. Baseboard heaters were checked before use, at the onset of cold weather season. The MS performs random checks no less than daily in the following manner: a. MS placed his/her hand on the outside of the unit. b. If baseboard heater is too hot to touch, the MS verifies the actual temperature by using a Laser thermometer AND recording the temperature in F on the Baseboard Heater Audit Map by room number and date. c. If the temperature is equal to or greater than 150 degrees F, the MS immediately provides for the safety of the resident by turning off the heater. d. MS attempts to correct the temperature Once a week, the MS tests the temperatures of all baseboard heaters by use of a Laser Thermometer AND documented temperature on the Baseboard Heater Audit Map. The EmpRes Healthcare Room and Baseboard Heater Temperature Log was reviewed for 1/2020 and 2/2020. Temperatures were recorded once monthly. Baseboard heater temperatures were all documented to be under 150 degrees. The warmest baseboard heater temperature recorded was on 1/21/20 in room [ROOM NUMBER] and was 124 degrees. On 2/4/20, room [ROOM NUMBER] was recorded as 90 degrees. In an interview on 2/19/20 at 4:20 PM and 2/21/20 at 12:00 PM, Staff 1 (Administrator) stated on 2/8/20, Resident 3 was found by facility staff on the floor in her/his room with her/his front side pressed against the baseboard heater. The resident rolled onto the floor from the right side of her/his bed. Staff intervened and the resident had a second degree burn on her/his right abdomen. According to the facility's investigation the resident was discovered shortly after falling onto the floor. Staff 1 stated the resident was last seen approximately 15 minutes prior to her/his fall. She then stated care plan interventions were in place and followed which included the resident's bed being in the lowest position, bilateral fall mats and a gap of at least 18 inches between the resident's bed and baseboard heater. Staff 1 stated a folding chair was positioned on the right side at the head of the resident's bed and created a gap of at least 18 inches. The chair was between the right side of the resident's bed and wall. She then stated due to the resident being obese, she/he likely rolled onto the baseboard heater during her/his fall. Staff 1 stated this was the first time Resident 3 fell on to the right side of her/his bed as all prior falls were on the left side. Staff 1 was informed of the baseboard heater temperatures in rooms [ROOM NUMBERS] being in excess of 123 degrees and how this created a potential accident hazard by exposing residents to unsafe heating unit surfaces. She reported the maintenance department audited baseboard heater temperatures and was not aware of any being a safety hazard. Staff 1 stated there was a minimum of 18 inch gaps between all resident beds closest to the baseboard heaters. She then stated residents who did not get out of bed and/or were not assessed to be fall risks occupied the beds closest to the baseboard heaters. Any bariatric resident would have his/her bed placed so the foot of the bed would be facing the baseboard heater eliminating the risk of coming into contact with the baseboard heater. Staff 1 reported no other incidents involving residents getting burned by the baseboard heaters. In an interview on 2/20/20 at 9:57 AM, Staff 7 (RN) acknowledged she worked the night shift during the 2/8/20 incident. She stated she was informed by one of the CNAs who found Resident 3 face down on the floor. Staff 7 reported the resident either scooted or rolled onto the baseboard heater and the resident's stomach was directly against the baseboard heater. She stated the resident received a second degree burn approximately 8.5 inches by 5 inches on her/his right abdomen. Initially the resident exhibited no signs or symptom of pain and was actually laughing out when asked about the incident, but later did wince when the burn was being treated. The resident was not hospitalized . Staff 7 stated Resident 3 was on hospice and going through a decline which included experiencing hallucinations. When asked how she/he fell on to the floor, the resident stated she/he saw a women in her/his room near the end of her/his bed and wanted to get closer to her. In an interview on 2/20/20 at 10:45 AM, Witness 6 (Hospice RN) stated she was the on-call hospice RN the weekend of the 2/8/20 incident. She stated she received a call from Staff 7 (RN) informing her of the resident's injury and immediately headed out to the facility. Witness 6 observed the burn and indicated it was 8.5 inches by 5 inches on the resident's right lower abdomen. She stated the burn was rated as a second degree burn that was blistered. At first, the resident did not appear to be in pain, but grimaced when the burn was touched and treated. The resident described it as a burning pain. In an interview on 2/20/20 at 10:52 AM, Staff 12 (CNA) verified she worked the night shift during the 2/8/20 incident. She stated Staff 11 (CNA) informed her Resident 3 was on the floor in her/his room and needed assistance. Staff 12 went into the resident's room and observed the resident on the floor with her/his stomach against the baseboard heater. The resident was rolled off of the baseboard heater and onto the floor. Resident 3 appeared to be in a little bit of pain, but was not screaming or yelling out. Overall, the resident appeared to be in some discomfort. Staff 12 was not aware of the baseboard heaters being hot. In an interview on 2/20/20 at 12:43 PM, Staff 11 (CNA) verified she was the CNA assigned to Resident 3 on the night of 2/8/20. She reported providing incontinence care for the resident around 3:00 AM that morning and left the room with the resident resting comfortably in bed. Approximately 15 minutes later while walking down the hall, she noticed the resident was on the ground against the wall laughing. Staff 11 immediately got help and moved the resident off of the wall. Resident 3 had a burn and blister on her/his stomach area and did not appear to be in any pain. Staff 11 was not aware of the baseboard heaters being hot.

Based on interview and record review, it was determined facility Staff 11 (CNA) failed to meet professional standards by not following the care plan for transfers for 1 of 4 sampled residents (#4) reviewed for accidents. This resulted in Resident 4 sustaining a [MEDICAL CONDITION] after an improper transfer. Findings include: According to the Oregon State Board of Nursing Authorized Duties and Standards for Certified Nursing Assistants: [PHONE NUMBER] (1) (d) Follow the care plan as directed by the licensed nurse; (j) Apply safety concepts in the workplace . Resident 4 was readmitted to the facility 3/27/17, with [DIAGNOSES REDACTED]. The care plan dated 12/2016 revealed the resident was an Extensive Two person mechanical lift transfer. The incident report dated 3/18/17 revealed Staff 11 (CNA) heard Resident 4 crying because she/he wanted to lay down. Staff 11 looked for another staff to help with the transfer but no staff were available. Staff 11 transferred Resident 4 out of her/his wheelchair and into bed by himself and used the mechanical lift. The report indicated the mechanical lift tipped over during the transfer and Resident 4 fell on to her/his left side on the floor. The resident sustained [REDACTED]. Staff 11's 3/18/17 written statement revealed he had the resident on the sling trying to transfer the resident to the bed and the mechanical lift tipped over on one side and Resident 4 landed on the floor. Staff 11 reported the incident to the charge nurse and called another CNA to help. On 5/18/17 at 9:47 am, Witness 1 (Former Administrator) indicated on 3/18/17 he received a report there was a fall involving Staff 11 and Resident 4. He investigated the fall and determined the transfer was done by one CNA and the care plan directed staff to use two CNA's for the transfer. They suspended the CNA immediately for not following the care plan. Refer to F323

Based on observation, interview and record review it was determined the facility failed to prepare food in a form designed to prevent choking for 5 of 8 sampled residents (#s 1, 2, 3, 4 and 10) reviewed for food service. The facility failed to provide Resident 1 with appropriately moist foods and the resident had a choking incident and died . Residents 2, 3, 4 and 10 were identified as at risk for choking and were served meals which were not modified to meet their assessed needs. The facility did not ensure foods were cut up and liquids were thickened appropriately to prevent choking. The facility's failure to prepare appropriate meals resulted in an Immediate Jeopardy situation. Findings include: 1. Resident 1 was admitted to the facility in February 2016 for rehabilitative care. At the time of the resident's discharge in March 2016, the resident's ordered diet was a mechanical soft diet, with extra gravy and sauces, and no bread products to facilitate swallowing due to choking incidents. Resident 1 was readmitted to the facility on [DATE] for respite hospice care. The resident was identified by the facility as at risk for choking, requiring supervision and a soft diet with gravies as appropriate. On 7/27/16 Resident 1 died at the facility following a choking incident. According to facility records and facility staff interviewed from 9/1/16 to 9/8/16 regarding the incident, Resident 1 was served a meal that was prepared inconsistently with her/his ordered diet as it did not have any type of gravy to create extra moisture. The resident was served a whole burrito with no gravy, sauces or condiments. On 9/1/16 at 12:49 pm Staff 5 (Dietary Manager) stated Resident 1's order for gravies as appropriate meant the resident was to receive sauces appropriate to the specific food served, which included sour cream and salsa. On 9/2/16 at 9:38 am Staff 9 (RD) stated Resident 1's burrito should have had some type of sauce on it due to the resident's order for gravies as appropriate. On 9/2/16 at 10:44 am Witness 3 (Visitor) stated she/he was present and sat next to Resident 1 while dinner was served on 7/27/16. Witness 3 described the meal as a whole burrito that was bulky with a soft tortilla shell. Witness 3 stated the steam had already dissipated and the burrito was gummy, chewy and tough. Witness 3 stated the resident began to eat independently and then choked. Witness 3 alerted staff to the resident's choking. Staff attempted to clear the resident's airway, but were unsuccessful and the resident died . See F-224. 2. Resident 4 was admitted in August 2016 with [DIAGNOSES REDACTED]. Physician diet orders dated 8/2/16 indicated Resident 4 was on a dysphagia (swallowing disorder) advanced diet and food was to be cut up into pieces half inch or smaller in size. The Nutritional Evaluation dated 8/15/16 indicated Resident 4 was on a dysphagia level three diet and food was to be cut up into pieces half inch or smaller in size due to risk for chewing and swallowing difficulties related to recent neck surgery. Resident 4's meal ticket indicated everything was to be cut in bite size pieces. On 9/1/16 at 12:23 pm staff 5 (Dietary Manager) delivered Resident 4's lunch tray, placed the meal ticket next to her/him and walked away. Resident 4's meal included a whole piece of cake approximately 3x3 inches in size. On 9/1/16 at 12:28 pm Staff 5 returned to resident 4's table and was shown the meal ticket and the whole piece of cake. Staff 5 confirmed Resident 4's food was not cut up into bite size pieces. 3. Resident 10 was admitted in August 2016 with [DIAGNOSES REDACTED]. The 8/29/16 Nutrition Evaluation signed by Staff 9 (RD) further identified the resident had a history of [REDACTED]. Staff 9 further documented, Shared with kitchen staff that this also includes bread, dessert, vegetables etc. until further notice. On 9/1/16 at 11:57 am Resident 10 was in the Assisted Dining Room. The resident was served lunch and the diet card on the tray clearly identified cut up into bite size . beverages NT (nectar thick). One of the beverages served was not thickened and the meal consisted of a whole cheese biscuit and piece of cake. At 12:02 pm Staff 15 ( Resident Care Manager/RCM) was asked to observe the beverage and she reported the contents had separated and needed to be stirred. Staff 16 (CNA) confirmed the biscuit and cake were not cut into bite size pieces. On 9/1/16 at 5:45 pm Resident 10 was in the Assisted Dining Room. The resident was served supper by nursing staff. One of the beverages served was not thickened throughout and had a watery texture of about one and a half inches on top. At 5:51 pm Staff 15 was asked to observe the beverage and she confirmed the contents had separated and needed to be stirred. 4. Resident 2 was admitted in 2014 with [DIAGNOSES REDACTED]. The 2/22/16 Nutrition Evaluation completed by Staff 9 (RD) identified the resident required nectar thick fluids to prevent aspiration. The July 2016 physician orders [REDACTED]. On 9/1/16 at 11:47 am the resident was in the Assisted Dining Room. Resident 2 was served lunch and one of the beverages served was not nectar thickened as the physician prescribed. At 11:52 am Staff 15 (RCM) confirmed the beverage was not prepared in the correct consistency. 5. Resident 3 was admitted in May 2016 with [DIAGNOSES REDACTED]. An 8/15/16 Nutrition Note signed by Staff 9 (RD) included a review of diet history textures and supplements with specifics to help resident to cut up food. The plan was to continue with diet as ordered. On 9/1/16 at 12:15 pm, Resident 3 was served lunch and the meal card identified cut up into bite size. The resident was served a whole biscuit and whole piece of cake. At 12:22 pm Staff 17 (CNA) confirmed Resident 3's food was not cut up. 6. On 9/2/16 at 1:20 pm after consultation with State agency survey managers, the survey team informed Staff 1 (Administrator) the failure to prepare meals that were consistent with the assessed needs of Residents 1, 2, 3, 4 and 10 constituted an Immediate Jeopardy situation. The survey team requested a plan of correction be developed and implemented by the facility to immediately protect the residents from serious harm. On 9/2/16 at 2:50 pm Staff 1 stated he was in the process of training staff in preparation for the evening meal. On 9/2/16 at 3:21 pm the plan of correction submitted by the facility was not accepted and corrections were requested. On 9/2/16 at 3:55 pm Staff 9 (RD) showed the survey team a supply of commercially-prepared pre-thickened drinks and stated the facility would begin using those drinks instead of serving thickened liquids prepared by facility staff. During meal observations on 9/2/16 from 6 pm to 7 pm there were no observations of residents receiving inappropriate meals. Staff were observed cutting food for residents and checking meal cards to assure residents received the appropriate meal. At 6:32 pm Staff 2 was observed to check a meal order for a newly admitted resident, prior to the meal being served to the resident. On 9/2/16 at 8:51 pm a plan of correction was provided by the facility that ensured resident safety regarding providing appropriate meals. It was reviewed and approved by the survey team and the Immediate Jeopardy was abated on 9/2/16 at 8:58 pm. The plan of correction included: - A new process involving double and triple checks put in place to assure residents received appropriately modified diets. - Diet orders would be reviewed for new residents prior to their first meal in the facility. - Diet orders would be reviewed at daily clinical meetings and weekly dietitian meetings. - Oversight of the new process provided by facility administration. - Purchase orders for commercially-prepared pre-thickened liquids. - In-service records indicating staff were trained on: - Use of thickened liquids - Modified Diets - New diet order process No concerns were observed during the evening meal on 9/2/16 and the lunch meal on 9/7/16. See F-224

Based on observation, interview and record review it was determined the facility failed to prevent neglect of care for 6 of 9 sampled residents (#s 1, 2, 3, 4, 6 and 10) reviewed for providing appropriately modified diets and First Aid choking interventions for residents at risk for aspiration. Resident 1 was served a meal that was inconsistent with assessed needs and contributed to a choking incident and an obstructed airway. Residents 2, 3, 4 and 10 were served a meal that was inconsistent with their assessed needs and were placed at risk for aspiration and choking. Resident 1 did not receive adequate First Aid interventions for choking prior to the resident's death. Resident 6 had a coughing/choking incident and did not receive appropriate First Aid interventions which placed Resident 6 at risk for an obstructed airway. The facility's failure to ensure food was appropriately prepared prior to being served and provide appropriate First Aid interventions resulted in an Immediate Jeopardy situation and was determined to be Substandard Quality of Care. Findings include: The facility's Abuse, Neglect, and Misappropriation of Resident Property Prohibition policy stated, Each resident has the right to be free from . neglect . The policy defined Neglect as, Failure to provide . services necessary to avoid physical harm . 1. Residents 1, 2, 3, 4 and 10 were served a meal that was inconsistent with their assessed needs. a. Resident 1 was admitted to the facility in February 2016 for rehabilitative care. At the time of the resident's discharge in [DATE], the resident's diet order was a mechanical soft diet, with extra gravy and sauces, and no bread products to facilitate swallowing due to choking incidents. Resident 1 was readmitted to the facility on [DATE] for respite hospice care. The resident's [DATE] hospice care plan indicated the resident was swallowing impaired and included a directive of Do Not Resuscitate (DNR). A [DATE] diet order indicated Resident 1 was to receive a soft diet with gravies as appropriate. Resident 1's [DATE] ADL Plan of Care indicated the resident was to receive supervision while eating. On [DATE] Resident 1 died at the facility following a choking incident. An Event Investigation regarding Resident 1's death, signed on [DATE] by Staff 1 (Administrator) and Staff 2 (DNS) revealed Witness 3 (Visitor) informed staff that Resident 1 might be choking during dinner. Staff 7 (CMA) and Staff 3 (CNA) began to assist the resident to clear her/his airway. Staff 4 (LPN) and Witness 5 (Agency LPN) were called to the dining room and assisted the resident to her/his room where they attempted to suction food from the resident's airway, but were unsuccessful, and the resident stopped breathing and died . The investigation concluded that abuse was not identified as the resident received an appropriate meal and staff acted appropriately to attempt to assist (Resident 1) to clear (her/his) airway. The investigation included statements by Staff 3, Staff 6 (CNA also present in the dining room during the incident), Staff 5 (Dietary Manager) and Staff 4, but did not include statements from Witness 3, Staff 7 or Witness 5. Staff 5's written statement indicated the resident received a burrito with salsa and sour cream on top, and did not receive lettuce or tomato due to the resident's soft diet and directions in the facility's recipe book. Staff 4's written statement indicated the resident's dinner meal was not appropriate as it did not have any type of sauce, and included chopped (not shredded) lettuce and tomatoes. The facility's [DATE] recipe book indicated residents on a soft diet were able to receive a burrito with sour cream, salsa and shredded lettuce. During interviews from [DATE] to [DATE] Staff 3, Staff 4, Staff 6, Staff 7, Witness 3 and Witness 5 all stated there was no type of sauce present on the burrito served to Resident 1, which was contrary to Staff 5's statement and the resident's diet order. Staff 3, Staff 4, Staff 7 and Witness 3 all stated the resident was also served a salad, which was also contrary to Staff 5's statement. On [DATE] at 12:49 pm Staff 5 stated Resident 1's order for gravies as appropriate meant the resident was to receive sauces appropriate to the specific food served, which included sour cream and salsa. On [DATE] at 9:38 am Staff 9 (RD) stated Resident 1's burrito should have had some type of sauce on it due to the resident's order for gravies as appropriate. On [DATE] at 10:44 am Witness 3 (Visitor) stated she/he was familiar with Resident 1 from the resident's previous stay at the facility. Witness 3 stated she/he was present on [DATE] and sat next to Resident 1 while the meal was served to the resident by Staff 6 (CNA). Witness 3 described the meal as a whole burrito that was bulky. Witness 3 stated the steam had already dissipated and the burrito was gummy, chewy and tough. Witness 3 told Staff 6, (Resident 1) can't eat that. Staff 6 indicated the meal was consistent with the resident's meal ticket. Witness 3 again told Staff 3 the meal was not appropriate for the resident and Staff 3 stated, They (Dietary Staff) wouldn't send it down if (Resident 1) couldn't have it. Witness 3 stated, I should have thrown it into the garbage. Witness 3 stated the resident began to eat independently and then choked. b. Resident 4 was admitted in [DATE] with [DIAGNOSES REDACTED]. Physician diet orders dated [DATE] indicated Resident 4 was on a dysphagia (swallowing disorder) advanced diet and food was to be cut up into pieces half inch or smaller in size. The Nutritional Evaluation dated [DATE] indicated Resident 4 was on a dysphagia level three diet and food was to be cut up into pieces half inch or smaller in size due to risk for chewing and swallowing difficulties related to recent neck surgery. Resident 4's meal ticket indicated all food was to be cut into bite size pieces. On [DATE] at 12:08 pm Resident 4 was seen in the dining room wearing a soft neck brace and was overheard stating her/his food was supposed to be cut up because she/he might choke. On [DATE] at 12:23 pm Staff 5 (Dietary Manager) delivered Resident 4's lunch tray, placed the meal ticket next to her/him and walked away. Resident 4's meal included a whole, uncut, piece of cake approximately 3x3 inches in size. On [DATE] at 12:28 pm Staff 5 returned back to Resident 4's table and was shown the whole piece of cake. Staff 5 stated she did not cut up the cake because it would have dried out and Resident 4 would tell staff when she/he wanted to have her/his food cut up. On [DATE] at 12:29 pm Resident 4 stated she/he never asked staff to cut up her/his food. c. Resident 10 was admitted in [DATE] with [DIAGNOSES REDACTED]. The [DATE] Nutrition Evaluation signed by Staff 9 (RD) further identified the resident had a history of [REDACTED]. Staff 9 further documented, Shared with kitchen staff that this also includes bread, dessert, vegetables etc. until further notice. On [DATE] at 11:57 am Resident 10 was in the Assisted Dining Room. The resident was served lunch by nursing staff and staff walked away. The diet card on the tray clearly identified cut up into bite size .beverages NT (nectar thick). The resident began to eat independently. One of the beverages served was not thickened and the meal consisted of a whole cheese biscuit and whole piece of cake. At 12:02 pm Staff 15 (Resident Care Manager/RCM) was asked to observe the beverage and she reported the contents had separated and needed to be stirred. Staff 16 (CNA) confirmed the biscuit and cake were not cut into bite size pieces. On [DATE] at 5:45 pm Resident 10 was in the Assisted Dining Room. The resident was served dinner by nursing staff and staff walked away. One of the beverages served was not thickened throughout and had a watery texture of about one and half inches on top. The resident began to eat independently. At 5:51 pm Staff 12 was asked to observe the beverage and she confirmed the contents had separated and needed to be stirred. d. Resident 2 was admitted in 2014 with [DIAGNOSES REDACTED]. The [DATE] Nutrition Evaluation completed by Staff 9 (RD) identified the resident required intermittent assistance to eat and nectar thick fluids to prevent aspiration. The [DATE] physician orders [REDACTED]. On [DATE] at 11:47 am the resident was in the Assisted Dining Room. Resident 2 was served lunch by nursing staff and staff walked away. One of the beverages served was not nectar thickened as the physician prescribed. At 11:52 am Staff 15 (RCM) confirmed the beverage was not served in the correct consistency and sometimes the resident ate and drank independently. e. Resident 3 was admitted in [DATE] with [DIAGNOSES REDACTED]. The [DATE] Nutrition CAA identified the resident was noted to eat food very fast and was at risk for choking due to her/his eating practices and history of delayed swallow. The resident received therapy, transitioned to an oral diet, and on [DATE] the feeding tube was discontinued. Dietary instructions included to cut up food and nectar thick fluids. On [DATE] the resident's fluid texture was changed to regular thin liquids. An [DATE] Nutrition Note signed by Staff 9 (RD) included a review of diet history textures and supplements with specifics to help resident to cut up food. The plan was to continue with diet as ordered. On [DATE] at 12:15 pm, Resident 3 was served lunch by Staff 17 (CNA) and she walked away. The meal card identified cut up into bite size. The resident was served a whole biscuit and whole piece of cake. At 12:22 pm Staff 17 (CNA) stated the resident was able to request foods when desired and cut up means mostly (her/his) meats. Staff 17 did not consider the whole biscuit or whole cake to require bite size pieces. 2. According to the Medic Basic First Aid for Adults Student Guide 2010 (copyright 2015) directs interventions for Foreign Body Airway Obstruction (Choking) including with a mild blockage, a person can speak, cough or gag .encourage someone with a mild blockage to cough forcibly .when a severe blockage occurs, a person cannot dislodge the object on his own .signs .include lack of sound, inability to speak or cough forcefully .stand behind person .reach around and locate navel .make a fist with other hand and place thumb side against the abdomen, just above navel and below ribs. Grasp fist with other hand. Quickly thrust inward and upward into abdomen .Repeat (abdominal thrusts, also known as the [MEDICATION NAME] Maneuver) Each thrust needs to be given with intent of expelling object. Continue until person can breathe normally. If person becomes unresponsive, carefully lower to ground .begin CPR starting with compressions. Look in mouth for an object before giving rescue breaths. Remove any object if seen. a. None of the written statements provided by staff involved in Resident 1's [DATE] choking incident (Staff 3 (CNA), Staff 4 (LPN) and Staff 6 (CNA)) indicated abdominal thrusts were attempted. On [DATE] at 5:31 pm Staff 2 (DNS) stated she was present during the choking incident and acknowledged abdominal thrusts were not attempted. When asked why abdominal thrusts were not performed, Staff 2 stated Resident 1 was on hospice and stated, How far do you go with heroic measures? On [DATE] at 8:57 am Witness 4 (Certified Medic CPR/First Aid Trainer) stated staff were trained according to the Medic Basic First Aid for Adults manual and were to respond to a choking resident by encouraging the resident to cough if the resident was able to cough, and by performing abdominal thrusts if the resident's airway was blocked. Asked how staff were to respond to a DNR status resident who was choking, Witness 4 stated staff would still perform abdominal thrusts and stated, At that point they (the resident) are not dead. Asked if patting a resident on the back or raising a resident's arms over their head while choking were appropriate, Witness 4 stated those methods were appropriate for a choking infant, but were not taught as interventions for choking adults. Witness 4 stated patting on the back could potentially force the blockage to be drawn tighter into the airway creating a severe blockage. On [DATE] at 10:06 am Witness 5 (Agency LPN) acknowledged abdominal thrusts were not performed during Resident 1's choking incident and described the lack of performing abdominal thrusts as, Probably a lapse in judgment. Witness 5 stated there was some discussion after the incident about the fact that abdominal thrusts could have been performed. On [DATE] at 10:44 am Witness 3 (Visitor) stated she/he sat next to Resident 1 during dinner on [DATE]. Witness 3 stated the resident began to eat and then choked. Witness 3 alerted staff to the resident's choking and Staff 7 (CMA) rubbed the resident's back. Witness 3 then told Staff 3 (CNA) to get the nurse and Staff 4 (LPN) arrived shortly after. On [DATE] at 11:20 am Staff 6 (CNA) stated facility staff patted Resident 1 on the back during the choking incident in an attempt to assist the resident while the resident coughed. Staff 6 stated she helped residents who choked by patting them on the back if they were able to cough. On [DATE] at 11:52 am Staff 7 stated she was not aware of Resident 1 receiving abdominal thrusts during the choking incident. On [DATE] at 1:02 pm Staff 2 acknowledged there was no indication staff performed abdominal thrusts during Resident 1's choking incident. When asked about her role as the RN during the choking incident, Staff 2 stated she was there for support and confirmed she did not intervene to ensure appropriate First Aid was provided. b. On [DATE] at 6:00 pm Resident 6, a long term resident, was observed in the main dining room seated in a wheelchair at the table eating dinner. The resident suddenly began coughing and choking. Staff 3 and Staff 10 (CNAs) approached the resident, raised and held both her/his arms over her/his head and repeatedly patted the resident on the back. Another staff member paged the charge nurse to the dining room. Staff 14 (CNA) approached, Staff 3 and 10 stopped patting the resident on the back, released her/his arms to the resident's sides, and the three CNAs repositioned the resident in the wheel chair. Resident 6 stopped coughing, the charge nurse arrived and determined the resident had resumed normal breathing. On [DATE] at 6:15 pm Staff 2 (DNS) stated First Aid training for staff was provided in [DATE]. She was informed of the CNAs' response to Resident 6's choking incident. Staff 2 said she did not know why they raised the resident's arms and patted the resident on the back. She further stated Did it work? On [DATE] at 8:56 am, Witness 4 (Certified Medic CPR/First Aid Trainer) stated raising arms above the head and patting on the back was not an appropriate intervention for a choking adult. Witness 4 stated patting on the back could potentially force the blockage to be drawn tighter into the airway creating a severe blockage. 3. On [DATE] at 1:20 pm after consultation with State agency survey managers, the survey team informed Staff 1 (Administrator) the failure to provide appropriately prepared meals consistent with the assessed needs of Residents 1, 2, 3, 4 and 10, and the failure to provide appropriate First Aid choking interventions for Residents 1 and 6 constituted an Immediate Jeopardy situation and resulted in Substandard Quality of Care. The survey team requested a plan of correction be developed and implemented by the facility to immediately protect the residents from serious harm. On [DATE] at 2:50 pm Staff 1 stated he was in the process of training staff in preparation for the evening meal. On [DATE] at 3:21 pm the plan of correction submitted by the facility was not accepted and corrections were requested. On [DATE] at 3:55 pm Staff 9 (RD) showed the survey team a supply of commercially-prepared pre-thickened drinks and stated the facility would begin using those drinks instead of serving thickened liquids prepared by dietary staff. During meal observations on [DATE] from 6 pm to 7 pm there were no observations of residents receiving inappropriate meals or choking. Staff cut residents' food and checked meal cards to assure residents received their appropriate meal. At 6:32 pm Staff 2 (DNS) checked a meal order for a newly admitted resident, prior to the meal being served to the resident. On [DATE] at 7:27 pm Staff 11 (LPN) stated if he saw a resident choking he would perform abdominal thrusts to try and clear the resident's airway. On [DATE] at 7:28 pm Staff 12 (CNA) stated if he saw a resident choking he would call for assistance and perform abdominal thrusts. On [DATE] at 8:51 pm a plan of correction was provided by the facility that ensured resident safety related to providing appropriate foods and fluids, and First Aid interventions for choking incidents. It was reviewed and approved by the survey team and the Immediate Jeopardy was abated on [DATE] at 8:58 pm. The plan of correction included: - A new process involving double and triple checks put in place to ensure residents received appropriately modified foods and fluids. - Diet orders would be reviewed for new residents prior to their first meal in the facility. - Diet orders would be reviewed at daily clinical meetings and weekly dietitian meetings. - Oversight of the new process would be provided by facility administration. - Purchase orders for commercially-prepared pre-thickened liquids. - In-service records indicating staff were trained on: - Use of thickened liquids - Modified Diets - New diet order process - First Aid choking interventions No concerns were observed during the evening meal on [DATE] and the lunch meal on [DATE].

Based on observation, interview and record review it was determined the facility staff failed to meet professional standards of practice; Staff #s 1 (Administrator) and 2 (DNS) failed to report a choking incident that preceded the resident's death for 1 of 1 sampled residents (#1) reviewed for death. Staff #s 2 (DNS), 3 (CNA), 4 (LPN), 6 (CNA), 7 (CMA), 10 (CNA) and Witness 4 (Agency LPN) failed to provide adequate First Aid choking interventions according to accepted standards of practice for 2 of 2 sampled residents (#s 1 and 6) reviewed for choking incidents. Facility staff including Staff #s 5 (Dietary Manager), 6 (CNA) and 17 (CNA) failed to ensure an appropriate meal was served to 5 of 8 sampled residents (#s 1, 2, 3, 4 and 10) reviewed for providing appropriately modified diets. Staff failed to provide correct First Aid choking interventions to Resident 1 during a choking incident after staff failed to ensure the resident received a meal that was consistent with assessed needs. Resident 1 did not receive abdominal thrust interventions when it was determined the resident's airway was obstructed. Resident 1 died . The facility did not report Resident 1's choking incident or death to the appropriate Stage agency. Resident 6 was observed coughing and choking. Staff failed to provide correct First Aid choking interventions which placed the resident at risk for severe airway obstruction. Staff failed to ensure meals provided to Residents #s 2, 3, 4 and 10 were appropriately prepared to avoid risk of choking. The facility's failure to ensure residents received appropriate meals, apply appropriate First Aid choking interventions and report incidents of neglect to the appropriate Stage agency resulted in an Immediate Jeopardy situation. Findings include: According to the Standards and Scope of Practice for the Licensed Practical Nurse and Registered Nurse, the Scope of Practice Standards for Registered Nurses includes, Implementing treatments and therapy, appropriate to the context of care, including emergency measures . Conduct Derogatory to the Standards of Nursing includes, Failing to take action to preserve or promote the client's safety based on nursing assessment and judgment . Neglecting a client. The definition of neglect includes, but is not limited to, carelessly allowing a client to be in physical discomfort or be injured . Failing to report actual or suspected incidents of client abuse through the proper channels in the work place and to the appropriate state agencies . Failing to conform to the essential standards of acceptable and prevailing nursing practice. According to the Standards and Authorized Duties for Certified Nursing Assistants and Certified Medication Aides, the Authorized duties and Standards for Certified Nursing Assistants includes, Tasks associated with maintaining environment and client safety. Conduct Unbecoming a Nursing Assistant includes, Neglecting a client. The definition of neglect includes but is not limited to unreasonably allowing a client to be in physical discomfort or be injured. According to the Medic Basic First Aid for Adults Student Guide 2010 (copyright 2015) directs interventions for Foreign Body Airway Obstruction (Choking) including with a mild blockage, a person can speak, cough or gag .encourage someone with a mild blockage to cough forcibly .when a severe blockage occurs, a person cannot dislodge the object on his own .signs .include lack of sound, inability to speak or cough forcefully .stand behind person .reach around and locate navel .make a fist with other hand and place thumb side against the abdomen, just above navel and below ribs. Grasp fist with other hand. Quickly thrust inward and upward into abdomen .Repeat (Abdominal Thrust.) Each thrust needs to be given with intent of expelling object. Continue until person can breathe normally. If person becomes unresponsive, carefully lower to ground .begin CPR starting with compressions. Look in mouth for an object before giving rescue breaths. Remove any object if seen. 1. Resident 1 was readmitted to the facility on [DATE] for respite hospice care. Resident 1 was identified by facility staff to have a risk of choking, and required a modified diet and supervision while eating. On [DATE] Resident 1 died at the facility following a choking incident. An Event Investigation regarding Resident 1's death, signed on [DATE] by Staff 1 (Administrator) and Staff 2 (DNS) revealed Witness 3 (Visitor) informed staff that Resident 1 might be choking during dinner. Staff 7 (CMA) and Staff 3 (CNA) began to assist the resident to clear her/his airway. Staff 4 (LPN) and Witness 5 (Agency LPN) were called to the dining room and assisted the resident to her/his room and attempted to suction food from the resident's mouth; the resident stopped breathing and died . The investigation concluded that abuse was not identified and the State agency did not need to be notified. On [DATE] at 1:02 pm Staff 2 acknowledged the State agency was not notified of the choking incident or death. 2. a. Resident 1 was readmitted to the facility on [DATE] for respite hospice care. Resident 1 was identified by facility staff to have a risk of choking. On [DATE] Resident 1 died at the facility following a choking incident. According to facility records and staff and witness interviews conducted from [DATE] to [DATE] during survey, Resident 1 began to choke during the evening meal and staff attempted to assist the resident in clearing her/his airway by patting the resident on the back. When the resident was no longer able to breathe staff attempted to suction the object from the resident's mouth, but did not perform abdominal thrusts. Staff terminated the choking interventions due to the resident's Do Not Resuscitate (DNR) directive after the resident was determined to have no pulse or respirations. On [DATE] at 5:31 pm Staff 2 (DNS) stated she was present during the choking incident and acknowledged abdominal thrusts were not attempted. When asked why abdominal thrusts were not performed, Staff 2 stated Resident 1 was on hospice and stated, How far do you go with heroic measures? On [DATE] at 8:57 am Witness 4 (Certified Medic CPR/First Aid Trainer) stated staff were trained according to the Medic Basic First Aid for Adults manual on [DATE], [DATE] and [DATE]. Training records indicate Staff 7 (CMA), Staff 10 (CNA), Staff 3 (CNA), Staff 17 (CNA) and Staff 14 (CNA) were in attendance. Witness 4 stated staff were trained to respond to a choking resident by encouraging the resident to cough if the resident was able to cough, and by performing abdominal thrusts if the resident's airway was blocked. Asked how staff were to respond to a DNR status resident who was choking, Witness 4 stated staff would still perform abdominal thrusts and stated, At that point they (the resident) are not dead. Asked about staff patting residents on the back or having a resident raise their arms over their head while choking, Witness 4 stated those methods were appropriate for a choking infant, but were not taught as interventions for choking adults. Witness 4 further stated patting on the back could potentially force the blockage to be drawn tighter into the airway, creating a severe blockage. On [DATE] at 1:02 pm Staff 2 (DNS) acknowledged there was no evidence that abdominal thrusts were performed during the choking incident on [DATE]. When asked about her role as the RN during the choking incident, Staff 2 stated she was there for support, retrieved supplies for the suction machine and checked the resident's carotid artery for a pulse. Staff 2 confirmed she did not intervene to ensure appropriate First Aid was provided, nor verify the absence of the resident's pulse and blood pressure following the choking incident. b. On [DATE] at 6:00 pm Resident 6, a long term resident, was observed in the main dining room seated in a wheelchair at the table eating dinner. The resident suddenly began coughing and choking. Staff 3 and Staff 10 (CNAs) approached the resident, raised and held both her/his arms over her/his head and repeatedly patted the resident on the back. Another staff member paged the charge nurse to the dining room. Staff 11 (CNA) approached, Staff 3 and 10 stopped patting the resident on the back, released her/his arms to the resident's sides, and the three CNAs repositioned the resident in the wheelchair. Resident 6 stopped coughing, the charge nurse arrived and determined the resident had resumed normal breathing. On [DATE] at 6:15 pm Staff 2 (DNS) stated First Aid training for staff was provided in [DATE]. She was informed of the CNAs' response to Resident 6's choking incident. Staff 2 said she did not know why they raised the resident's arms and patted the resident on the back. She further stated Did it work? On [DATE] at 8:56 am, Witness 2 (Certified Medic CPR/First Aid Trainer) stated raising arms above the head and patting on the back is not an appropriate intervention for a choking adult. Patting on the back could potentially force the blockage to be drawn tighter into the airway creating a severe blockage. There was no rationale for raising arms above the head. 3. a. Resident 1 was admitted to the facility in February 2016 for rehabilitative care. At the time of the resident's discharge in [DATE], the resident's diet order was a mechanical soft diet, with extra gravy and sauces, and no bread products to facilitate swallowing due to choking incidents. Resident 1 was readmitted to the facility on [DATE] for respite hospice care. The resident was identified by the facility as at risk for choking, requiring supervision and a soft diet with gravies as appropriate. On [DATE] Resident 1 died at the facility following a choking incident. According to facility records and facility staff interviewed from [DATE] to [DATE] regarding the incident, Resident 1 was served a meal that was inconsistent with her/his ordered diet as the food did not have any type of gravy to create extra moisture. There was no evidence staff intervened to ensure the burrito had gravy to ensure it was appropriately moist. On [DATE] at 12:49 pm Staff 5 (Dietary Manager) stated Resident 1's order for gravies as appropriate meant the resident was to receive sauces appropriate to the specific food served, which included sour cream and salsa. On [DATE] at 9:38 am Staff 9 (RD) stated Resident 1's burrito should have had some type of sauce on it due to the resident's order for gravies as appropriate. On [DATE] at 10:44 am Witness 3 (visitor) stated she/he was familiar with Resident 1 from the resident's previous stay at the facility. Witness 3 stated she/he was present on [DATE] and sat next to Resident 1 while dinner was served to the resident by Staff 6 (CNA). Witness 3 described the meal as a whole burrito that was bulky with a soft tortilla shell. Witness 3 stated the steam had already dissipated and the burrito was gummy, chewy and tough. Witness 3 saw what was served and told Staff 6, (Resident 1) can't eat that. Staff 6 indicated the meal was consistent with the resident's meal ticket. Witness 3 again told Staff 3 the meal was not appropriate for the resident and Staff 3 stated, They (Dietary Staff) wouldn't send it down if (Resident 1) couldn't have it. Witness 3 stated, I should have thrown it into the garbage. Witness 3 stated the resident began to eat independently and then choked. Witness 3 alerted staff to the resident's choking. Staff attempted to clear the resident's airway, but were unsuccessful and the resident died . b. Resident 4 was admitted in [DATE] with [DIAGNOSES REDACTED]. Physician diet orders dated [DATE] indicated Resident 4 was on a dysphagia (swallowing disorder) advanced diet and food was to be cut up into pieces half inch or smaller in size. The Nutritional Evaluation dated [DATE] indicated Resident 4 was on a dysphagia level three diet and food was to be cut up into pieces half inch or smaller in size due to risk for chewing and swallowing difficulties related to recent neck surgery. Resident 4's meal ticket indicated food was to be cut into bite size pieces. On [DATE] at 12:23 pm Staff 5 (Dietary Manager) delivered Resident 4's lunch tray and placed the meal ticket next to her/him and walked away. Resident 4's meal included a whole piece of cake approximately 3x3 inches in size. On [DATE] at 12:28 pm Staff 5 returned to resident 4's table and was shown the meal ticket and the whole piece of cake. Staff 5 confirmed Resident 4's food was not cut up into bite size pieces. c. Resident 10 was admitted in [DATE] with [DIAGNOSES REDACTED]. The [DATE] Nutrition Evaluation signed by Staff 9 (RD) further identified the resident had a history of [REDACTED]. Staff 9 further documented, Shared with kitchen staff that this also includes bread, dessert, vegetables etc. until further notice. On [DATE] at 11:57 am Resident 10 was in the Assisted Dining Room. The resident was served lunch by nursing staff and staff walked away. The diet card on the tray clearly identified cut up into bite size . beverages NT (nectar thick). The resident began to eat independently. One of the beverages served was not thickened and the meal consisted of a whole cheese biscuit and piece of cake. At 12:02 pm Staff 15 (RCM) was asked to observe the beverage and she reported the contents had separated and needed to be stirred. Staff 16 (CNA) confirmed the biscuit and cake were not cut into bite size pieces. On [DATE] at 5:45 pm Resident 10 was in the Assisted Dining Room. The resident was served dinner by nursing staff and staff walked away. One of the beverages served was not thickened throughout and had a watery texture of about one and a half inches on top. The resident began to eat independently. At 5:51 pm Staff 15 was asked to observe the beverage and she confirmed the contents had separated and needed to be stirred. d. Resident 2 was admitted in 2014 with [DIAGNOSES REDACTED]. The [DATE] Nutrition Evaluation completed by Staff 9 (RD) identified the resident required intermittent assistance to eat and nectar thick fluids to prevent aspiration. The [DATE] physician orders [REDACTED]. On [DATE] at 11:47 am the resident was in the Assisted Dining Room. Resident 2 was served lunch by nursing staff and staff walked away. One of the beverages served was not nectar thick as the physician prescribed. At 11:52 am Staff 15 (Resident Care Manager/RCM) confirmed the beverage was not served in the correct consistency and sometimes the resident ate and drank independently. e. Resident 3 was admitted in [DATE] with [DIAGNOSES REDACTED]. The [DATE] Nutrition CAA identified the resident was noted to eat food very fast and was at risk for choking due to her/his eating practices and history of delayed swallow. The resident received therapy, transitioned to an oral diet, and on [DATE] the feeding tube was discontinued. Dietary instructions included to cut up food and nectar thick fluids. On [DATE] the resident's fluid texture was changed to regular thin liquids. An [DATE] Nutrition Note signed by Staff 9 (RD) included a review of diet history textures and supplements with specifics to help resident to cut up food. The plan was to continue with diet as ordered. On [DATE] at 12:15 pm, Resident 3 was served lunch by Staff 17 (CNA) and she walked away. The meal card identified cut up into bite size. The resident was served a whole biscuit and whole piece of cake. At 12:22 pm Staff 17 (CNA) stated the resident was able to request foods when desired and cut up means mostly (her/his) meats. Staff 17 did not consider the whole biscuit or whole cake to require bite size pieces. 4. On [DATE] at 1:20 pm after consultation with State agency survey managers, the survey team informed Staff 1 (Administrator) the failure to notify the appropriate State agency regarding Resident 1's choking incident and death, perform appropriate First Aid choking interventions and ensure resident received appropriately prepared meals constituted an Immediate Jeopardy situation. The survey team requested a plan of correction be developed and implemented by the facility to immediately protect the residents from serious harm. On [DATE] at 3:21 pm the plan of correction submitted by the facility was not accepted and corrections were requested. On [DATE] at 7:27 pm Staff 11 (LPN) stated if he saw a resident choke he would perform abdominal thrusts to try and clear the resident's airway. On [DATE] at 7:28 pm Staff 12 (CNA) stated if he saw a resident choke he would call for assistance and perform abdominal thrusts. On [DATE] at 8:51 pm a plan of correction was provided by the facility that ensured resident safety regarding performing appropriate First Aid choking interventions. It was reviewed and approved by the survey team and the Immediate Jeopardy was abated on [DATE] at 8:58 pm. The plan of correction included: - A new process involving double and triple checks put in place to assure residents received appropriately modified diets. - All events resulting in death, injury or potential harm to residents would be immediately reported to proper agencies. - In-service records indicating administrative staff reviewed Oregon Administrative Rules regarding abuse. - In-service records indicating administrative staff reviewed the facility abuse prevention policies, including the Event Reporting and Investigation Policy. - In-service records indicating staff were re-trained on First Aid choking interventions on [DATE]. - In-service records indicating staff were trained on: - Use of thickened liquids - Modified diets - New diet order process No concerns were observed during the evening meal on [DATE] and the lunch meal on [DATE]. See F-224

Based on observation, interview and record review it was determined the facility failed to ensure foods and fluids were served in a manner to prevent accidental choking for 5 of 8 sampled residents (#s 1, 2, 3, 4 and 10) who were reviewed for accident hazards. Resident 1 was identified to be at risk for choking and was served a meal which was inconsistent with her/his identified needs as it was not appropriately moist. Resident 1 had a choking incident and died . Residents 2, 3, 4 and 10 were identified as at risk for choking and were served meals which were not modified to meet their assessed needs. The facility did not ensure the food was cut up into bit size pieces and fluids were thickened to prevent choking. The facility's failure to serve appropriate meals resulted in an Immediate Jeopardy situation and was determined to be Substandard Quality of Care. Findings include: 1. Resident 1 was admitted to the facility in February 2016 for rehabilitative care. At the time of the resident's discharge in [DATE], the resident's diet order was a mechanical soft diet, with extra gravy and sauces, and no bread products to facilitate swallowing due to choking incidents. Resident 1 was readmitted to the facility on [DATE] for respite hospice care. The resident was identified by the facility as at risk for choking, requiring supervision and a soft diet with gravies as appropriate. On [DATE] Resident 1 died at the facility following a choking incident. According to facility records and facility staff interviewed from [DATE] to [DATE] regarding the incident, Resident 1 was served a meal that was inconsistent with her/his ordered diet as the food did not have any type of gravy to create extra moisture. There was no evidence staff intervened to ensure the burrito had gravy to ensure it was appropriately moist. On [DATE] at 12:49 pm Staff 5 (Dietary Manager) stated Resident 1's order for gravies as appropriate meant the resident was to receive sauces appropriate to the specific food served, which included sour cream and salsa. On [DATE] at 9:38 am Staff 9 (RD) stated Resident 1's burrito should have had some type of sauce on it due to the resident's order for gravies as appropriate. On [DATE] at 10:44 am Witness 3 (visitor) stated she/he was familiar with Resident 1 from the resident's previous stay at the facility. Witness 3 stated she/he was present on [DATE] and sat next to Resident 1 while dinner was served to the resident by Staff 6 (CNA). Witness 3 described the meal as a whole burrito that was bulky with a soft tortilla shell. Witness 3 stated the steam had already dissipated and the burrito was gummy, chewy and tough. Witness 3 saw what was served and told Staff 6, (Resident 1) can't eat that. Staff 6 indicated the meal was consistent with the resident's meal ticket. Witness 3 again told Staff 3 the meal was not appropriate for the resident and Staff 3 stated, They (Dietary Staff) wouldn't send it down if (Resident 1) couldn't have it. Witness 3 stated, I should have thrown it into the garbage. Witness 3 stated the resident began to eat independently and then choked. Witness 3 alerted staff to the resident's choking. Staff attempted to clear the resident's airway, but were unsuccessful and the resident died . See F-224. 2. Resident 4 was admitted in [DATE] with [DIAGNOSES REDACTED]. Physician diet orders dated [DATE] indicated Resident 4 was on a dysphagia (swallowing disorder) advanced diet and food was to be cut up into pieces half inch or smaller in size. The Nutritional Evaluation dated [DATE] indicated Resident 4 was on a dysphagia level three diet and food was to be cut up into pieces half inch or smaller in size due to risk for chewing and swallowing difficulties related to recent neck surgery. Resident 4's meal ticket indicated food was to be cut into bite size pieces. On [DATE] at 12:23 pm Staff 5 (Dietary Manager) delivered Resident 4's lunch tray and placed the meal ticket next to her/him and walked away. Resident 4's meal included a whole piece of cake approximately 3x3 inches in size. On [DATE] at 12:28 pm Staff 5 returned to resident 4's table and was shown the meal ticket and the whole piece of cake. Staff 5 confirmed Resident 4's food was not cut up into bite size pieces. 3. Resident 10 was admitted in [DATE] with [DIAGNOSES REDACTED]. The [DATE] Nutrition Evaluation signed by Staff 9 (RD) further identified the resident had a history of [REDACTED]. Staff 9 further documented, Shared with kitchen staff that this also includes bread, dessert, vegetables etc. until further notice. On [DATE] at 11:57 am Resident 10 was in the Assisted Dining Room. The resident was served lunch by nursing staff and staff walked away. The diet card on the tray clearly identified cut up into bite size . beverages NT (nectar thick). The resident began to eat independently. One of the beverages served was not thickened and the meal consisted of a whole cheese biscuit and piece of cake. At 12:02 pm Staff 15 (RCM) was asked to observe the beverage and she reported the contents had separated and needed to be stirred. Staff 16 (CNA) confirmed the biscuit and cake were not cut into bite size pieces. On [DATE] at 5:45 pm Resident 10 was in the Assisted Dining Room. The resident was served dinner by nursing staff and staff walked away. One of the beverages served was not thickened throughout and had a watery texture of about one and a half inches on top. The resident began to eat independently. At 5:51 pm Staff 15 was asked to observe the beverage and she confirmed the contents had separated and needed to be stirred. 4. Resident 2 was admitted in 2014 with [DIAGNOSES REDACTED]. The [DATE] Nutrition Evaluation completed by Staff 9 (RD) identified the resident required intermittent assistance to eat and nectar thick fluids to prevent aspiration. The [DATE] physician orders [REDACTED]. On [DATE] at 11:47 am the resident was in the Assisted Dining Room. Resident 2 was served lunch by nursing staff and staff walked away. One of the beverages served was not nectar thick as the physician prescribed. At 11:52 am Staff 15 (Resident Care Manager/RCM) confirmed the beverage was not served in the correct consistency and sometimes the resident ate and drank independently. 5. Resident 3 was admitted in [DATE] with [DIAGNOSES REDACTED]. The [DATE] Nutrition CAA identified the resident was noted to eat food very fast and was at risk for choking due to her/his eating practices and history of delayed swallow. The resident received therapy, transitioned to an oral diet, and on [DATE] the feeding tube was discontinued. Dietary instructions included to cut up food and nectar thick fluids. On [DATE] the resident's fluid texture was changed to regular thin liquids. An [DATE] Nutrition Note signed by Staff 9 (RD) included a review of diet history textures and supplements with specifics to help resident to cut up food. The plan was to continue with diet as ordered. On [DATE] at 12:15 pm, Resident 3 was served lunch by Staff 17 (CNA) and she walked away. The meal card identified cut up into bite size. The resident was served a whole biscuit and whole piece of cake. At 12:22 pm Staff 17 (CNA) stated the resident was able to request foods when desired and cut up means mostly (her/his) meats. Staff 17 did not consider the whole biscuit or whole cake to require bite size pieces. 6. On [DATE] at 1:20 pm after consultation with State agency survey managers, the survey team informed Staff 1 (Administrator) the failure to provide meals that were consistent with the assessed needs of Residents 1, 2, 3, 4 and 10 constituted an Immediate Jeopardy situation and resulted in Substandard Quality of Care. The survey team requested a plan of correction be developed and implemented by the facility to immediately protect the residents from serious harm. On [DATE] at 2:50 pm Staff 1 stated he was in the process of training staff in preparation for the evening meal. On [DATE] at 3:21 pm the plan of correction submitted by the facility was not accepted and corrections were requested. On [DATE] at 3:55 pm Staff 9 (RD) showed the survey team a supply of commercially-prepared pre-thickened drinks and stated the facility would begin using those drinks instead of serving thickened liquids prepared by facility staff. During meal observations on [DATE] from 6 pm to 7 pm there were no observations of residents receiving inappropriate meals or choking. Staff were observed cutting food for residents and checking meal cards to ensure residents received the appropriately prepared meal. At 6:32 pm Staff 2 was observed to check a meal order for a newly admitted resident, prior to the meal being served to the resident. On [DATE] at 8:51 pm a plan of correction was provided by the facility that ensured resident safety regarding providing appropriate meals. It was reviewed and approved by the survey team and the Immediate Jeopardy was abated on [DATE] at 8:58 pm. The plan of correction included: - A new process involving double and triple checks put in place to assure residents received appropriately modified diets. - Diet orders would be reviewed for new residents prior to their first meal in the facility. - Diet orders would be reviewed at daily clinical meetings and weekly dietitian meetings. - Oversight of the new process provided by facility administration. - Purchase orders for commercially-prepared pre-thickened liquids. - In-service records indicating staff were trained on: - Use of thickened liquids - Modified Diets - New diet order process No concerns were observed during the evening meal on [DATE] and the lunch meal on [DATE].

Based on findings establishing Substandard Quality of Care and multiple citations in the areas of Resident Rights, Staff treatment of [REDACTED].#s 1, 2, 3, 4, 6, and 10 it was determined the management team failed to administer facility resources in an effective manner. As a result residents did not receive the necessary care and services to attain or maintain their highest practicable physical, mental and psychosocial well-being. Findings include: Facility administration failed to: 1. Protect residents from neglect of care by ensuring meals were served with appropriate textures and fluid consistencies to meet residents' needs. Refer to F-224. 2. Report a choking incident preceding a resident's death to the State Agency as required. Refer to F-225. 3. Provide appropriate First Aid choking interventions according to acceptable standards of practice. Refer to F-224 and F-281. 4. Ensure residents at risk for choking were served appropriately prepared foods to prevent accidental choking incidents. Refer to F-323 5. Prepare foods in a form designed to prevent accidental choking. Refer to F-365. 6. Ensure a resident's physician, responsible party, facility Medical Director and hospice agency were informed of a choking incident that preceded the resident's death. Refer to F-157.

Based on interview and record review it was determined that facility failed to conduct a thorough investigation and report findings of death to the State agency for 1 of 1 sampled residents (#1) reviewed for death. The failure to conduct a thorough investigation and report findings to the State agency resulted in a lack of corrective actions which placed additional residents at risk for accidents related to choking. This failure resulted in an Immediate Jeopardy situation and was determined to be Substandard Quality of Care. Findings include: The facility's Abuse, Neglect, and Misappropriation of Resident Property Prohibition policy stated, The Center conducts a thorough investigation of allegations of . neglect . in accordance with state and federal regulation. The policy also stated, The Center reports allegations to the state survey and certification agency and appropriate state agency per state regulation. The Center reports investigation findings to the state survey and certification agency and appropriate state agency per state regulation within five working days of the event. Resident 1 was readmitted to the facility on [DATE] for respite hospice care. Resident 1 was identified by facility staff to have a risk of choking, and required a modified diet and supervision while eating. On [DATE] Resident 1 died at the facility following a choking incident. An Event Investigation regarding Resident 1's death, signed on [DATE] by Staff 1 (Administrator) and Staff 2 (DNS) revealed Witness 3 (Visitor) informed staff that Resident 1 might be choking during dinner. Staff 7 (CMA) and Staff 3 (CNA) began to assist the resident to clear her/his airway. Staff 4 (LPN) and Witness 5 (Agency LPN) were called to the dining room and assisted the resident to her/his room and attempted to suction food from the resident's mouth; the resident stopped breathing and died . The investigation concluded that abuse was not identified and the State agency did not need to be notified as the resident received an appropriate meal and staff acted appropriately to attempt to assist (Resident 1) to clear (her/his) airway. The investigation included statements by Staff 3, Staff 6 (CNA also present in the dining room during the incident), Staff 5 (Dietary Manager) and Staff 4, but did not include statements from Witness 3, Staff 7 or Witness 5. The investigation included conflicting statements from staff members regarding the appropriateness of the resident's meal and did not include an analysis of that discrepancy. The investigation included a description of interventions attempted by staff in effort to clear Resident 1's airway. However, the investigation did not identify that the interventions were inconsistent with First Aid training for choking adults as the resident did not receive abdominal thrusts (the [MEDICATION NAME] Maneuver). On [DATE] the State survey team observed four current residents receive meals that were inconsistent with assessed needs. Three residents received food that was not cut up, and one resident did not receive a thickened drink, as required to assist with choking prevention. On [DATE] the State survey team observed one resident receive inappropriate choking interventions during a meal while coughing and choking. Staff patted the resident on the back and raised the resident's arms over her/his head. On [DATE] at 1:20 pm after consultation with State agency survey managers, the survey team informed Staff 1 (Administrator) the failure to complete a thorough investigation of Resident 1's death and report findings to the State agency, resulted in continued deficient practice which placed residents at risk for choking. These findings constituted an Immediate Jeopardy situation and Substandard Quality of Care. The survey team requested a plan of correction be developed and implemented by the facility to immediately protect residents from serious harm. On [DATE] at 3:21 pm the plan of correction submitted by the facility was not accepted and corrections were requested. On [DATE] at 8:51 pm a plan of correction was provided by the facility that ensured resident safety regarding completing thorough investigations and reporting findings to the State agency. It was reviewed and approved by the survey team and the Immediate Jeopardy was abated on [DATE] at 8:58 pm. The plan of correction included: - A new process for investigations which included: - All witnesses would be identified and interviewed. - All witness statements would be analyzed carefully. - Witness statement clarification would be obtained as necessary. - Administrative staff will participate in a training provided by Adult Protective Services. - Oversight by corporate compliance team. - All events resulting in death, injury or potential harm to residents would be immediately reported to proper agencies. - Facility administration will review reportable events with the inter-disciplinary team. - Abuse policies and results of the new processes would be reviewed quarterly with the quality assurance committee. - In-service records indicating administrative staff reviewed Oregon Administrative Rules regarding abuse. - In-service records indicating administrative staff reviewed the facility abuse prevention policies, including the Event Reporting and Investigation policy. On [DATE] at 1:02 pm Staff 2 acknowledged the investigation was not comprehensive and the State agency was not notified of Resident 1's death. See F-224