Every finding on record at Mount Saint Joseph Rehab Center

Based on record review and staff interview, the facility failed to ensure its arbitration agreement contained all necessary information. This had the potential to affect all residents. The facility census was 82. Findings include: Review of the facilities arbitration agreement revealed the agreement did not address the selection of a neutral arbitrator for the arbitration proceedings. Further review of the agreement also revealed it did not address the selection of a neutral venue for arbitration proceedings. The agreement noted Any arbitration conducted pursuant to Article IV (of the admission agreement) shall be conducted at the facility Interview with the Administrator on 04/09/25 at 3:30 P.M. verified the facilities arbitration agreement did not address the selection of a neutral arbitrator or a neutral venue for arbitration proceedings.

Based on record review and staff interview, the facility failed to ensure a follow-up to a pharmacy recommendation for Resident #51 was completed as required. This affected one (Resident #51) of five residents reviewed for unnecessary medications. The facility census was 82. Findings include: Resident #51 was admitted to the facility on [DATE] with diagnoses that included dementia, high cholesterol and insomnia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #51 was severely cognitively impaired and required extensive assistance of one staff person for completing her activities of daily living. Review of the pharmacy recommendation for Resident #51 dated 02/09/24 revealed the facilities contracted pharmacist recommended to a review of Resident #51's ordered anti-psychotic medication examined for appropriate diagnoses and necessity. Review of the physician's response to the recommendation revealed Resident #51's primary care physician requested a Psychiatric evaluation to confirm diagnoses and antipsychotic necessity. Review of both the electronic and hard charts revealed no evidence of a psychiatric evaluation. Interview with the Director of Nursing (DON) on 04/08/25 at 2:30 P.M. verified no psychiatric evaluation was completed as instructed by Resident #51's physician in response to the 02/09/24 pharmacist recommendation.

Based on record review and interview, the facility failed to ensure certified nurse aides (CNAs) received twelve hours of in-services on an annual basis. This affected one (CNA#546) of three CNAs reviewed for employee files. This had the potential to affect all residents. The facility census was 82. Findings include: Record review of CNA#546's employee file revealed a hire date of 12/27/16. Review of the employee file revealed CNA #546 only received eight hours of continuing education in 2024. Interview with the Administrator on 04/10/25 at 12:04 P.M. confirmed the above findings.

Based on record review and interview the facility failed to ensure the physician was notified of an elevated lab value for Resident #5. This affected one resident (#5) of three residents reviewed for infections. The facility census was 69. Findings include: Review of the medical record for Resident #5 revealed an admitted [DATE]. Diagnoses included displaced fracture of cervical vertebra, displaced fracture of clavicle, and osteoarthritis. The resident was discharged to the hospital on 08/27/23. Review of the Medicare-5 Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had severely impaired cognition. The resident required the extensive assistance of two staff for bed mobility, transfers, walking, dressing, and toilet use. Review of physician orders for August 2023 identified orders for a complete blood count (CBC) and basic metabolic panel (BMP) every Friday starting 07/07/23. A Urinalysis (UA) and Culture and Sensitivity (C&S) were ordered on 08/17/23. Review of lab results from 08/04/23 revealed Resident #5's white blood cell count was 11.0 (normal range is 4.0 to 11.0), on 08/11/23 the resident's white blood cell count was 11.3, and on 08/18/23 the resident's white blood cell count had more than tripled to 34.4, indicating the resident had an infection. Review of the nurses' notes dated 08/18/23 at 10:04 A.M. through 08/21/23 at 10:12 A.M. revealed no documented evidence the physician was notified of Resident #5's elevated white blood cell count from 08/18/23. Interview on 10/05/23 at 3:43 P.M. with the Director of Nursing (DON) verified the lack of documented evidence regarding physician notification of the elevated white blood cell count from 08/18/23. This deficiency represents non-compliance investigated under Complaint Number OH00146849.

Based on record review and interview the facility did not ensure Resident #5 was adequately monitored after a change in condition. This affected one resident (#5) of three residents reviewed for change in condition. The facility census was 69. Findings include: Review of the medical record for Resident #5 revealed an admitted [DATE]. Diagnoses included displaced fracture of cervical vertebra, displaced fracture of clavicle, and osteoarthritis. The resident was discharged to the hospital on 08/27/23. Review of the Medicare-5 Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had severely impaired cognition. The resident required the extensive assistance of two staff for bed mobility, transfers, walking, dressing, and toilet use. Review of the Progress Note from 08/18/23 at 9:18 P.M. revealed Resident #5's vital signs were obtained at 8:00 P.M. The resident's blood pressure was 167/59, pulse was 119, respirations 16, temperature was 96.4 degrees Fahrenheit, and the pulse oximeter (pulse ox) was without a number. The physician was called at 8:05 P.M. and informed of the resident's condition. The physical ordered Resident #5 to be sent to the hospital. At 8:10 P.M. an emergency call was placed, and the Emergency Medical Squad (EMS) arrived at 8.15 P.M. and saw the resident with pulse oximetry on his right finger without a figure, at 8.30 P.M. the resident's pulse ox was 97 percent (%). EMS felt it was no longer necessary to take the resident to the hospital. The physician and daughter were notified. The resident was responsive but very lethargic. The next resident assessment was completed on 08/21/23 at 10:12 A.M. Resident #5 was alert and oriented, forgetful at times. There were no complaints of pain or discomfort. No respiratory distress was noted, pulse ox was 97% on room air. Interview 10/05/23 at 3:43 P.M. with the Director of Nursing (DON) verified there were no assessments for Resident #5 after a change of condition was identified on 08/18/23 at 9:18 P.M. until 08/21/23 at 10:12 A.M. This deficiency represents non-compliance investigated under Complaint Number OH00146849.

Based on a record review, staff interview, and facility policy review, the facility failed to ensure an allegation of sexual abuse was reported to the state agency as required. This affected one (#60) of three residents (#5, #6, and #60) reviewed for abuse. The facility census was 64. Findings include: Review of the medical record for Resident #60 revealed an admitted [DATE]. Diagnoses included but not limited to viral hepatitis C, seizures, major depressive disorder, personal history of sex reassignment. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/03/23, revealed the resident had severely impaired cognition. The resident required extensive assistance of two staff for bed mobility and transfers. Further review of the MDS revealed no behaviors were noted during the look back period. Interview on 04/10/23 at 9:12 A.M. with Infection Control Preventionist (ICP) #206 revealed Resident #60 stated that someone came into her room and pleased her. Resident #60 stated that it was not good, but it was good because it has been so long, and she reported it right away. ICP #206 revisited Resident #60 and stated that a lot of people visited her, and she was okay. Interview on 04/10/23 at 8:46 A.M. with Administrator revealed Resident #60 made comments about someone touching her last week to ICP #206 who told the Assistant Director of Nursing (ADON). Administrator and Staff Member #212 investigated and found no need for a self-reported incident (SRI) because it was not true. Interview on 04/10/23 at 2:34 P.M. with Administrator and Staff Member #212 revealed that they did not make an SRI because the Resident #60 stated she made up the story and it did not happen. Review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated 12/10/16, revealed the Administrator or his/her designee will notify Ohio Department of Health (ODH) of an alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident. or Misappropriation of Resident Property and Injuries of Unknown Source as soon as possible, but in no event later than twenty-four (24) hours from the time the incident/allegation was made known to the staff member. This deficiency represents non-compliance investigated under Complaint Number OH00141800.

Based on interview, observation, record review, and facility policy review the facility failed to ensure Resident #54's passive range of motion and splint for the right upper extremity was completed per the occupational therapy recommendation. This affected one resident (Resident #54) of one resident reviewed for use of splints. This had the potential to affect five residents (Resident's #1, #10, #18, #53, #54) that had occupational therapy recommendations for splints. The facility census was 65. Findings include: Review of the medical record for Resident #54 revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 04/27/20 revealed Resident #54 had multiple medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included right hand splint as ordered. There were no interventions regarding passive range of motion to right hand and elbow. Review of the Occupational Discharge Summary dated 04/29/22 and authored by Occupational Therapist (OT) #607 revealed Resident #54 received occupational therapy from 04/01/22 to 04/28/22. The discharge summary recommended a restorative program be established including a restorative range of motion program and a restorative splint and brace program. The summary revealed passive range of motion was to be completed to Resident #54's right hand and elbow and a right-hand splint was to be worn six to eight hours per day as tolerated. Review of the form labeled Therapy Follow-Up Treatment Program, dated 04/29/22, authored by OT #607 revealed Resident #54 had passive range of motion exercises to the right hand and elbow with extended stretch for three to five minutes and right finger and elbow extensions. The form revealed staff was to perform range of motion, cleanse right hand, pat dry, and apply the right-hand splint. The form revealed Resident #54 was to wear the right-hand splint daily, six to eight hours as tolerated. Review of the July 2022 physician orders revealed Resident #54 had an order dated 05/30/20 to apply a right-hand splint and right shoulder brace when out of bed as tolerated every day shift. There were no physician's orders regarding range of motion exercises to the right hand and elbow or to wear right hand splint six to eight hours per day as tolerated as per Occupational Discharge Summary or Therapy Follow-Up Treatment program. Review of the quarterly Minimum Data Set (MDS) 3.0 dated 07/15/22 revealed Resident #54 had impaired cognition and no behaviors. She required extensive assist of two staff for transfers and was unable to ambulate. She required limited assist of one staff with locomotion on the unit. The MDS revealed no restorative program was completed per the assessment period for passive range of motion and/or splint assistance. Interview and observation on 08/01/22 at 3:05 P.M. with Resident #54 revealed she was in bed, and she stated she had not worn her right-hand splint today, 08/01/22, and she stated staff had not completed passive range of motion. She revealed she was unsure when she was supposed to wear her splint. She revealed she had not worn her right-hand splint for a long time and could not remember when the last time she wore it as staff do not apply the right-hand splint. Interview on 08/02/22 at 2:44 P.M. with State tested Assistant (STNA) #602 revealed Resident #54 refused almost every day to get out of bed. She revealed she thought Resident #54 was only to wear her right-hand splint when she was up out of bed as she had never applied her splint when she was in bed. Interview on 08/02/22 at 2:59 P.M. with Registered Nurse (RN) #603 revealed Resident #54 had an order to wear her right-hand splint only when she was out of bed. She revealed Resident #54 almost always refused to get out of bed, so she very rarely wore her splint. Interview on 08/03/22 at 1:46 P.M. with OT #607 revealed Resident #54 was to wear her right-hand splint in and/ out of bed. He revealed he discharged Resident #54 from occupational therapy on 04/29/22 and referred Resident #54 for restorative passive range of motion program and restorative splint program to her right upper extremity. He revealed he provided nursing with the Therapy Follow- Up Treatment program dated 04/29/22 with the new recommendations. He revealed Resident #54 was to wear her right-hand splint six to eight hours per day as tolerated and he had not heard Resident #54 was not wearing her right-hand splint or that passive range of motion was not being completed as he recommended per the Therapy Follow-Up Treatment Program. He revealed Resident #54's order on her July 2022 physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 08/03/22 at 1:52 P.M. with LPN #608 revealed she was the charge nurse for Resident #54 and only worked at the facility as needed and had not worked at the facility for several months. She revealed she signed off on the treatment administration record that the right-hand splint and right shoulder brace when out of bed as tolerated every day shift had been applied but she verified that this was in error as she had not seen the brace or splint on Resident #54 all day and did not know anything about her splint. Interview on 08/03/22 at 1:58 P.M. with STNA #609 revealed she was the aide for Resident #54 and was not aware when Resident #54 was to wear her right-hand splint, and she verified she had not applied her right-hand splint today, 08/03/22. Interview on 08/03/22 at 2:02 P.M. with the Director of Nursing revealed she had worked at the facility since November 2021 and since then the facility had not had any restorative programs. She revealed any referral received from therapy, nursing placed the order on the treatment administration record (TAR) including range of motion and splints for the nurse and the aide to complete on the floor for that resident. She verified the order on Resident #54's physician's order for the right-hand splint and right shoulder brace when out of bed as tolerated every day shift dated 05/20/20 was an old order and the new recommendations from the last occupational therapy discharge summary and Therapy Follow-Up Treatment Program dated 04/29/22 for passive range of motion and right-hand splint for six to eight hours per day as tolerated was not transcribed to Resident #54's orders. She verified she had no documented evidence passive range of motion was completed for Resident #54 as recommended. Review of the undated facility policy labeled Splint/ Brace Application revealed qualified nursing personnel would ensure that residents received correct application and care of splints and braces to promote proper joint alignment, healing, avoid complications of immobility while monitoring skin integrity and avoiding discomfort. The policy revealed a splint and brace was individualized to reflect resident needs and functional problems. The policy revealed the splint wearing schedule orders would be in the treatment record of the resident's chart.

Based on interview, record review, and facility procedure review the facility failed to provide copies of the medical record for Resident #222 after request. This affected one resident (Resident #222) of four residents (Resident's #31, #223, #224, and #225) reviewed for the facility honoring the right to have access and/ or purchase copies of medical records upon request. The facility census was 65. Findings include: Review of the closed medical record for Resident #222 revealed an admitted [DATE]. Resident #222 passed away on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed Resident #222's daughter was her responsible party/ guardian. Review of the letter of guardianship dated [DATE] revealed the court deemed Resident #222 incompetent, and Resident #222's daughter was named her guardian of person and estate. Review of care plan dated [DATE] revealed Resident #222 had impaired cognition related to Alzheimer's disease. Interventions included Resident #222 required supervision and assistance with all decision making. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed Resident #222 had impaired cognition as she was rarely or never understood. Review of the nursing note dated [DATE] at 5:05 A.M. authored by Licensed Practical Nurse (LPN) #605 revealed the nurse for Resident #222 alerted LPN #605 that Resident #222 was coding, and a code blue was paged. The nursing note revealed the emergency rescue squad was called and other nurses assisted with the code by initiated cardiopulmonary resuscitation (CPR) until the emergency rescue squad arrived and took over the CPR. Review of an email dated [DATE] at 5:15 P.M. revealed Resident #222's daughter sent Admission/ Social Service Designee (SSD) #600 an email that requested all medical records including all progress notes, labs, medications given and any other information regarding Resident #222's care from [DATE] through [DATE]. Review of an email dated [DATE] at 6:29 A.M. revealed Admission/ SSD #600 emailed back to Resident #222's daughter and stated she was not in the facility but would forward her request to the facility and see if someone at the facility could assist with the request. Review of an email dated [DATE] at 9:03 A.M. revealed Admission/ SSD #600 emailed Resident #222's daughter and revealed she had just returned to work [DATE] and asked Resident #222's daughter if she received the medical records that Resident #222's daughter requested or if she needed to follow-up on the request. Review of an email dated [DATE] at 9:21 A.M. revealed Resident #222's daughter responded back to the Admission/ SSD #600 that she had not received the medical records and asked if they were sent in the mail or by email. Review of an email dated [DATE] at 9:44 A.M. revealed Admission/ SSD #600 responded that she would check and let Resident #222's daughter know. Review of the nursing note dated [DATE] at 1:44 P.M. authored by Admission/ SSD #600 revealed a copy of the email for the request for medical records for Resident #222 along with copies of the requested medical records were given to the Administrator. The nursing note revealed the Admission/ SSD #600 had not given the copy of the medical records to the guardian until it was authorized. Review of an email dated [DATE] at 11:58 A.M. revealed Resident #222's daughter emailed Admission/ SSD #600 and stated that she had not received Resident #222's medical records yet and requested the medical records to be sent to her. Resident #222's daughter provided her address that she wanted the records sent to or she requested the medical records be sent to her email. Review of an email dated [DATE] at 12:41 P.M. revealed Admission/ SSD #600 replied to Resident #222's daughter that she would notify the Administrator. Review of an email dated [DATE] at 12:41 P.M. revealed Admission/ SSD #600 forwarded the email from Resident #222's daughter to the Administrator and stated that Resident #222's daughter had not received the medical records she had requested, and that the Admission/ SSD #600 had put a copy of the email in her box. Interview on [DATE] at 9:59 A.M. with Resident #222's daughter revealed she contacted the Admissions/ SSD #600 in [DATE] and in [DATE] and requested Resident #222's medical records and that she still had not received the medical records as of today, [DATE]. Interview on [DATE] at 9:29 A.M. with Admission/ SSD #600 revealed Resident #222's daughter requested the medical records for Resident #222 on two different occasions- [DATE] and [DATE]. She revealed Resident #222's daughter emailed her the request that included all the medical records from [DATE] through [DATE] regarding Resident #222's care during this time frame. She revealed she forwarded both requests to the Administrator as she revealed the Administrator was the one who authorized if the medical records could be sent. She revealed she did not know if the medical records were sent to Resident #222's daughter per her request. Interview on [DATE] at 9:50 A.M. with the Administrator revealed she had not sent the medical records to the Resident #222's daughter. She revealed if the Admission/ SSD #600 had forwarded her the request, she had to be honest, she had failed to send the medical records and she stated that the request had fell through the cracks. She stated after reviewing the emails that she was in the loop and she was responsible to send the medical records to Resident #222's daughter but had not. Review of the undated facility procedure titled Medical Records, revealed the facility had a processing fee of 15 dollars for medical records and the copying fees included one dollar for pages one to ten, 50 cents pages 11 through 50, and 20 cents for pages 51 and more. This deficiency substantiates Complaint Number OH 734.

Based on interview and record review, the facility failed to administer medications as per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the medical record for Resident #364 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/02/21, revealed Resident #364 had intact cognition. Review of the plan of care dated 05/08/20, revealed Resident #364 had [CONDITION(S)]. Interventions included to give medications and treatments per the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of medication administration records (MAR) for May 2021 revealed Resident #364 received [MEDICATION(S)] on 05/01/21 and 05/02/21. Resident #364 then received her next dose of [MEDICATION(S)] on 05/25/21. The medication was held 22 days instead of the ordered 21 days on and seven days off for [CONDITION(S)] in May 2021. Interview on 08/02/21 at 2:30 P.M. with Director of Nursing (DON) revealed Resident #364 went to a medical appointment on 05/02/21, she returned the same day, and the charge nurse (no longer employed) put in the new orders into the electronic medical records and accidentally omitted the [MEDICATION(S)] order. DON revealed the physician was notified of the omission and the medication was restarted on 05/25/21. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .M. for date of service 05/25/21 included Discussed with her and staff in detail. In review of her chemo medications which was initially ordered by her Oncologist on March 7, 2021 but due to delay in delivery from pharmacy, her chemo meds were actually started a week after, on March 15, 2021 specifically daily for 21 days then off seven days as ongoing direction for her [MEDICATION(S)]. She received her chemo meds on schedule for April. There was a two-week delay for her May schedule and Oncologist was notified asap. A new scheduled cycle was ordered. Routine blood tests were being faxed to Oncologist when Chemo meds started in March. As of this date no additional treatment was ordered. Review of medication error report for Resident #364 completed by DON, undated, revealed [MEDICATION(S)] capsule was not administered after receiving a blood transfusion and returning to the facility. Interventions included the medication was ordered and administered with a calendar placed in the chart. Staff were educated. Review of facility policy titled, General Guidelines for Medication Administration Policy, dated 06/02/15, revealed medications are administered as prescribed, in accordance with good nursing principals and practices by persons authorized to do so. Medications are administered in accordance with written physician orders. All current medications and dosage schedules are listed in the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] This deficiency substantiates Complaint Number OH 248.

Based on observation, interview, review of nursing home guidance from the Centers for Disease Control (CDC), record review, review of facility education and facility policy review, the facility failed to implement appropriate precautions for new admissions/readmissions on the St. Ann's unit and failed to ensure staff used personal protective equipment (PPE) properly to prevent potential spread of COVID-19. This affected 10 of 79 facility residents residing on the St.(NAME)unit (Residents #1, #4, #5, #6, #7, #8, #9, #10, #11 and #12). Findings include: Interview on 10/22/20 at 9:08 A.M. with the Administrator and Assistant Administrator (AA) #102 revealed the facility devoted the St. Ann's unit as the quarantine unit for new admissions and COVID-positive residents as the unit had two separate halls. As of 10/22/20 the facility did not have any COVID-positive residents. Eye protection was required to enter resident rooms. Observation of the St. Ann's unit on 10/22/20 starting at 10:12 A.M. revealed two hallways. Each occupied room had signage to see the nurse before entering and a bin with drawers containing PPE including gloves, hand sanitizer, red bags and isolation gowns. At 10:16 A.M., Physical Therapist (PT) #117 was noted to have glasses and a surgical mask on and then donned an isolation gown and gloves before entering Resident #5's room. PT #117 was noted to be seated at the bedside less than six feet away from Resident #5 during the observation. Interview on 10/22/20 at 10:24 A.M. with State tested Nursing Assistant (STNA) #103 revealed an N95 respirator mask was required on every unit. Interview on 10/22/20 at 10:29 A.M. with STNA #104 revealed she did not work on the St. Ann's unit but believed an N95 mask, gloves, gowns and protective eyewear was required to enter those resident rooms. Interview on 10/22/20 at 10:34 A.M. with Licensed Practical Nurse (LPN) #105 revealed N95 masks had been required across all resident units for at least two weeks. Interview on 10/22/20 at 10:37 A.M. with Registered Nurse (RN) #106 revealed either a surgical mask or an N95 mask could be used as PPE on the St. Ann's unit and gowns were used for direct patient contact. RN #106 stated if there was a confirmed case of COVID-19 then the N95 mask was required in these rooms. A follow-up interview on 10/22/20 at 11:26 A.M. with AA #102 revealed she did not know if N95 masks were required on the St. Ann's unit or if the unit was under contact or droplet transmission-based precautions. Interview on 10/22/20 at 11:30 A.M. and 11:55 A.M. with LPN #107, who served as the facility's infection preventionist, revealed new resident admissions and readmissions were on the St. Ann's unit for two weeks. LPN #107 stated a gown, gloves, N95 mask and protective eyewear were required and verified these residents were under contact and droplet isolation. Interview on 10/22/20 at 1:47 P.M. with PT #117 revealed on the St. Ann's unit, a gown, gloves and surgical mask were required and recently, protective eyewear was also required. PT #117 had plastic pieces on the sides of her glasses which she showed the surveyor and stated she thought these counted as goggles or a face shield. PT #117 stated she did not think an N95 mask was required for the St. Ann's unit. Review of the current physician orders [REDACTED].#1, #4, #5, #6, #7, #8, #9, #10, #11 and #12 revealed no orders for isolation precautions for 14 days after admission to the facility. Review of the CDC's guidance, Responding to Coronavirus (COVID-19) in Nursing Homes, (https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html) revealed all recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator, eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Newly admitted or readmitted residents should be monitored for evidence of COVID-19 for 14 days after admission and cared for using the recommended PPE. Review of the facility's undated policy on admission and readmission revealed residents would return to the facility with placement on the St. Ann's unit for 14 days observation of any symptoms related to COVID-19. Residents will be treated as necessary per physician' s orders. A chart attached to the policy stated for hospital admissions, residents were to be placed on contact precautions. If not tested prior to discharge to the facility residents were to be assumed to be COVID-positive. Review of a policy on droplet precautions revised 06/09/20 revealed an N95 was worn during resident care if a resident was on isolation, coughing, with aerosol treatments or exhibiting any signs or symptoms of COVID. Don the mask and eye protection upon entry into the resident room or resident space. Review of staff education from June 2020 and July 2020 revealed if a resident was in isolation or received respiratory treatments, an N95 was to be worn. This deficiency substantiates Complaint Number OH 627.

Based on observation, record review, and interview, the facility failed to ensure appropriate interventions to prevent a fall with injury for Resident #18. Actual Harm occurred when State tested Nurse Aide (STNA) #301 propelled Resident #18 in a wheel chair, without footrests. The resident's foot dropped to the floor and she fell , resulting in a hematoma of the forehead and transfer to the hospital. This affected one resident (Resident #18) of one resident reviewed for falls. Findings include: Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] revealed the resident had severe cognitive impairment and required the extensive assistance of one person for all activities of daily living, including locomotion, via wheel chair. The resident was sent to the hospital on [DATE]. Observation on 08/28/19 at 8:06 [NAME]M. revealed an STNA (unidentified) approached Registered Nurse (RN) #302 on the 500-unit hallway and informed her Resident #18 had fallen in the dining room. RN #302 went to the dining room and found Resident #18 sitting upright in her wheelchair with a hematoma across her forehead. No other nurse was noted on the scene. RN #302 promptly removed Resident #18 to her room for assessment. Interview with RN #302 on 08/28/19 at 8:17 [NAME]M. revealed when a resident fell , unlicensed staff should wait until a nurse assessed the resident before getting them up. Interview with STNA #301 on 08/28/19 at 8:25 [NAME]M. verified he was pushing Resident #18 in the wheelchair when her foot caught on the floor (no footrests were on the wheel chair) and she fell forward, hitting her head, resulting in a bruise across her forehead. He revealed he got the resident back into the wheelchair before a nurse arrived and confirmed he should not have moved the resident until she was assessed by the nurse Interview with the Director of Nursing (DON) on 08/28/19 at 9:36 [NAME]M. confirmed the resident fell during transport in a wheel chair without footrests in place and fallen residents should not be moved until a nurse assessed them for injury. The DON revealed Resident #18 was sent to the hospital for evaluation following the fall. Record review of the facility's fall prevention protocol (undated) revealed staff was not to move a fallen resident until a nurse assessed them for injury.

Based on record review and staff interview the facility failed to check all potential new hires against the State Nurse Aide Registry (NAR) to ensure no employee had a finding entered into the NAR concerning abuse, neglect, exploitation, mistreatment of [REDACTED]. This had the potential to affect all 88 residents currently residing in the facility. Findings include: Review of a document titled Phone List by Department, revealed the record reflected 75 State tested Nurse Aides (STNAs) currently employed at the facility, 32 of which worked on an as needed (PRN) basis. These employees were checked against the State NAR. Review of a document titled New Hires Last 12 Months, dated 08/29/19 revealed the record reflected 14 Licensed Practical Nurses (LPN) #820, #825, #830, #835, #840, #845, #850, #855, #860, #875, #880, #885, #890, and #895. There were four Registered Nurses (RN) #800, #805, #810, and #815. Three housekeeping and laundry staff (Housekeeper) #945, #950, and #955. Seven dietary staff (Dietary) #905, #910, #915, #920, #925, #930, and #935. One activity staff #960 and one receptionist #940. All were hired in the last 12 months. Record review revealed no evidence these employees had been checked against the State NAR. On 08/29/19 at 4:01 P.M. interview with the Administrator and Human Resources (HR) #900 verified she had not been checking all potential new hires against the NAR.

Based on observation, record review, and interview, the facility failed to ensure Resident #7 received eating assistance promptly upon the delivery of her food, and had their clothing protector removed when the meal was over. This affected one of four residents reviewed for dignity concerns. The facility census was 88. Findings include: Record review for Resident #7 revealed [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment revealed the resident was severely cognitively impaired and requiring limited assistance from one staff member when eating. Observation of Resident #7 on 08/26/19 at 12:09 P.M. revealed she was sitting upright in her bed with an uncovered, uneaten lunch tray in front of her. She appeared to be awake, and made no effort to eat the food in front of her. Continuous observation revealed the situation unchanged until 12:27 P.M., when an unidentified State tested Nurse Aide (STNA) entered the room and began to assist her with eating. A white towel was wrapped around Resident #7's neck and shoulders during this process to serve as a clothing protector. Observation of Resident #7 on 08/26/19 at 2:20 P.M. revealed she still had the clothing protector on, which had food debris on it. She was not interviewable. Interview at 2:23 P.M. on 08/26/19 with Licensed Practical Nurse (LPN) #400 confirmed the towel was still on Resident #7. LPN #400 immediately removed the towel and verified it should not have been left on after the meal and a clothing protector should have been used not a towel. On 08/28/19 at 4:40 P.M. the Director of Nursing verified the above concerns.

Based on record review, observation and interview, the facility failed to ensure Resident #41's care plan was revised and updated to meet her individual needs. This affected one (Resident #41) out of 27 residents whose care plans were reviewed. Findings include: Resident #41 was admitted to this facility on 07/24/18. Her admitting [DIAGNOSES REDACTED]. Her Minimum Data Set Assessment 3.0 ((MDS) dated [DATE] showed this resident had severe cognitive impairment. She needed extensive assistance for bed mobility, toilet use and personal hygiene. For all other activities of daily living she was totally dependant on staff. Her skin assessment from this MDS revealed she was at risk for pressure ulcer development and did at the time of this MDS have skin tears on her legs and arms. This resident resided on the dementia unit and received Hospice services. Review of the resident's plan of care dated 07/25/18 revealed the resident had a potential for actual skin impairment and or development of pressure ulcers related to her [DIAGNOSES REDACTED]. Interventions included: keeping the skin clean and dry; provide a pressure relieving air mattress; provide pressure reducing cushion to char; pad corners of dressers, night stand and food board; provide a Roho cushion; and to use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface. Observation of Resident #41's bilateral upper and lower extremities revealed brushing on bilateral elbows and a skin tear on the lower left arm. The bilateral lower extremities showed bruising in several areas on bilateral legs and a skin tear noted to her left shin/calf area with a dressing. These bruises and skin tears were verified by Licensed Practical Nurse (LPN) #459 on 08/28/19 at 10:06 [NAME]M. She stated the resident had a habit of forcibly moving her legs and arms over the sides of the wheelchair and while in bed. She stated that was the reason for the dermal sleeves for the arms and legs. Observation of the resident's room on 08/28/19 at 11:06 [NAME]M. revealed there was no padding noted on the dresser or the nightstand. The food board of the bed was not padded and the food board of the wheelchair was not padded. Interview with LPN #459 on 08/28/19 at 11:15 [NAME]M. verified that the dressers and the food boards were not padded. LPN #459 revealed those interventions did not really apply to the resident at the present time because the resident was now non ambulatory and was unable to move around. When asked about striking her arms/legs against objects and padding them for protection she stated that Hospice changed the orders. The orders were changed to a perimeter mattress with extra padding attachments to the perimeters of the bed to prevent the resident from striking her arms/legs when in bed. Resident #41 was also ordered to wear the derma sleeves to extremities for extra protection. LPN #459 verified present interventions including the perimeter mattress and the dermal sleeves were not listed on the current care plan.

Based on record review and interview, the facility failed to ensure comprehensive assessments were accurate. This affected three (Residents #19, Resident #46, and Resident #64) of four residents reviewed for Pre-Admission Screen - Resident Review. The facility census was 88. Findings include: 1. Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #19's medical record revealed the Minimum Data Set (MDS) 3.0 assessment, dated 05/07/19, revealed Section A did not indicate a mental illness as identified by Ohio Mental Health and Addiction Services. 2. Review of Resident #46's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #46's medical record revealed the MDS 3.0 assessment, dated 07/09/19, revealed Section A did not indicate a mental illness as identified by Ohio Mental Health and Addiction Services. 3. Review of Resident #64's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #64's medical record revealed the MDS 3.0 assessment, dated 11/23/18, revealed Section A did not indicate a mental illness as identified by Ohio Mental Health and Addiction Services. On 08/29/19 at 11:25 [NAME]M. an interview with MDS Nurse #895 verified the comprehensive assessments for Residents #19, #46, and #64 did not accurately reflect their mental health status.

Based on record review and interview, the facility failed to inform the Ohio Department of Health when it hired a new Director of Nursing (DON). The total census was 88. Findings include: Interview with the Administrator on 08/29/19 at 4:35 P.M. revealed their Director of Nursing (DON) began work in the facility in (MONTH) of 2019. They did not know if information regarding her hire had been communicated to the Ohio Department of Health (ODH). Review of the DON's employee file revealed her hire date was 01/30/19. Review of both that file and the ODH secured website for provider communications revealed no evidence the DON's hire had been communicated to ODH.

Based on observation, record review and interview, the facility failed to ensure Resident #64 was treated with dignity and respect during lunch. This affected one resident (Resident #64) of two residents observed for meal intake in the dining room. This had the potential to affect ten residents (Resident #71, Resident #47, Resident #55, Resident #40, Resident #37, Resident #34, Resident #29, Resident #32, Resident #13 and Resident #1) who were still eating lunch in the dining room. The facility census was 84. Findings include: Review of the medical record for Resident #64 revealed she was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Her quarterly Minimum Data Set Assessment (MDS) 3.0 assessment, dated 01/19/19, revealed the resident was cognitively intact. Functionally, she required supervision for eating. Observation on 04/09/19 at approximately 11:45 A.M. revealed Resident #64 was brought to her lunch table. State tested Nurse Aide (STNA) #202 set her plate in front of her. The resident immediately went to reach for her chicken finger. The aide immediately stated stop. She then placed the resident's clothing protector on her without asking the resident if she wanted it. The resident again attempted to reach for the her chicken, and again the aide stopped her stating you have to wash your hands first, wait. While walking away the aide told the resident don't eat yet, you have to wash your hands. The aide then proceeded to get a wash cloth and handed it to the resident. The resident proceeded to wash her hands and then layed the cloth on the table. As the resident was laying the wash cloth on the table, the aide then said don't, I knew you were going to do that. The resident hung her head down, lifted up the wash cloth and stated I'm sorry. The aide then presented the plastic bag to the resident who threw the wash cloth into the plastic bag. Interview with STNA #202 on 04/09/19 at 12:40 P.M. verified she did place the clothing protector on the resident without asking if she wanted it. She also verified that she did tell the resident to not eat until she washed her hands and to not lay the wash cloth on the table. The aide verified that the resident was not treated with dignity and respect. Interview with Resident #64 on 04/09/19 at 1:00 P.M. verified the incident that occurred in the dining room.

Based on record review and staff interview the facility failed to ensure a complete and thorough investigation was completed for an allegation of physical abuse alleged by Resident #285. This affected one of two self-reported incidents reviewed. The facility census was 88. Findings Include: Resident #285 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set 3.0(MDS) assessment dated [DATE] revealed Resident #285 was cognitively intact and required limited assistance of one person for activities of daily living (ADL). Resident #285 was discharged to another facility on 05/08/18. Review of facility self-reported incident (SRI) tracking number 7 filed on 04/25/18 revealed Resident #285 alleged that she was forcefully held down by Registered Nurse (RN) #29 while her dressing was changed. In a follow up interview later in the day, Resident #285 recanted her story and stated she was tired of hearing the nurse talk about needing to change her dressing and rolled over and allowed the dressing change to take place. The facility unsubstantiated the allegation of abuse. Review of the facility investigation revealed as a result of the investigation we (the facility) interviewed the residents on the unit. They all felt safe, that their needs were being met, and they did not have any concerns regarding the staff. There was no documentation noted to indicate which residents were interviewed and when they were interviewed. Further review of the investigation revealed no staff were interviewed regarding the alleged incident of abuse. Interview on 07/24/18 at 3:36 P.M. with the Director of Nursing (DON) verified the lack of documentation regarding resident interviews and lack of staff interviews. Review of the facilities Abuse, Neglect, Exploitation, and Misappropriation of Resident Property policy dated 12/10/16 revealed when abuse is alleged the facility will interview the resident, the accused, and all witnessed. Witnesses generally include who: witnessed or heard the incident; came in close contact with the resident the day of the incident (including other residents, family members); and employees who worked closely with the accused employee(s) and or alleged victim the day of the incident.

Based on record review and interview the facility failed to obtain advance directives for Resident #47. This affected one of three Resident's (#47, #38, and #17) reviewed for advanced directives. Finding include: Review of the medical record for Resident #47 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Physician orders, care plans, and the electronic medical record were silent of the resident's code status. Review of Resident #47 hard chart did not contain documentation of the resident's code status. Interview on 07/24/18 at 12:55 P.M. with Licensed Practical Nurse (LPN) #31 revealed the code status should be located either in the front of the hard chart or in the electronic medical record. LPN #31 verified that Resident #47's electronic medical record and hard chart did not contain the resident's code status. LPN #31 then stated the resident would be considered a full code status. On 07/24/18 at 1:35 P.M. with LPN #32 presented a hard copy of a code status stating Resident #47's code status was a do not resuscitate comfort care-arrest (DNRCC- arrest), signed by the physician and dated 07/24/18. Review of the facility's policy titled Advanced Care Planning-Advanced Directives and Code Status dated 01/22/16 revealed the resuscitation order, whether its's full code, DNRCC-Arrest, or DNRCC, is obtained by the nurse as soon as possible after admission.

Based on observation, interview, record and nursing guidelines review, the facility failed to accommodate Resident #29's assessed needs to promote independence in drinking fluids. This affected one of two Residents (#59) reviewed for hydration. The facility census was 88. Findings include: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the current physician's orders [REDACTED]. Review of the quarterly comprehensive Minimum Data Set 3.0 (MDS) assessment dated [DATE] indicated she was alert and oriented and independent in daily decision making ability. She required supervision and set up for eating and drinking and extensive assistance of one for personal hygiene. Review of the nutrition plan of care indicated interventions included a two handle sippy cup, bendable utensils, and divided plate. Interview with Resident #5 on 07/23/18 at 10:54 A.M. said she did not always get water to drink. She said she was supposed to drink more fluids, often throughout the day because she had a urinary catheter and had frequent infections, but staff did not refill her two handled sippy cup. Observation of Resident #5's cup on 07/23/18 at 10:54 A.M. revealed it was empty with evidence of orange juice at the bottom from her breakfast meal. She said she had to use this type of cup because she could not use her hands adequately to grasp a typical cup. She attempted to open her hand and was only able to open a couple of fingers. On 07/23/18 at 12:05 P.M., 07/24/18 at 4:43 P.M., 07/25/18 at 8:02 A.M. and 12:03 P.M. she was observed at meals in the dining room with one two handled sippy cup, while the other residents had a choice in two or more beverages because they drank out of typical cups. On 07/24/18 at 11:23 A.M. she had the two handled sippy cup and a Styrofoam cup that were empty on her over bed table. On 07/24/18 at 12:45 P.M. she was at the unit picnic in the courtyard with other residents and visitors. She only had one cup compared to others. On 07/24/18 at 1:54 P.M. she was observed in her room with no beverages available to her. On 07/25/18 at 10:41 A.M. she was asleep in her room and had one two handle sippy cup that was filled with water. On 07/25/18 at 11:26 A.M. she was drinking out of her cup. She said they used to have more cups for her but they were gone. She said that was the only way she could drink independently without spilling on herself. On 07/25/18 at 12:03 P.M. Interview with Licensed Practical Nurse (LPN) #31, he stated the staff were to offer her water every time it was offered to the other residents. The surveyor informed him she did not have a water pitcher in her room. He said even though she did not have a water pitcher, they were to provide her water at those times. He confirmed Resident #5 used to have other two handled sippy cups and now only had one. He called the kitchen and requested a two handled sippy cup for Resident #5. The kitchen brought one right away. LPN #31 went to Resident #5 and asked if had she been given water. She said sometimes no. She said she was supposed drink water all the time. He informed her another cup was available, and she requested it be filled with ice water and brought to her room. Interview with the Director of Nursing (DON) on 07/25/18 at 1:15 P.M. said Resident #5 used to have one cup for the dining room and one for her room. She was informed Resident #5 only had one cup available to her. She confirmed the resident should have had two cups available for her and due to her use of an indwelling catheter, she should be encouraged to drink fluids. Review of the undated Hydration Nursing Guideline indicated water/ice was passed to residents in their room each shift and as needed. Beverages were available 24 hours a day in the server at the residents request. The goal was to ensure each resident received beverages to promote proper hydration.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on observation, review of medical records, facility investigation notes, facility manual for Mechanical Soft Diet, in-service records and staff interviews, the facility failed to ensure one resident with swallowing difficulty, (Resident #199), was served the correct diet consistency and provided with needed staff assistance. Immediate Jeopardy began when Resident #199 was given a regular diet instead of the physician ordered mechanical soft diet and choked on a food item. Serious, life threatening harm occurred when Resident #199 choked, the [MEDICATION NAME] maneuver was unsuccessful, her pulse oxygen level dropped to 56 percent (%) and the resident required emergent transport to the hospital. This affected one resident of three sampled residents on mechanically altered diets and had the potential to affect 22 residents (Residents #2, #14, #19, #26, #38, #39, #42, #48, #54, #55, #58, #59, #61, #64, #71, #74, #75, #80, #83, #84, #89 and #96) with physicians' orders for a mechanical soft textured diet. The facility census was 98. On 10/05/17 at 4:32 P.M., the Administrator, Assistant Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on 07/13/17 at 12:00 P.M. when Resident #199 was served a meal tray with a fruit plate made up of lettuce on the bottom, cottage cheese, cantaloupe and blocks of cheese along with a muffin. Cheese blocks or cheese slices were not included on the facility Diet and Nutrition Care Manual for Mechanical Soft Diet guidelines as a food item that could be served to residents on a mechanical soft diet. Resident #199 was served the lunch meal in her room with no staff present to assist or supervise her. Approximately thirty minutes after the delivery of the resident's tray, Licensed Practical Nurse (LPN) #32 observed Resident #199 as blue in the face and gasping for breath. LPN #33 attempted the [MEDICATION NAME] maneuver approximately five times to clear the resident's airway but nothing was expelled. Physician #300 then attempted to suction Resident #199 by nasal suction which was not effective. LPN #24 attempted the [MEDICATION NAME] maneuver approximately seven to ten more times which was ineffective. The staff were unable to clear Resident #199's airway and the resident's oxygen saturation level was 56%. Resident #199 was observed gasping for breath and was blue in the face. Emergency Medical Services (EMS) was notified and the resident was transported to the hospital on [DATE] at 1:05 P.M. The Immediate Jeopardy was removed on 07/14/17 when the facility implemented the following corrective actions and the deficiency remained at Severity Level II (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) until the deficient practice was corrected on 08/01/17. · On 07/14/17 at 3:45 P.M. Dietary Manager #103 and Dietary #114 provided in-service education to 13 of l3 dietary employees including a review of foods to avoid on a mechanical soft diet and dietary food trays would not be passed without meal tickets. · From 07/14/17 to 07/17/17 Staff Development #1 in-serviced all 112 staff confirming the charge nurse would assign one state tested nursing assistant (STNA) per meal to observe, monitor and supervise residents who are eating meals in their rooms. STNAs must have tray cards and present them to dietary staff for all resident meals. Staff should encourage residents to eat in the dining room for all meals and no food would be given to residents without following the tray cards. · A new facility policy was implemented dated July 2017 for maintaining resident safety and reducing choking hazards. The charge nurse on each unit will assign an STNA to supervise residents that choose to eat in their rooms. STNAs in the dining rooms must give the dietary aide the tray card to plate the food. The STNAs assigned to monitor on the unit during meals would continually circulate through the entire meal time. If a resident was noted to be in distress, the STNA would call for assistance from the charge nurse and emergency services would be activated. · Random tray audits to ensure correct diets and food textures were delivered to residents were performed by Dietary #114 from 07/22/17 to 08/15/17. · An audit performed by the DON was completed on 08/01/17 to ensure resident diets listed on the master dietary list matched the physicians' orders. The facility identified four residents (Residents #14, #42, #55 and #200) who were receiving the incorrect diet and/or food textures based upon the physicians' orders. The dietary master list was updated to ensure the residents received the correct diet texture as indicated in the physician orders. · Interview with the Assistant Administrator on 10/05/17 at 11:12 A.M. confirmed Kitchen Staff #250, the staff person who made the plate of food for Resident #199, was no longer employed as of 09/18/17. The Assistant Administrator confirmed all other staff were in-serviced on checking the meal served with the meal tickets to ensure the residents receive the appropriate diet and food textures as ordered. The Assistant Administrator also indicated a list of inappropriate foods for mechanical soft and pureed diets was placed in each satellite kitchen as part of staff education. · The administrative staff including the Administrator, Assistant Administrator and the DON, the Assistant DON, the social service designee, Dietary Manager #103, RN #3, RN #4, Staff Development #1 and Therapy Manager #400 continue to meet weekly during quality of life meetings to monitor resident diets. Observations on 10/05/17 from 9:01 A.M. to 9:12 A.M. of Residents #1, #73 and #96's breakfast meals revealed the residents received the meal according to their lunch tickets. Observations on 10/05/17 from 12:01 P.M. to 12:30 P.M. of Residents #4, #5, #39, #54, #84 and #98's lunch meals revealed the residents received the meal according to their lunch tickets. Interviews on 10/12/17 from 3:05 P.M. to 3:15 P.M. with STNA's #39, #50, #61 and #74 confirmed they were educated on the correct food items to serve to residents requiring mechanical soft diets, pureed diets and regular diets and they identified the new policy to match the meal trays to the dietary tickets to ensure residents received the correct food items. Interviews on 10/12/17 from 3:25 P.M. to 3:28 P.M. with Cook #107 and Dietary Aide #110 confirmed they were educated on the correct food items to serve residents requiring mechanical soft diets, pureed diets and regular diets. Cook #107 and Dietary Aide #110 confirmed they were also educated on the new policy to match the meal trays to the dietary tickets to ensure residents received the correct food items. Findings include: Review of Resident #199's closed medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #199's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had memory problems and was severely cognitively impaired. She required the extensive assistance of one staff person for eating meals. Review of Resident #199's care plan dated 04/08/15 indicated the resident was on a mechanical soft diet requiring extensive assistance from staff for eating/feeding. Review of Resident #199's Activities of Daily Living (ADL) report form confirmed she required extensive assistance with one person physical assist with eating. Review of Resident #199's physician orders [REDACTED]. Review of Resident #199's dietary quarterly progress note by Registered Dietician (RD) #301 dated 05/11/17 indicated the resident's diet was mechanical soft with fortified juice drink and med pass (a nutritional supplement) and to continue with the diet prescription. Review of Resident #199's progress note by Registered Nurse (RN) #8 dated 07/13/17 at 1:01 P.M. indicated at 12:50 P.M. all staff were in the resident's room with Physician #300 and Resident #199 was in respiratory distress and short of breath. Physician #300 indicated Resident #199 was to be transported to the emergency department. Review of Resident #199's progress note by Physician #300 dated 07/13/17 at 3:14 P.M. indicated the resident had an aspiration (breathing in a foreign object into the airway) episode at lunchtime. The [MEDICATION NAME] maneuver was done several times by staff at the facility but the procedure failed. Resident #199's blood pressure was elevated and her oxygen saturation was only in the 50's. Resident #199 was sent to the hospital. On arrival to the emergency department, the resident was given some sedation and the emergency department removed some pineapple chunks from the resident's trachea. There is some discrepancy noted in the type of food eaten, as the facility indicated they served cheese chunks, not pineapple. Neither food would be served as part of a mechanical soft diet. The resident was observed overnight in the hospital for possible aspiration pneumonitis (infection/inflammation from food being inhaled into the airway or lung). Review of Resident #199's progress note by LPN #32 dated 07/13/17 at 3:36 P.M. indicated at approximately 12:30 P.M., LPN #32 was informed by STNA #85 that Resident #199 was blue and the STNA thought she couldn't breathe. Upon arrival in the resident's room, LPN #32 noted the resident was in bed sitting at a 90-degree angle and gasping for breath. The resident was blue in the face. The nurse immediately had the nursing assistant grab the chart and called for administration to bring the crash cart. The [MEDICATION NAME] maneuver was performed a total of thirteen times by staff and was not effective. Resident #199's oxygen level was 56%. An order was obtained to send the resident to the emergency department. The resident's daughter was notified. Review of Resident #199's emergency room progress note dated 07/13/17 at 5:45 P.M. revealed upon arrival by EMS the resident was medicated with [MEDICATION NAME] (for pain) and [MEDICATION NAME] (for anxiety). Using forceps, a large, approximately 3.0 centimeters (cm) by 4.0 cm by 4.0 cm chunk of pineapple was pulled from the trachea. Review of Resident #199's Discharge Plan and Hospital Summary form dated 07/14/17 indicated the resident had a [DIAGNOSES REDACTED]. Review of Resident #199's progress note by LPN #32 dated 07/14/17 at 5:22 P.M. indicated the resident returned to the facility at 5:19 P.M. by stretcher. Resident #199 came back on a pureed consistency for meals diet and was to continue with thin liquids. Review of Resident #199's progress note by LPN #11 dated 07/15/17 at 6:53 P.M. indicated the resident showed signs of pain (grimacing) when swallowing and consumed 25-100 % (percent) of meals. Review of Resident #199's progress note by LPN #17 dated 07/17/17 at 6:08 A.M. indicated the resident had been unusually quiet since her return from the brief hospital stay. When Resident #199 tried to speak, the resident's voice was minimum and feeble. Review of Resident #199's progress note by LPN #32 dated 07/18/17 at 12:50 P.M. indicated the resident continued to be on antibiotic therapy and continued to consume small amounts of fluid and pureed meals. Review of the undated facility investigation and witness statement by Dietary #103 indicated on 07/13/17, the alternate meal was a cottage cheese fruit platter which consisted of a scoop of cottage cheese, cantaloupe, lettuce, cubed cheese and a blueberry muffin. Review of the facility investigation witness statement dated 08/01/17 authored by Dietary Aide #250 revealed the dietary aide knew Resident #199 was on a mechanical soft diet and received a room tray. Dietary Aide #250 indicated the nursing assistants had asked the resident what she wanted and wrote on the ticket that the resident wanted a fruit plate. The nursing assistant who took Resident #199's meal order is unknown as no one admitted to taking her order. Dietary Aide #250 made up the fruit plate with the lettuce on the bottom, cottage cheese next, cantaloupe on the side of the plate and blocks of cheese on the other side of the plate. A muffin was placed on the plate. Review of the facility investigation witness statement dated 07/13/17 by LPN #32 indicated around 12:30 P.M. STNA #85 reported Resident #199 was bluish in color and gasping for breath. LPN #32 immediately called a code blue for administrative staff and attempted to make Resident #199 comfortable. Emergency services were activated and picked the resident up around 1:05 P.M. to be taken to the emergency room . Review of the facility investigation witness statement dated 07/13/17 by STNA #85 indicated Resident #199's meal tray was delivered about 12:00 P.M. and it was a mechanical soft tray. Around 12:15 P.M., STNA #85 walked past the resident's room and observed Resident #199 eating. STNA #85 indicated she walked past the room again around 12:30 P.M. and observed Resident #199 gasping for air and turning blue. Interview on 10/05/17 at 11:00 A.M. with STNA #85 indicated Resident #199 was in her room feeding herself. STNA #85 confirmed the resident's meal tray was delivered at approximately 12:00 P.M. STNA #85 stated at approximately 12:30 P.M., she noticed Resident #199 was trying to catch her breath. STNA #85 verified the resident was served cottage cheese and a fruit plate but did not remember pineapple on the resident's tray. Interview on 10/05/17 at 11:12 A.M. with the Administrator and Assistant Administrator confirmed the facility investigation indicated the emergency room report identified pineapple in Resident #199's trachea but the resident was not served pineapple based on their facility investigation. The Administrator indicated Resident #99 was served chunk cheese in error as it was not on the approved list for a mechanical soft diet. Interview on 10/05/17 at 11:15 A.M. with the Assistant Administrator confirmed the dietary aides plated the food and the nursing assistants and/or nurses delivered the food trays to the residents. The Assistant Administrator confirmed Dietary Aide #250 plated Resident #199's food on the day of the choking incident and STNA #85 delivered the meal tray but did not stay to supervise and assist the resident. Interview on 10/05/17 at 3:04 P.M. with Physician #300 indicated she was aware Resident #199 was having some type of respiratory problem while eating. Physician #300 also indicated the emergency room identified some foreign material in Resident #199's throat, like fruit was in there. Physician #300 confirmed the resident required supervision with meals but said she certainly had the ability to eat food. Interview on 10/05/17 at 3:20 P.M. with RD #301 confirmed extensive assist of one staff member indicated Resident #199 should have had supervision and/or assistance with meals. Interview on 10/05/17 at 3:30 P.M. with RN #3 indicated Resident #199's comprehensive assessment revealed Resident #199 did require extensive assist with one staff for meals. RN #3 confirmed extensive assist with meals indicated the resident required staff to feed the resident or staff to cue the resident to eat and/or extensive supervision. Interview on 10/06/17 at 9:32 A.M. with the Assistant Administrator confirmed the facility would complete quality of life meetings weekly to monitor resident diets and educate all new staff of the facility policy to deliver meal trays to residents. Review of the Diet and Nutrition Care Manual dated 2015 indicated foods to avoid on a mechanical soft diet included dry, tough meat, fish or poultry, any other whole pieces of meat, and cheese slices or cheese cubes. This deficiency substantiates Complaint Number OH 692.