Every finding on record at White Oak Manor - Lancaster

Based on observations, record review, and interviews, the facility failed to provide an ongoing activity program, including both group and individual activities, to meet the needs of one of five residents (Resident (R) 45) reviewed for activities out of a total of 26 sample residents. The failure created the potential for R45 to miss activities of interest and opportunities to be out of bed and out of her room for group activities identified as preferred, and to experience difficulty independently watching television due to the placement of the resident's television. Findings include:Review of the Face Sheet, located under the Resident Dashboard tab in the electronic medical record (EMR), noted R45 was admitted on [DATE] with diagnoses that included hemiplegia (paralysis on one side) and hemiparesis (weakness on one side) following a cerebral infarction (stroke) affecting the right dominant side and aphasia (difficulty speaking). Review of the quarterly Minimum Data Set (MDS), located in the EMR under the RAI [Resident Assessment Instrument] tab with an Assessment Reference Date (ARD) of 05/14/26, revealed a Brief Interview for Mental Status (BIMS) score of eight out of 15, which indicated R45 was moderately cognitively impaired. Review of the Life Enrichment Quarterly Progress Notes dated 05/14/26, located under the Progress Notes tab in the EMR, read [R45] is alert and verbal with confusion noted. She has been observed dressed and in bed most days but does get OOB [out of bed] on occasion. She uses a W/C [wheelchair] for mobility and can propel herself. She enjoys when her family comes to visit with her. She likes to propel herself around the hallways or sit in the day room on her neighborhood and watch TV [television] with other residents. She also enjoys watching TV in her room and reading any mail that she receives. She will come to activities on occasion but will leave during them. She has not shown any S/S [signs/symptoms] of behaviors when interacting with LE [Life Enrichment] staff and is pleasant when engaged in conversation. Her care plan states: [R45] will affirm enjoyment of at least one program/one to one visits during look back period. Goal has been met and is appropriate. Goal will continue to remain ongoing. Review of the comprehensive Care Plan, dated 05/21/26, located under the RAI tab in the EMR, revealed a LIFE ENRICHMENT Problem, of [R45] needs encouragement and one to one interventions to help build trust and rapport and to support leisure and social participation. Approaches included: Staff will assist resident with her TV channel as she enjoys watching hallmark channel. Staff will invite [the resident] to special events with a trust[ed] peer/family member. Staff will provide support and encouragement through one to one visits. Staff will allow extra time for resident to respond to the best of her ability due to dx [diagnosis] of CVA [cerebral vascular accident]. During an initial observation, on 05/27/26 at 11:59 AM, R45 was observed lying flat in bed. The resident was able to answer questions by shaking her head up and down for yes and side to side for no. The resident's bed was positioned against the wall, on her left side. The resident's television was located high on the wall, behind the resident's right shoulder. The television was turned on at the time of the observation. When asked if she liked watching television, R45 smiled, shook her head yes, turned her head to the right, over her right shoulder, and upward in an attempt to watch the television. When asked if turning her head so far was uncomfortable, R45 did not definitively indicate yes or no; she frowned at the question. During an observation on 05/27/26 at 4:00 PM, R45 was observed in her room with the television on. The television was located very high on the wall in the right corner.The resident was observed watching the television with her head turned to the right and slightly upward over her right shoulder. During an observation on 05/28/26 at 9:37 AM, R45 was observed in her room, in bed. The resident's television was observed to be on. The resident was observed turning her head to the right, over her shoulder, to watch the television. During an observation on 05/29/26 at 9:13 AM, R45 was observed in her room, in bed, with the head of the bed elevated. When asked if she attended facility activities, the resident smiled. When asked if she was able to see the television, an activity the resident was identified to enjoy, when seated up in bed, the resident had to turn her head further behind her in an attempt to watch the television. The resident was observed in the same position on 05/29/26 at 9:40 AM. During an interview on 05/29/26 at 9:43 AM, the Activity Assistant (AA) stated that R45 attended some group activities if she was up. The AA indicated the resident was not routinely asked if she wanted to attend activities identified in her care plan and that staff were not asked to assist the resident in getting out of bed for activities of interest. The AA further stated the resident liked to go outside; however, the resident had not been taken to the courtyard. The AA demonstrated that R45 had to turn her head to attempt to watch her television and acknowledged that the television had not been repositioned to improve visibility. During an interview on 05/29/26 at 11:02 AM, the Director of Nursing (DON) and the Staff Development Coordinator (SDC), said they were not aware of the resident's television being difficult to see.

Based on review of the facility policy, observations, and interviews, the facility failed to ensure the kitchen was free of expired food items. Findings include: Review of the facility's policy titled, Storage of Food and Supplies, revised on [DATE] revealed: Food and supplies are received, stored, and monitored according to federal, state, and local guidelines. Under Procedures, Food and supplies are received and checked for accuracy, damage, and appropriate temperature . Any food not stamped with a manufacturer's expiration or use-by date will be marked with the date of delivery. During the initial tour of the kitchen on [DATE] at 10:10 AM, observation of the beverage nourishment refrigerator revealed the following:-40, 4 ounce (oz). cups of Dannon Light and Fit Yogurt, flavored Strawberry, Blueberry and Raspberry with an expiration date of [DATE]. -1, ,d+[DATE] pint of Chocolate milk expired [DATE]. -1, ,d+[DATE] pint of Chocolate milk expired [DATE]. -4, ,d+[DATE] pints of Chocolate milk expired [DATE] These items were confirmed as expired by Cook1. During an interview on [DATE] at 10:18 AM, Cook1 stated, Items are supposed to be checked in here daily to make sure they aren't expired. During the initial tour of the dry storage room on [DATE] at 10:22 AM, observation revealed the following: -1, 0.7 oz bag of Cheetos Puffs with an expiration date of [DATE]. This was confirmed as expired by Kitchen Aide (KA)1. During an interview with the Certified Dietary Manager (CDM) on [DATE] at 10:35 AM, the CDM was made aware of the previous findings and agreed expiration dates should be checked daily.

Based on observation, interview, and review of facility policy, the facility failed to ensure that all drugs and biologicals were stored in locked compartments for one of one resident, Resident (R)57. Findings include: Review of the facility's policy titled, Medication Storage In The Facility, last revised on 09/21/22, revealed, Policy: Medications and biologics are stored safely, securely, and properly following manufacturers recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personal, pharmacy personal, or staff members lawfully authorized to administer medications. Procedure : 2. Only licensed nurses, consultant pharmacist, designated pharmacy staff and those lawfully authorized to administer medications ( e.g. medication aides) are allowed access to medications. Medication rooms, carts and medication supplies are locked or attended by persons with authorized access. Review of the facility's policy titled, Self Administration Of Medication, last revised on 09/21/22, revealed, Policy: Residents are not allowed to practice self- administration of medication unless specifically ordered by the physician and determined to be safe by the interdisciplinary team . Procedure: 1. The determination by the interdisciplinary resident assessment team that a resident may self - administer medications is documented on the plan of care. Documentation of this assessment should be indicated by the following, Resident prefers nursing to administer all medications except (enter medication(s)) which is/are kept at the bedside or in resident's immediate possession for self-administration per physician's order and facility policy or a similar statement. Review of the facility's policy titled, Bedside Storage Of Medication, last revised on 09/21/22, revealed, Bedside medication storage is permitted for residents who are able to self- administer medications upon the written order of the prescriber and when it is deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team. Procedure: 1. A written order from the attending physician for the bedside storage of medication is placed in the resident's medical record. 2. Bedside storage of medications is indicated on the resident's medical record and in the care plan for the appropriate medications. During an observation on 05/04/25 at 10:35 AM, a Pain patch Lidocaine 4% x2 was noted at R57's bedside. Review of R57's Electronic Medical Record (EMR) did not reveal order to keep medication at bedside or an order for R57 to self administer medications. During a telephone interview on 05/04/25 at 4:52 PM, Licensed Practical Nurse (LPN) confirmed R57 does not have an order to self administer medication and R57 does not have an order to keep medication at bedside. LPN1 stated the Lidocaine patches should not be at bedside if there is no order. During an interview on 05/04/25 at 4:55 PM, the Nursing Supervisor revealed the pain patches should be placed on the resident at 8:00 AM and off at bedtime. The Nursing Supervisor verified there was no order for R57 to keep the patches at bedside and there was no order to self administer medications. During an interview on 05/05/25 at 2:20 PM, the Director of Nursing (DON) revealed her expectations are that nurses do not leave medications at a resident's bedside without a doctor's order.

Based on observation, interview, and review of the facility's policy, the facility failed to monitor and manage Resident (R)64's pain to the extent possible in accordance with the comprehensive assessment and care plan, as well as professional standards of practice, for 1 of 1 resident reviewed for pain. Findings include: Review of the facility policy titled, Pain Management Program revised on August 2016, documented, Objective: To enable the resident to be at a consistent level of comfort while maintaining as much function as possible. 5. Residents with uncontrolled pain levels will have a pain management program implemented to include a Pain Flow Sheet form N(079). 7. The documentation will be monitored by the licensed nurse and the interdisciplinary team to determine the effectiveness of the pain relief for the resident. 8. The plan will be adjusted as needed to assure adequate pain relief is obtained, while maintaining the resident's highest quality of life, both physically and psychosocially with the fewest side effects possible. Review of R64's Face Sheet revealed R64 was admitted to the facility on [DATE], with diagnoses including but not limited to: dementia, pressure ulcer stage 4 right heel, age related osteoporosis, atrial fibrillation and heart failure. Review of R64's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 04/09/25, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating R64 was moderately cognitively impaired. This Quarterly MDS also revealed that R64 is in constant pain with a pain intensity score of 8 out of 10. Review of R64's Care Plan with a start date of 11/30/21 and target date of 01/30/25, documented, Focus At risk for episodes of uncontrolled pain r/t dx of polyosteoarthritis, osteoporosis, current pressure ulcers and h/o R hip fx. The goal documented, Will be free of any s/s of uncontrolled pain. The interventions directed staff to, Monitor for s/s of pain (verbalization, grimacing, guarding, restlessness, irritability, change in mood or behavior, decline in physical functioning). Review of the Physician's Order, located in the Electronic Medical Record (EMR) under the Physician's Order tab, revealed R64 is scheduled to receive two tablets of acetaminophen 500 mg three times a day for pain. Further review of the Physician's Order did not reveal an order to monitor the resident's pain level. Review of R64's EMR did not reveal a Pain Flow Sheet to monitor the resident pain. During an interview on 05/04/25 at 2:54 PM, R64 revealed, I hurt all the time. Nothing helps. I just stay in bed because I hurt so bad. During an observation and interview on 05/05/25 at 8:30 AM, R64 was laying in bed. R64 stated, I do not want to do nothing but lie here. I hurt all the time. During an interview on 05/06/25 at 11:47 AM, Licensed Practical Nurse (LPN)1 revealed, A resident's pain regimen is reevaluated every six months. If the pain medication is PRN (as needed), it is reevaluated every 14 days. A resident's pain is addressed using a 1-10 pain scale. If the resident is nonverbal, we watch for grimacing, moaning and facial expressions. We have a standing order for Tylenol, and we log them for the doctor to see the next morning. The nurse should make a progress note that details why the doctor needs to see the resident. I do not work this hall usually, I am not familiar with these residents. I can't help you. During an interview on 05/06/25 at 11:52 AM, the Restorative Aide revealed, I do active range of motion on his arms and legs once a day. He does it himself. He verbalizes pain sometimes due to that sore on his heel. He is no longer ambulating due to the sore on his heel. The hope is that the sore will heal, and we will refer him back to therapy. During an interview on 05/06/25 at 7:51 PM, the Resident Assessment Coordinator (RAC)1 talked to the nurse practitioner as well as his nurse after that interview about his pain. RAC1 stated that the nurse practitioner ordered Tylenol three times a day for him. He stated that the site of his pain was his right heel. During an interview on 05/06/25 at 8:35 PM, the Medical Director revealed that the resident and family have declined narcotics, but it is her expectation that the nurses should be monitoring resident's pain every shift and reporting that to myself and the nurse practitioner. During an interview on 05/06/25 at 8:03 PM, the Director of Nursing (DON) revealed pain medication should work and if not we should reevaluate in a day or two. The DON stated it should be on the MAR (medication administration record) for the nurses to be evaluating the resident's pain every shift after a new pain medication is started.

Based on observation, interview, and review of facility policy, the facility failed to ensure staff did not refer to Resident (R)65 as a feeder during meals, for one (1) of one (1) dependent resident. Additionally, the facility failed to ensure that residents were able to use the bathroom in their rooms, causing R27 to be incontinent of bowel and bladder, for 1 of 1 dependent resident. Findings include: 1. Review of the facility policy titled, Points to Remember in Respecting Dignity revised on 08/16, revealed, . Promote good dining (no disturbances in dining room, etc.) Review of R65's Electronic Medical Record (EMR) revealed R65 was admitted to the facility on [DATE], with diagnoses including but not limited to: Alzheimer's disease, dementia, psychotic disturbance, mood disturbance, anxiety, muscle weakness (generalized), right bundle-branch block, osteoarthritis, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of R65's Quarterly Minimum Data Set with an Assessment Reference Date (ARD) of 04/02/25, indicated R65 had severe cognitive impairment, and the resident was dependent on staff for assistance with meals and activities of daily living (ADL). During an observation on 05/05/25 at 12:54 PM, R65 was being assisted with lunch meal by a certified nursing assistant (CNA). CNA referred to R65 as a feeder. During an interview on 05/05/25 at 1:04 PM, CNA1 revealed she has been in her position for [AGE] years. CNA1 stated R65 is a feeder. CNA1 continued, We have feeders, that's what we call residents that we are assisting with their meals. I have always called residents that need assistance with their meals feeders, and no one has ever corrected me. Staff use this verbiage all the time. We have a white binder at the nurse's station and it has the feeders list in it, this list has feeding assignments for staff. During an interview and record review on 05/05/25 at an unspecified time, Licensed Practical Nurse (LPN)1 showed this surveyor a document from a white binder that was labeled Unit 2 assignment book, the book was located on the front counter of the nurse's station, where anyone could have access to it. The first document in the binder was labeled Feed List - For all shifts. LPN1 stated this is the feeding list so that we know who is feeding who, so that we don't miss a resident. LPN1 stated she has occasionally heard staff refer to resident as feeders. During an interview on 05/05/25 at 1:28 PM, CNA2 revealed she has been in her position for [AGE] years; she has heard staff refer to residents that require assistance with their meals as feeders, CNA2 stated, but it's not supposed to be that way. During an interview on 05/06/25 at 4:19 PM, the Director of Nursing (DON) revealed staff should use the verbiage dependent diners instead of feeders when referring to residents that require assistance with meals. 2. Review of the facility policy titled, Points to Remember in Respecting Dignity revised on 08/16, documented, . Any treatments that dehumanizes a resident or creates an environment that perpetuates a disrespectful and/or potentially abusive attitude toward the resident(s) will be considered grounds for disciplinary action and/or termination. Review of 27's EMR revealed R27 was admitted to the facility on [DATE], with diagnoses including but not limited to: other cholangitis, nausea with vomiting, urgency of urination, other abnormalities of gait and mobility, and overactive bladder. Review of R27's Quarterly Minimum Data Set with an Assessment Reference Date (ARD) of 03/30/25, revealed R65's cognition was intact, and the resident was dependent on staff for assistance with activities of daily living (ADL). During an interview on 05/04/25 at 11:32 AM, R27 stated she cannot use the bathroom in her room because her wheelchair will not fit in that bathroom. I must use the hall bathroom, and it takes 30 to 45 minutes most of time to get someone to take me to the bathroom. I wet myself frequently and then I must sit there in wet clothes. During an observation on 05/06/25 at 9:52 AM, R27 was sitting in a wheelchair fully dressed in a rose and blue blouse, paired with jean and shoes. R27's call bell was within reach and functioning. R27's bathroom opens out directly beside her bed, however R27's wheelchair would not fit in the bathroom. During an interview on 05/06/25 at 11:55 AM, the Maintenance Director (MD) stated that this is the first of him knowing that R27 could not get into her bathroom with her wheelchair. The MD states that all problems are reported by the nurse and he was going to see what solution that he could come up with regarding R27's issue of not be able to utilize the bathroom in her room. During an interview on 05/06/25 at 2:52 PM, R27 stated that she does not drink a lot because then she will have to go to the bathroom and she does not want to go to the bathroom a lot, it takes staff very long to respond to the call bell. R27 stated she promised the staff that she would not go into the bathroom in her room because her chair got stuck because the bathroom is not large enough for her wheelchair. R27 further stated she does not feel comfortable going to the bathroom in her room without her wheelchair, because there are not enough rails to hold onto, and the one that is in there is elbow shape and it is awkward and hard for her to hold onto and she is afraid of falling. During an interview on 05/06/25 at 2:53 PM, Certified Nursing Assistant (CNA)1 revealed she does recall a time when R27 had a hard time getting out of her bathroom with the wheelchair. CNA1 stated it is hard to maneuver the wheelchair and the resident in the bathroom because the bathroom is small. CNA1 confirms that there have been times that R27 was soiled before she can get to the bathroom down the hall and around the corner. During an interview on 05/06/25 at 2:57 PM, CNA2 stated she never assisted R27 to the bathroom in her room, she always brings her to the central bathroom down the hall, because there is rail in that bathroom. CNA2 further stated there is not enough room in her bathroom for staff, the resident, and the wheelchair. All the bathrooms are the same. CNA2 stated R27 does experience many incontinent episodes of bladder and bowel due to having go so far to the bathroom. During an interview on 05/06/25 at 4:29 PM, the Director of Nursing (DON) revealed she is not sure if R27 can walk into the bathroom in her bedroom. The DON stated R27 has use of the central bathroom and she was not aware that this was an issue for R27.

Based on observations, staff interviews, and facility policy review, the facility failed to ensure dishware/utensils were cleaned, storage areas were cleaned, and the oven was cleaned in accordance with professional standards for 121 census residents who received meals from the kitchen. These failures had the potential to lead to food-borne illness among all facility residents. Findings include: During the initial visit to the kitchen on 9/12/23 at 11:09 AM, lunch meal preparation was taking place. Observations and interviews revealed: - Tea, water, and coffee area needed cleaning because of brown liquid-like substance build-up on surface. - The three-level tea cart beside the beverage area contained a built-up sticky substance, crumbs, and trash particles. - A thick orange-tannish syrup substance covered the walls and containers of the produce washing area. The Dietary Manager (DM) said that the areas needed to be wiped down due to the substance build-up. - Black dust-like particles that resembled mold covered the inside office window ledge. Kitchen staff stored clean cups, resident water pitcher and pitcher straws directly under the ledge. - Random pieces of trash throughout the floor and along the perimeter of the kitchen: mainly small pieces of paper. - Two lipstick-stained straws on the resident water pitcher storage cart. The DM said that lipstick-stained straws needed to be removed. During a subsequent visit to the kitchen on 9/14/23 at 10:18 AM, lunch meal preparation was taking place. Observations and interviews revealed: - The ovens were covered with a waxy, black grime build-up. Some areas contained a crusted and peeling black substance on the bottom and around the wall of the ovens. The bottom oven contained layers of the substance. The DM stated that the ovens were supposed to be cleaned daily and they tried to scrap it clean on 9/1/2023 but the black substance could not be removed. - Seven knives hanging openly above the fresh produce two sink washing area contained a heavy residue on about four of the knives. The Corporate Dietary Consultant (CDC) and DM stated that the buildup on the knives was residue from the dishwasher water because the knives must be air dried. - A three level tray that the Dietary Cook (DC) used to prepare cooked food contained embedded crumbs, a sticky substance built-up on all levels and appeared worn. The CDC said that they agreed the three-level portable tray did contain build-up, but it was not a food safety issue. Review of the facility's Sanitation/Infection Control policy dated 08/10 revealed, Bedside water pitchers and accessories shall be cleaned and sanitized on a scheduled basis. And All fruits and vegetables are cleaned prior to peeling. Knives and other portioning utensils are cleaned and sanitized between each fruit or vegetable preparation. In addition, Surfaces, countertops, utensils, equipment, and cutting boards are thoroughly cleaned and sanitized between processing steps.

Based on observations, record review, staff interview, and facility policy review, the facility failed to ensure that one (Resident (R)20) of one resident reviewed for dysphagia had a care plan in place for the diagnosis of dysphagia. Findings include: Review of the facility's 2023 RAI Process policy dated 5/18/17, revealed Each discipline will enter into the computer their assigned Problem/Strength Statement, measurable Goal statement, and specific Approaches and interventions. And Care Plans will be updated/revised to reflect current physician's orders; however, specific orders will not be attached to Care Plan problems. Rather, Care Plans will reflect, for example: Meds as ordered for , Meds as ordered for or PT 5x wk for 4 wks as ordered. These types of interventions may be entered by each discipline as an intervention to the appropriate care plan problem to ensure that current care interventions from the physician's orders are referenced in the Plan of Care. Review of R20's Profile tab of the electronic medical record (EMR) revealed R20 was admitted to the facility on [DATE]. Review of the R20's Diagnosis list in the EMR dated 9/14/23 showed a diagnosis of dysphagia, oropharyngeal phase, (RTP) gastro-esophageal reflux disease without esophagitis, and pneumonitis due to inhalation of food and vomit. Review of R20's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 07/2/23 located in the MDS tab of the EMR, revealed she scored 11 out of 15 on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. Observations of R20 on 09/12/23 at 12:36 PM revealed that R20 received a regular texture lunch meal that included pork chops cut into about four squares. R20 did not eat the pork chops or any of the regular texture items listed on the menu. However, R20 did receive and ate an alternative meal that resembled a grilled cheese sandwich. On 9/13/23 at 6:17 PM, R20 seemed to enjoy eating what appeared to be a sandwich. Although, R20 received a regular texture meal that included ham and beans. Observations of R20 on 9/14/23 at 1:08 PM revealed that R20 did not eat anything from R20's lunch of baked beans, crumbled bread strawberry shortcake, breaded whole chicken breast patty between hamburger buns. R20 rolled away in her wheelchair to the nurse's station. Review of R20's Diet Order tab of the EMR dated 11/15/2021 showed a regular diet order for R20. During an interview with Certified Nursing Assistant (CNA)5 on 9/14/23 at 2:28 PM, CNA5 stated that R20 had a good appetite and that R20 loved to eat pimento cheese sandwiches. In an interview with CNA1 on 9/14/23 at 3:27 PM, CNA1 said that R20 ate well and loved pimento cheese sandwiches. In an interview with Licensed Practical Nurse (LPN) 2 on 9/14/23 at 2:43 PM, LPN2 stated that R20 had recent diagnosis of dysphagia and was surprised of the diagnosis considering that LPN2 had not noticed R20 having difficulty swallowing. R20 added that there was no care plan for R20's dysphagia. In an interview with MDS Coordinator (MDSC) on 09/14/23 at 3:31 PM, MDSC said R20 had not had any choking incidents in a year, and they had not noticed any problems with R20's dysphagia. MDSC stated that the dysphagia diagnosis was no longer active and that they would address it with R20's physician.

Based on observations and interviews, the facility failed to maintain all mechanical and electrical equipment in safe operating condition. The kitchen ice machine condensation draining pipes were not clean and in place. The facility was unable keep the floor behind and underneath the ice-maker clean and free from debris for one of one kitchen observed. The findings included: During the initial kitchen observation on 1/13/20 at 10:39 AM and in the presence of the registered dietitian/quality improvement support person, the surveyor noticed cups, some of which were Styrofoam on the floor behind the ice-maker. There was also paper trash on the floor and the floor appeared soiled (dark brown and oily). On 1/15/20 at 9:24 AM, during a second observation of the ice-machine, in the presence of the registered dietitian/quality support person, the surveyor observed the same cups (including Styrofoam), and paper-trash on the floor behind the ice-maker. The floor still appeared soiled (dark brown and oily). On 1/15/20, at approximately 9:25 AM, the registered dietitian got on his/her knees and attempted to remove the cups and paper-trash. At this time, the surveyor looked underneath the ice-machine and noticed two condensation draining pipes covered with black matter and the pipes were not aligned with the drainage underneath the ice-machine. The pipes were touching the floor. In a brief interview with the registered dietitian/quality improvement support person on 1/15/20 at approximately 9:27 AM (s/he) acknowledged that the floor and pipes were dirty and that the condensation draining pipes were touching the floor underneath the ice-machine.

Based on record review and interview, the facility failed to report an allegation of abuse within the required timeframe for Resident #98, 1 of 7 reviewed for abuse. CNA #3 allegedly witnessed CNA #2 physically abuse Resident #98 on 1/30/19. The allegation was not reported to the State Agency until 2/6/19. The findings included: The facility admitted Resident #98 on 11/21/18 with [DIAGNOSES REDACTED]. On 1/14/20 at 12:13 PM, review of the Initial 2/24-Hour revealed it was faxed to the State Agency on 2/6/19 at 09:34 AM. The Initial 2/24-Hour Report indicated Resident #98 was physically abused by CNA #2 and indicated the date/time of incident as 2/6/19 at 07:40. The report indicated there was an allegation that while two CNAs were providing care to resident, resident became combative and hit a CN[NAME] There is an allegation that CNA may have physically retaliated. Further review revealed a Five-Day Report dated 2/8/19 that indicated the incident occurred on 1/30/19 at 08:50 PM at which time an incident report was done. The summary indicated physical abuse not substantiated by facility. CNA #3 reported that CNA #2 struck Resident #98 of the arm after the resident struck him/her and was forceful when turning the resident. At 12:33 PM on 1/14/20, review of the Occurrence Report also indicated the incident occurred on 1/30/19 and indicated the resident had 2 skin tears measuring 2.5x1.0 and 4.0x3.5 cm and was completed by LPN #2. On 1/30/19, CNA #3's statement on the Occurrence Report stated s/he was changing Resident #98 and observed a skin tear abrasion on (his/her) left arm. (S/he) was combative during care and hitting and grabbing at us. There was no statement obtained from CNA #2. Review of the Occurrence Report also indicated a 24 hour follow-up was done by Unit Manager RN #1 on 1/31/19 and was also signed by the Director of Nursing on 2/1/19. LPN #2's facility-obtained statement dated 2/6/19 indicated s/he was notified by CNA #3 that Resident #98 sustained a skin tear. Per statement, CNA stated s/he was putting Resident #98 to bed and that resident was fighting and once I got (him/her) into the bed I noticed a skin tear on (his/her) arm. LPN #3's facility-obtained statement dated 2/6/19 indicated s/he was informed that Resident #98 had a skin tear. Went to the resident's room and noted the resident did not appear to be in any distress. A few minutes later CNA #4 asked LPN #3 to to talk to CNA #3. At that time CNA #3 said (s/he) got the skin tear because (s/he) roller (him/her) to hard. The LPN asked the CNA if s/he had written a statement and the CNA responded that s/he had. RN #2's facility-obtained statement indicated on 2/5/19 at 10:50 PM, CNA #4 informed the nurse that CNA #3 reported s/he had worked with CNA #2 and that the resident smacked CNA #2 and CNA #2 smacked the resident back and then threw the resident over to his/her side so they could change him/her and caused a skin tear. The statement also indicated when the RN spoke to CNA #3, the CNA stated they reached down to turn the resident and resident smacked (CNA #2) and (CNA #2) smacked (him/her) back and then pushed (him/her) over hard and resident hit (him/her) arm and got a skin tear. CNA #3 wrote another statement dated 2/6/19 stating s/he and CNA #2 used the total lift with the resident and that Resident #98 was getting irritated and combative, grabing at everything. S/he stated the resident hit CNA #2 and CNA #2 hit (him/her) back causing (him/her) to hit (his/her) hand on the rail. CNA #3 stated s/he told CNA #2 to turn the resident back towards him/her, and CNA #2 pushed (him/her) back more like shoved. CNA #3 stated CNA #2 then left the room stating I better leave before I lose my job. CNA #3 found the skin tear after CNA #2 left the room per the statement. CNA #3 then reported the skin tear to the nurse and afterward told CNA #4 what had happened. CNA #4 got LPN #3 at that time and CNA #3 told (him/her) everything that had happened. CNA #4's statement corroborated CNA #3's statement and that s/he witnessed CNA #3 telling LPN #3 about the incident. CNA #2's statement confirmed s/he assisted a co-worker putting Resident #98 to bed with the total lift. The statement also confirmed Resident #98 hit him/her on his/her left arm. CNA #2's statement indicated s/he pushed (his/her) arm down to stop (him/her). CNA #2 stated s/he used pads to turn Resident #98 and pushed his/her bottom. During an interview on 1/16/20 at 9:44 AM, the Nursing Home Administrator confirmed the incident occurred on 1/31/19 and that the Initial 2/24-Hour Report was sent to the State Agency on 2/6/20.

Based on record review, interview, and review of the facility's policy Protocol for Reporting Abuse the facility failed to follow policy to report an allegation of abuse within the required timeframe for Resident #98, 1 of 7 reviewed for abuse. CNA #3 allegedly witnessed CNA #2 physically abuse Resident #98 on 1/30/19. The allegation was not reported to the State Agency until 2/6/19. The findings included: The facility reported an allegation of physical abuse for Resident #98 by CNA #2 to the State Agency. On 1/14/20 at 12:13 PM, review of the Initial 2/24-Hour revealed it was faxed to the State Agency on 2/6/19 at 09:34 AM. The Initial 2/24-Hour Report indicated Resident #98 was physically abused by CNA #2 and indicated the date/time of incident as 2/6/19 at 07:40. The report indicated there was an allegation that while two CNAs were providing care to resident, resident became combative and hit a CN[NAME] There is an allegation that CNA may have physically retaliated. Further review revealed a Five-Day Report dated 2/8/19 that indicated the incident occurred on 1/30/19 at 08:50 PM at which time an incident report was done. The summary indicated physical abuse not substantiated by facility. CNA #3 reported that CNA #2 struck Resident #98 on the arm after the resident struck him/her and was forceful when turning the resident. At 12:33 PM on 1/14/20, review of the Occurrence Report also indicated the incident occurred on 1/30/19 and indicated the resident had 2 skin tears measuring 2.5x1.0 and 4.0x3.5 cm and was completed by LPN #2. On 1/30/19, CNA #3's statement on the Occurrence Report stated s/he was changing Resident #98 and observed a skin tear abrasion on (his/her) left arm. (S/he) was combative during care and hitting and grabbing at us. There was no statement obtained from CNA #2. Review of the Occurrence Report also indicated a 24 hour follow-up was done by Unit Manager RN #1 on 1/31/19 and was also signed by the Director of Nursing on 2/1/19. LPN #3's facility-obtained statement dated 2/6/19 indicated s/he was informed that Resident #98 had a skin tear. Went to the resident's room and noted the resident did not appear to be in any distress. A few minutes later CNA #4 asked LPN #3 to to talk to CNA #3. At that time CNA #3 said (s/he) got the skin tear because (s/he) roller (him/her) to hard. The LPN asked the CNA if s/he had written a statement and the CNA responded that s/he had. RN #2's facility-obtained statement indicated on 2/5/19 at 10:50 PM, CNA #4 informed the nurse that CNA #3 reported s/he had worked with CNA #2 and that the resident smacked CNA #2 and CNA #2 smacked the resident back and then threw the resident over to his/her side so they could change him/her and caused a skin tear. The statement also indicated when the RN spoke to CNA #3, the CNA stated they reached down to turn the resident and resident smacked (CNA #2) and (CNA #2) smacked (him/her) back and then pushed (him/her) over hard and resident hit (him/her) arm and got a skin tear. CNA #3 wrote another statement dated 2/6/19 stating s/he and CNA #2 used the total lift with the resident and that Resident #98 was getting irritated and combative, grabing at everything. S/he stated the resident hit CNA #2 and CNA #2 hit (him/her) back causing (him/her) to hit (his/her) hand on the rail. CNA #3 stated s/he told CNA #2 to turn the resident back towards him/her, and CNA #2 pushed (him/her) back more like shoved. CNA #3 stated CNA #2 then left the room stating I better leave before I lose my job. CNA #3 found the skin tear after CNA #2 left the room per the statement. CNA #3 then reported the skin tear to the nurse and afterward told CNA #4 what had happened. CNA #4 got LPN #3 at that time and CNA #3 told (him/her) everything that had happened. CNA #4's statement corroborated CNA #3's statement and that s/he witnessed CNA #3 telling LPN #3 about the incident. CNA #2's statement confirmed s/he assisted a co-worker putting Resident #98 to bed with the total lift. The statement also confirmed Resident #98 hit him/her on his/her left arm. CNA #2's statement indicated s/he pushed (his/her) arm down to stop (him/her). CNA #2 stated s/he used pads to turn Resident #98 and pushed his/her bottom. Review of the facility's policy entitled Protocol for Reporting Abuse stated Immediately notify, but not later that 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later that 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. During an interview on 1/16/20 at 9:44 AM, the Nursing Home Administrator confirmed the incident occurred on 1/31/19 and that the Initial 2/24-Hour Report was sent to the State Agency on 2/6/20. The Administrator further confirmed the facility failed to follow its policy related to reporting.

Based on record review and staff interview, the facility failed to provide the resident or the resident's representative with the written bed-hold policy prior to a facility initiated hospital transfer/discharge for one of three sampled residents reviewed for hospitalization . Resident #118 was sent to the hospital on [DATE] and 12/16/19 and the facility did not provide written information that specified the bed-hold policy. The findings included: The facility admitted Resident #118 on 7/26/19 with [DIAGNOSES REDACTED]. Review of Resident #118's Quarterly Minimum (MDS) data set [DATE] revealed the resident was coded as having short-term and long-term memory problems with severely impaired cognitive skills for daily decision-making. Nurse's notes reviewed on 1/16/20 at 8:16 AM revealed that the facility sent Resident #118 to the hospital emergency roiagnom on [DATE] with difficulty breathing, wheezing, pneumonia and foul smelling urine. Resident #118 was admitted back to the facility on [DATE]. The nurse's notes also revealed that Resident #118 went back to the hospital emergency room again on 12/16/19 for increased respiratory distress. Resident #118 returned to the facility on [DATE]. In an interview with the social worker on 1/16/20 at 8:32 AM s/he stated that the facility did not provide/discuss the bed-hold policy with the resident or the resident's representative for the two hospital transfers that occurred during (MONTH) 2019.

Based on observations, interview, and review of the facility policy, the facility failed to maintain the dignity of residents with catheter bags for 1 of 1 resident reviewed for catheters. Resident #25's catheter bag was exposed on the 100 hall. The findings included: On 9/24/18 at approximately 1:16 PM, an observation on the 100 hall of Resident #25's catheter bag hanging on the right side of the bed facing the hallway and was approximately ½ full of urine. The catheter bag was not covered and in full view from the hallway. On 9/24/18 at approximately 3:32 PM, an observation on the 100 hall of Resident #25's catheter bag hanging on the right side of the bed facing the hallway. The catheter bag was not covered and in full view from the hallway. On 9/25/18 at approximately 8:59 AM, an observation on the 100 hall of Resident #25's catheter bag hanging on the right side of the bed and was approximately 1/4 full of urine. The catheter bag was not covered and in full view from the hallway. On 9/25/18 at approximately 5:20 PM, an observation with Licensed Practical Nurse (LPN) #1 on the 100 hall of Resident #25's catheter bag hanging on the right side of the bed that was approximately 1/4 full of urine. The catheter bag was not covered and in full view from the hallway. On 9/25/18 at approximately 5:20 PM, during an interview LPN #1 verified the catheter bag was in full view from the hallway and indicated the bag should be placed in a privacy bag on the side of the bed away from view from the hallway. Review of the facility policy, Closed Urinary Drainage states under procedure (3.) Attach drainage bag to bed frame, below level of resident's bladder, not touching floor; cover with dignity bag (unless fig leaf bag used).

Based on record review, interview and review of the facility policy titled, Standard Of Care, the facility failed to ensure the physician and the personal representative for Resident #5, #105, #82 and #56 was notified of refusal of multiple medications on multiple days. The facility further failed to ensure the physician was notified of falls/falls with injury for Resident #30 for 5 of 5 residents reviewed for Notification. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review on 9/26/2018 at approximately 1:24 PM of the medical record for Resident #5 revealed on multiple days multiple medications were refused by Resident #5. Resident #5 had refused medications on 5/2/2018, 5/16/2018, 5/29/2018, 5/30/2018, 5/31/2018, 6/3/2018, 6/4/2018, 6/6/2018, 6/15/2018, 7/24/2018, 7/27/2018, 8/6/2018, 8/9/2018, 8/10/2018, 8/15/2018, 8/16/2018, 8/22/2018, 8/28/2018, 9/5/2018 and 9/21/2018. No documentation could be found in the medical record for Resident #5 to ensure the physician or the personal representative was notified of the refusal of medications. The facility admitted Resident #30 with [DIAGNOSES REDACTED]. Review on 9/27/2018 at approximately 2:00 PM of the medical record for Resident #30 revealed a fall on 7/12/2018 and 7/14/2018. No documentation could be found in the medical record for Resident #30 to ensure the physician was notified. Review on 9/27/2018 at approximately 2:30 PM of the, Occurrence Report, for Resident #30 dated 7/12/2018 revealed a fall with a laceration above right eye and discoloration to the right outer calf. Further review on 9/27/2018 at approximately 2:30 PM of a second Occurrence Report for Resident #30 dated 7/14/2018 revealed a fall from the bed with no injury assessed. No documentation could be found in the medical record nor on the Occurrence report to ensure the physician was notified of either fall. During interview on 9/27/2018 at approximately 2:40 PM with LPN (Licensed Practical Nurse) #4 stated, If a resident receives an injury then we call the physician but if they do not sustain an injury then we log it in the communication book and he/she will be informed when they come in to see the patients on rounds. An interview on 9/27/2018 at approximately 2:50 PM with the physician, he/she verbalized his/her expectation was for the nurses to notify him/her of refusal of medications and falls/falls with injury. The physician also stated that he/she would expect to be notified of refusal of medications in case a change needed to be made in the medications and to update the plan of care. The physician went on to say that the nurses were good about letting him/her know of refusal of medications/care and falls/falls with injury. Review on 9/27/2018 at approximately 3:00 PM of the facility policy titled, Standards of Care, states under Policy: Each resident shall receive quality of care that is designed to meet individual needs and enhance the quality of life. Under Supervision 1. states, The physician and the family (or the resident's representative) shall be informed of any change in the resident's condition. Resident # 56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nurse's notes reviewed on 9/25/18 at 2:57 PM revealed that Resident #56 refuses to take /his/her medication, or spits them out multiple occasions. However, there is no documentation to indicate that the physician and the resident's representative have been notified. Medication Administration Record [REDACTED]. In (MONTH) Resident #56 did not take medication on 10th and the 11th. For (MONTH) the resident did not receive multiple medications on the 14th, 17th, 24th, and 28th. For (MONTH) the resident did not take medication on 3rd, 7th, and 18th. Resident # 82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., [MEDICAL CONDITION], and Dysphagia. Nurse's notes reviewed on 9/27/18 at 9:24 AM revealed that Resident #82 refuses to take /his/her medication, or spits them out multiple occasions. However, there is no documentation to indicate that the physician and the resident's representative have been notified. Medication Administration Record [REDACTED]. In (MONTH) Resident #82 did not take medication on 3rd, 7th, 15th, 23rd, and 30th. In (MONTH) the resident did not receive medication on the 6th. Resident # 105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nurse's notes reviewed on 9/27/18 at 2:37 PM revealed that Resident #105 refuses to take his/her medication, or spits them out multiple occasions. However, there is not documentation to indicate that the physician and the resident's representative have been notified. Medication Administration Record [REDACTED]. In (MONTH) Resident #105 did not take medication on 4rd and the 11th7th. In (MONTH) the resident did not receive mediation on the 20th and in (MONTH) s/he did not take medication on the 3rd.

Based on record review and interview, the facility failed to ensure a Comprehensive Plan of Care was developed for Resident #5 related to refusal of medications. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review on 9/26/2018 at approximately 1:24 PM of the medical record for Resident #5 revealed on multiple days multiple medications were refused by Resident #5. Resident #5 had refused medications on 5/2/2018, 5/16/2018, 5/29/2018, 5/30/2018, 5/31/2018, 6/3/2018, 6/4/2018, 6/6/2018, 6/15/2018, 7/24/2018, 7/27/2018, 8/6/2018, 8/9/2018, 8/10/2018, 8/15/2018, 8/16/2018, 8/22/2018, 8/28/2018, 9/5/2018 and 9/21/2018. Review on 9/26/2018 at approximately 3:10 PM of the Plan of Care for Resident #5 revealed no problem, goals or interventions for refusal of medications. An interview on 9/26/2018 at approximately 3:15 PM with the Care Plan Coordinator confirmed that there was no care plan developed for refusal of medications.

Based on observation, interview and review of the facility policy titled, Medication Storage In The Facility, the facility failed to ensure medications were secured and out of reach of residents that were capable of obtaining them on Unit 200 for 1 of 3 units observed. The findings included: An observation on 9/25/2018 at approximately 9:10 AM revealed unsecured medications on the top of a treatment cart on the 200 Unit. The medications consisted of [MEDICATION NAME] Powder, [MEDICATION NAME] Cream and Santyl. Residents were observed sitting in wheel chairs approximately 3 feet from the treatment cart and others were observed walking by the cart on the unit. An interview on 9/25/2018 at approximately 9:10 AM with LPN (Licensed Practical Nurse) #2 confirmed the findings and stated, these medications came in during the night and were left on the cart. LPN #2 went on to say that the medications should have been secured in the treatment cart and not stored on the top of it. Review on 9/25/2018 at approximately 10:00 AM of the facility policy titled, Medication Storage In The Facility, states, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on record review and interview the facility failed to provide follow up and appropriate treatment and services to prevent urinary tract infection to a resident with signs and symptoms of urinary tract infection for one of one sample resident reviewed for bowel and bladder incontinent. Findings: Resident # 56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nurse's notes reviewed on 9/25/18 at 2:57 PM revealed that on 6/7/18 Resident #56 on 6/7/18 complained of dysuria and also had some foul smelling urine. According to the nurse's notes, the nurse notified the physician. However, there is no documentation to support that the physician or the facility staff took any further action or performed a urinalysis to rule out urinary tract infection [MEDICAL CONDITION]. On 6/9/18 the nurse's notes indicated that the resident wanted to get out of the facility. S/he has thrown his/her cover on the floor and was attempting to get out of bed. On 6/13/18 the facility found the resident on the floor with his/her back against the bedside commode. On 6/20/18 the facility sent the resident at the hospital where s/he was treated for [REDACTED]. During an interview with the director of nursing (DON) and registered nurse consultant on 9/26/18 at 9:23 AM the DON confirmed that the facility did not perform a urinalysis to rule out UTI.

Based on observation, and interview the facility failed to provide food prepared at an appetizing temperature for 2 of 2 residents reviewed during lunch meal. Two Residents on the 300 unit were served melted ice cream. The findings included: On 9/25/18 at 1:57 PM, an observation of the meal service on the 300 hall revealed the meal trays were placed on the hall at 12:15 PM. The last 2 trays were removed from the uncovered food cart at 12:57 PM. Certified Nursing Assistant (CNA) #1 and CNA #2 removed the last 2 trays from the cart and verified the ice cream on the tray was melted.

Based on observation, record review, interview, and review of the facility policy, the facility failed to maintain a medication error rate of less than 5%. There were 3 errors out of 31 opportunities for error, resulting in a medication error rate of 9.68%. The findings included: Error #1 and #2 On 9/26/18 at approximately 8:50 AM, during an observation of Resident #5's medication administration on the 100 hall, Registered Nurse (RN) #1 crushed [MEDICATION NAME] 10 meq. and [MEDICATION NAME] HCL 10 mg. and placed the medication in applesauce and attempted to administer the medication to Resident #5. RN #1 was stopped before administering the medication and was asked to review Resident #5's physicians orders which stated, [MEDICATION NAME] 10 MEQ Tablet- Give one tablet by mouth twice daily with or after meals and with at least 4 oz of liquid.***Do not crush***, also [MEDICATION NAME] HCL 10 MG Capsule- Give 1 capsule by mouth daily. **Do not crush**. Following the review of Resident #5's physician's orders RN #1 verified s/he crushed [MEDICATION NAME] and [MEDICATION NAME] and indicated s/he should not have. Error #3 On 9/26/18 at approximately 8:55 AM, during an observation of Resident #5's medication administration on the 100 hall, Registered Nurse (RN) #1 administered (1) drop of Artificial Tears into each of the residents' eyes. RN #1 then returned to the cart and placed the Artificial Tears back into the Resident #5's drawer in the medication cart, and signed the medication off as given. On 9/26/18 at 9:00 AM, during reconciliation of Resident #5's med pass, a review of the Medication Administration Record [REDACTED]. On 9/26/18 at 9:00 AM, during an interview with RN #1, s/he verified giving only 1 drop per eye of Artificial Tears instead of 2 drops per eye. Review of the facility policy, Oral Medication Administration Procedure states under procedure (6.b.) Medications, not otherwise indicated may be crushed. If Do Not Crush is added to a medication order and the resident needs to have the medication crushed, please consult the pharmacy.

Based on observations, interview and review of the facility policy titled, Dressing - Non-Sterile, the facility failed to follow a procedure during wound care for Resident #8 and #24 consistent with professional standards of practice to promote healing and prevent infection for 2 of 3 residents reviewed for wound care. The findings included: The facility admitted Resident #8 with [MEDICAL CONDITION], Pneumonia, Heart Failure, Pain and Pressure Ulcers. An observation on 9/26/2018 at approximately 10:30 AM during wound care for Resident #8, revealed a pair of scissors on the over the bed table. The scissors were not observed to be cleaned by RN (Registered Nurse) #3 prior to cutting a small amount of calcium alginate for placement on wound beds for Resident #8 during wound care. An additional observation on 9/26/2018 at approximately 10:40 AM, during wound care, revealed RN #3 removing gloves from his/her pocket to use for the dressing changes for Resident #8 after each time cleansing his/her hands. The facility admitted Resident #24 with [DIAGNOSES REDACTED]. An observation on 9/26/2018 at approximately 11:10 AM, during wound care for Resident #24, revealed RN #3 removing a pair of scissors from his/her pocket and cutting a piece of Calcium Alginate with Silver for the wound beds. An additional observation on 9/26/2018 at approximately 11:10 AM , during wound care for Resident 24, revealed RN #3 removing gloves from his/her pocket and applying them each time he/she removed the soiled gloves and after washing his/her hands. During an interview on 9/26/2018 at approximately 11:35 AM with RN #3 confirmed that he/she had not cleaned the scissors prior to wound care and had removed gloves from his/her pocket for use during wound care for Resident #24 and #8. Review on 9/26/2018 at approximately 11:50 AM of the facility policy titled, Dressing - Non Sterile, states under Objective: number 1. states, To protect wound from contamination and/or injury. Under Note: number 1 states, Clean scissors before and after each resident use.

Based on review of the facility files, interview, and review of the facility's policy titled, Neglect, Abuse, Mistreatment, Threatened or Alleged Abuse of Residents, the facility failed to ensure that all alleged violations including resident to resident altercations were reported to the State Health Agency. Resident # 9 involved in an altercation that resulted with an injury for 1 of 3 residents reviewed for accidents. The findings included: The facility admitted Resident #9 with [DIAGNOSES REDACTED]. During record review of the facility's occurrence reports on 06/15/17 at 9:21 AM, revealed Resident # 9 had resident to resident altercations on 4/12/17, 4/29/17, and 5/2/17. Report for 4/12/17 revealed Resident #9 was trying to enter in the TV room and Resident #41 would not move. Resident #9 began hitting the Resident #41 there were no injuries. Report for 4/29/17 Resident #9 entered into Resident #92's room and began hitting the resident. Resident #92 had redness on the right side of the face. Report for 5/2/17 Resident #9 wandered into Resident # 38's room and starting grabbing him. Resident#9 stated she can go anywhere she wants. Resident #9 suffered with bruises on the face and hematoma. Staff separated Resident #9 from the 3 incidents that occurred. There was no documentation of the incidents being reported in the section for Reported to State Agency. During an interview on 06/15/17 at 9:15 AM with the Administrator, Director of Nursing, and the facility's consultants it was confirmed the incidents that occurred were not reported. It was also stated it was not required to report to the health agency if it was a resident to resident altercation. Review of the facility's policy, Neglect, Abuse, Mistreatment, Threatened or Alleged Abuse of Residents, revealed under VII. Reporting/Response Section B: Upon receipt of allegation of abuse or neglect, the Administrator or designee will notify the appropriate State agency as soon as practicable, but not exceed twenty four (24) hours.

On the days of the Complaint and Extended survey, based on record reviews, interviews, review of the facility policy entitled "[MEDICATION NAME] Maneuver", and review of information from the National Institutes of Health, the facility failed to provide basic emergency medical care to maintain the airway for Resident #2, one of one sampled residents reviewed for choking. The findings included: Cross refer to F-281 as it relates to the failure of the facility nursing staff to provide basic emergency medical care to maintain the airway for Resident #2, one of one sampled resident reviewed for choking. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set Assessment with an Assessment Reference Date of [DATE] revealed Resident #2 had a Brief Interview for Mental Status score of 9, indicating moderate cognitive impairment at the time of the assessment. According to the assessment, Resident #2 had clear speech, and usually made her/himself understood and usually had the ability to understand others. Resident #2 required limited assistance of one person for eating; and had no natural teeth. Review of the Care Plan revealed Resident #2 had upper and lower dentures, but did not always wear them. Record review on [DATE] at 1:45 PM revealed a Departmental Note dated [DATE] at 1:20 PM which stated, "12:15 PM-- Resident was eating in dining room and was witnessed choking by her/his family members and several staff members. When RNs (Registered Nurses), (the Staff Development Coordinator and Director of Nursing) arrived immediately thereafter, s/he was breathing, but appeared to be struggling with coughing something up. Some food was coughed up in the dining room, and resident was taken back to her/his room and placed in the bed. Resident appeared limp, and her/his tongue and mouth were blue at this time. Resident was breathing agonally. Pulse is still palpable. Family at bedside. Resident is a DNR (Do Not Resuscitate), but the RP (Responsible Party), ---, states over the phone that s/he wants all life saving measures taken at this time. EMS (Emergency Medical Services) called and is on the way. Resident coughed up a large piece of what appears to be chicken, and within 5 minutes, s/he is beginning to breathe normally, and is beginning to talk. Family continues to be at bedside. 12:45 PM-- EMS has arrived and is leaving facility with resident. Further review of the medical record revealed Resident #2 fed her/himself after setup and had an order for [REDACTED]. During a telephone interview on [DATE] at 1:35 PM, CNA #1 was asked about the [DATE] choking incident with Resident #2. CNA #1 stated that Resident #2's family member had grabbed her/him by the arm and pointed to Resident #2, s/he responded by hollering to get help. According to CNA #1, Resident #2 usually had the ability to communicate or talk, but Resident #2 was not talking at the time of the incident. CNA #1 stated that s/he could not tell if the resident was moving air or not. CNA #1 stated s/he said the resident's name, and then told Medical Records worker #1 to go get help. When asked how the resident looked, CNA #1 stated the resident was pale. When asked if either s/he or Medical Records worker #1 patted the resident on the back, CNA #1 stated that s/he believed Medical Records worker #1 patted the resident's back. According to CNA #1, "I made sure s/he wasn't choking". It was just a flash (in time). CNA #1 stated s/he did not see Resident #2 cough up any food or chicken and said that s/he had stayed in the dining room after the nurses took the resident to her/his room. When asked what s/he thought when s/he first saw the resident, CNA #1 stated s/he had thought maybe Resident #1 was choking. When asked for specifics on what was done for the resident, CNA #1 stated s/he called the resident's name, s/he started coughing, and the DON was standing right there. When asked if s/he patted Resident #2's back, CNA #1 could not recall and s/he stated s/he just remembered the resident coughing. CNA #1 stated, "If s/he hadn't coughed when s/he did, I would have done the [MEDICATION NAME]". CNA #1 stated Resident #2 was a small (lady/man) and went on to describe what s/he would have done if the resident needed the [MEDICATION NAME] maneuver by demonstrating the abdominal thrusts from behind and/or from the front. When asked what training s/he received on the [MEDICATION NAME] maneuver, CNA #1 stated that s/he received training from the facility about 1 ,[DATE] hours ago, and before that, had received an annual inservice in April or May of 2013. CNA #1 stated s/he did not see any food come up or hear any congestion or rattling noises coming from the resident at the time of the incident. During an interview on [DATE] at 4:08 PM, Medical Records worker #1 stated that s/he didn't recall the exact date of the choking incident for Resident #2, but that the incident occurred at lunchtime. According to Medical Records worker #1, CNA #1 told her/him that Resident #2 was choking, and that s/he needed help. Medical Records worker #1 then went to Resident #2 and asked if s/he was all right, but all Resident #2 would do was nod, s/he wouldn't speak. Medical Records worker #1 stated s/he then patted the resident on the back and Resident #2 started coughing, at which time s/he ran and got the nurses out of the meeting. Medical Records worker #1 stated s/he had not witnessed any chicken or food coming out of the resident's mouth, but that after s/he patted the resident's back, the resident was able to cough. Medical Records worker #1 stated that Resident #2 sounded like s/he had congestion when s/he was breathing and that led her/him to believe something else was going on. Resident #2 was still not acting right. Medical Records worker #1 stated that s/he was scared the food would go back into the resident's airway, so s/he hollered "help someone choking". According to Medical Records worker #1, while s/he went to get help, CNA #1 stayed with Resident #2 and her/his family who was present in the dining room during the incident. When the RNs got to the dining room, they asked the resident if s/he was all right, and the resident shook her/his head "yes", but was still congested. Medical Records worker #1 stated the nurses rolled Resident #2's wheelchair back, because the resident was not able to pick up her/his feet, and took her/him to the room. Medical Records worker #1 and CNA #1 stayed behind in the dining room. When asked to demonstrate the pats applied to Resident #2's back, Medical Records worker #1 demonstrated open handed sideways facing firm pats to the back, and stated s/he had done this 3 or 4 times. Medical Records worker #1 stated s/he did not want to do the [MEDICATION NAME]. When questioned further, Medical Records worker #1 stated that the resident was moving air after s/he had patted Resident #2 on the back, but before patting the resident's back, the resident was not moving air and was not making any sounds, no gurgling sounds or sounds of congestion. When asked why s/he did not perform the [MEDICATION NAME] maneuver, Medical Records worker #1 stated that s/he was afraid to do more damage, and said that s/he was unsure if the food was really lodged. When asked what CNA #1 was doing during all this, Medical Records worker #1 stated CNA #1 had been patting the resident on the back too. During an interview on [DATE] at 2:25 PM, the Assistant Director of Nursing (ADON) stated that 2 dining room staff (Medical Records worker #1 and Certified Nursing Assistant (CNA) #1) were present in the dining room for lunch on [DATE] when the choking incident happened. According to the ADON, s/he had been in a meeting across the hall from the dining room with others when they heard Resident #2 was choking. The Director of Nursing (DON) and Staff Development Coordinator (SDC) took Resident #2 from the dining room to the resident's room which took about ,[DATE] minutes, and placed the resident in the bed. According to the ADON, Resident #2 was not responsive but gasping and passing some air with agonal stomach breathing. The ADON stated that someone left to call EMS (Emergency Medical Services) and someone left to call the resident's family. The ADON stated that s/he had raised the head of the bed and leaned the resident over the side of the bed rail because it looked like the resident was going to vomit. It was at this time the resident went "blah" and a piece of chicken came up. The ADON stated the chicken was all balled up and looked like it had been chewed and swallowed. The ADON thought that possibly due to the resident's Barrett's Esophagus, the food had got caught/stuck. When asked about how long it took for the chicken [MEDICATION NAME] to be expelled, the ADON stated that it was hard to tell the time frame but believed it was less than 5 minutes. According to the ADON, someone went to get Oxygen and someone went to call EMS. When asked if anyone attempted the [MEDICATION NAME] maneuver, the ADON stated that if the resident was coughing and passing air, they were not supposed to do the [MEDICATION NAME]. The ADON stated the resident's eyes were open and that s/he heard the resident breathing. When asked if anyone performed an ABC (Airway, Breathing, and Circulation) assessment on the resident, the ADON stated that when they got the resident in bed, that s/he had rolled the resident's head up, listened (for breathing), and felt a good pulse. The ADON said that s/he could hear air passing through and even wondered if they should suction the resident. The ADON stated that as soon as they got the resident in bed the DON went to check to see if the resident was a DNR (Do Not Resuscitate status) and the Staff Development Coordinator (SDC) called the resident's Responsible Party (RP) on the phone. When asked what s/he thought was wrong with the resident, the ADON said that s/he believed the resident aspirated the chicken into her/his lungs since s/he could feel and hear air passing. The ADON stated the resident had stomach breathing that was indicative of someone in bad shape. When asked if anyone had tried to give any breaths to see if the chest would rise or fall, the ADON stated, "No, you don't do rescue breathing". The ADON stated that no one tried to give breaths. When asked about the use of an ambu-bag, the ADON stated that the DON told them not to use an ambu-bag or give compressions because the resident was a DNR. When asked what the facility policy was related to a DNR status, the ADON stated that they were not to do chest compressions or rescue breathing to resuscitate anyone, but that the [MEDICATION NAME] maneuver or antibiotics could be administered. The ADON could not remember if Oxygen was brought and/or administered before EMS arrived and stated that once the resident coughed up the chicken, s/he got better. When asked about why the resident's RP revoked the DNR after the incident, the ADON stated that the family thought the facility had not done enough for the resident related to the choking incident. According to the ADON, the resident's family filed a grievance related to the choking incident and the Administrator handled the investigation into the grievance. During an interview on [DATE] at 3:15 PM, RN #1 stated that s/he had not initially responded to the dining room, but was told the resident choked. In the resident's room s/he observed Resident #2 with agonal breathing, struggling, and turning blue. RN #1 stated s/he could hear air passing. Another staff member had the resident's family on the phone and sat the resident up in bed at which time the resident coughed up a huge golf ball sized piece of chicken. Within 5 minutes after coughing up the chicken, the resident started breathing normally. RN #1 stated that initially upon going into the resident's room s/he thought about doing the [MEDICATION NAME] maneuver, but since the resident was passing air, did not. RN #1 stated that someone did check a pulse oximetry reading and it was low, possibly in the 60% range but that s/he was not sure of the exact reading. When asked what kind of treatment was done for the resident, RN #1 stated that s/he had not been one of the primary responders and that s/he went to check the resident's chart for a DNR status. RN #1 stated that the only thing s/he knew for a fact was that when the ADON sat the resident up, the resident moved more air and coughed or attempted to cough enough to get the meat up. RN #1 could not recall if Oxygen was administered and stated that no one attempted the [MEDICATION NAME] maneuver at the bedside. When asked if anyone listened or checked the resident's ABC's (airway, breathing, and circulation), RN #1 stated that s/he had not witnessed this. RN #1 stated s/he had not witnessed staff attempting to give or giving any breaths; but added that s/he was not there when the choking incident initially happened. According to RN #1, EMS initially was called when the resident was taken to her/his room, and then EMS was called off. When asked why EMS was called off, RN #1 stated that maybe EMS was called off because they didn't know what to do. RN #1 stated that one family member was in the hallway and this family member called the RP while the SDC was trying to get a decision on whether to send the resident out. RN #1 stated, "It happened so quick". The DON did check the code status and returned stating the resident was a DNR. When asked what the DNR meant, RN #1 stated that it meant not to do CPR (Cardiopulmonary Resuscitation) or a chemical code. RN #1 stated that with a DNR, EMS could be called and that staff could perform the [MEDICATION NAME] maneuver if necessary. During an interview on [DATE] at 3:25 PM, the SDC (staff development coordinator) stated that they were in a meeting on [DATE] between 12:00 Noon and 12:30 PM when one of the dining room attendants came and said that Resident #2 was choking and that s/he needed help now. The SDC stated they arrived to the dining room within 10 seconds; at which time Resident #2 was in distress but was not choking. Resident #2 was able to cough, so they told her/him to keep coughing, which the resident did; and they removed her/him from the table. The SDC stated s/he went to the telephone in the break room and called 911 while the ADON and DON assisted the resident to her/his room. In the room, the SDC directed RN #1 to check the resident's DNR status because the resident had deteriorated and had turned blue; but was still coughing and in the wheelchair. At that time, the ADON and SDC placed the resident in the bed. Two of the resident's family members were there, but not the RP. According to the SDC, Resident #2 was blue with agonal breathing, "like a fish out of water", with deep open mouthed breaths. The resident's eyes were open but s/he was not talking. The resident's eyes were moving but her/his extremities were not. The SDC stated that s/he raised the head of the bed up to assist/reposition the resident onto her/his pillow. By that time, they were told the resident was a DNR. The SDC stated s/he then told the family members that they could not resuscitate the resident because of the DNR status. According to the SDC, they tried to explain to the family members that since the person responsible for making decisions said that the resident should not be resuscitated, that they could not go against his/her wishes. One of the family members at the bedside said, "Let me call (another family member)". The SDC stated that s/he told them to call the RP instead, since s/he made the decisions and was the Power of Attorney. The family member at the bedside then left a message for the RP to call back and then called (the other family member). When the other family member got on the phone, s/he asked why the facility staff couldn't do anything for Resident #2. The SDC stated that s/he then told this family member that the resident was a DNR, and that only the RP could make that decision. It was then that the RP called back and the SDC explained to the RP that Resident #2 was in the dying process. According to the SDC, there was no pulse that s/he could feel for about 2 minutes (guesstimate). The SDC stated s/he kept her/his hand on the resident's wrist as s/he was talking to the RP. The SDC stated that s/he told the RP that Resident #2 did not have a pulse that s/he could feel. The RP asked what had happened. The SDC stated s/he told the RP what had happened and that the resident had been coughing and was placed back in bed. The RP then told the SDC that s/he wanted the facility staff to do everything possible for Resident #2. The SDC asked the RP if s/he wished to rescind the resident's DNR status and the RP rescinded the DNR. When asked if any treatment was provided to Resident #2, the SDC said, "No, the resident was a DNR, the DNR status was rescinded, and EMS was there". The SDC stated they were trying to follow the wishes for the DNR. When asked about the policy related to a DNR, the SDC stated that it meant no CPR or ventilations. That the staff was allowed to do the [MEDICATION NAME] maneuver if a resident was choking, but no chest compressions or ambu-bag (ventilations). When asked when s/he first identified the resident as having no pulse, the SDC stated that it was soon after they got the resident in bed; the resident's pulse just faded away. The SDC added that if the resident was breathing, it was so shallow you couldn't tell. The SDC stated, "There was a time that I couldn't tell s/he was breathing". When asked how long this lasted, the SDC stated, "No more than 2 minutes". Once the RP rescinded the DNR, s/he felt the resident's radial pulse come back. The SDC stated that the resident's pulse came back before the resident expelled the chicken [MEDICATION NAME]. When asked what s/he thought had happened (for the resident's pulse to return), the SDC stated that by putting the resident in the bed, they may have dislodged what was partially blocking the resident's airway. The SDC stated that s/he told the RP that the resident's pulse was getting stronger and asked the RP if s/he still wanted the resident sent out. According to the SDC, s/he called 911 after the DNR was rescinded; and by the time s/he hung up, EMS arrived and took over, placed the resident on a stretcher, and started Oxygen. The SDC did not know how the chicken [MEDICATION NAME] was removed, and stated that the chicken [MEDICATION NAME] was expelled after EMS arrived and s/he left the room. When asked if EMS had been called off because staff did not know what to do, the SDC stated that it wasn't because they didn't know what to do, but because the resident was a DNR. The SDC stated s/he called EMS from the break room not knowing the resident was a DNR. Once the SDC found that the resident was a DNR, s/he told RN #1 to go ahead and call EMS off. According to the SDC, the DON said the resident was a DNR, so they could not do resuscitative measures; that's when the family at the bedside said, "Why can't you do it?" When asked if RN #1 called EMS off, the SDC stated that RN #1 had; but once the RP wanted the DNR rescinded, EMS was called back. During an interview on [DATE] at approximately 3:50 PM, the DON stated that a staff member came and got them and said Resident #2 was choking. The resident was noted to be coughing. By the time they got Resident #2 to her/his room, the resident looked like s/he was going to pass. Some of the resident's family members were there, but not the RP. Because the resident looked so bad, they asked the family members to come into the room. The SDC spoke with another family member by phone and told her/him Resident #2 was going to die since that was what Resident #2 looked like - with agonal respirations. The SDC then spoke with the RP who revoked the DNR, and by the time all this transpired, Resident #2 started looking better. According to the DON, the resident initially expelled a piece of food in the dining room, then after the DON left the resident's room, the resident coughed up another piece of food, though s/he had not seen what came out of the resident's mouth. When asked if Oxygen was administered for the resident, the DON stated that it was so crazy that s/he was sure they had Oxygen going. The DON then stated that s/he couldn't say for sure. When asked about an assessment of the resident's ABC's (airway, breathing, and circulation) the DON stated Resident #2 was breathing and that was why the [MEDICATION NAME] was not done. The DON stated s/he spoke with the resident's RP later, after the incident, and informed him/her that they couldn't do the [MEDICATION NAME] maneuver when the resident was moving air. The DON stated that s/he explained to the RP that if the resident became unconscious, and if the resident's heart stopped, that they could not do anything because of the DNR status. When asked why they wouldn't have been able to do anything because of the DNR, the DON stated that they do not do rescue breathing or chest compressions if the heart stops. The DON stated Resident #2 was never without a pulse or respirations. The DON said that s/he thought Resident #2 was going to die; that the resident had agonal breathing. The DON was unsure if a pulse oximetry reading was taken and said the resident just started getting better and better. According to the DON, if you are trying to dislodge food from a choking victim, then you can do the [MEDICATION NAME] maneuver; but once the person stops breathing and their heart stops; if the resident was a DNR, the facility staff would not be able to do anything. The DON stated that if a resident who is a DNR choked and lost their pulse or respirations, that facility staff do not do CPR, and that was just policy. For an acute episode, if the resident was sick and had a DNR status, then staff could send the resident out, but it would depend on what the family said and if the resident was near death. An instance of this would include an acute episode like a new stroke or something that could be reversed; then they would still send the resident out. When asked if anyone did any breaths to see if the airway was blocked or if the air would go through, the DON stated that the resident was a DNR, so they didn't. During an interview on [DATE] at 4:00 PM, the ADON stated that the plan was to do an inservice on [DATE], on how to do the [MEDICATION NAME] maneuver. S/he initially planned to do it on [DATE]. The ADON stated the inservice would include information that back thrusts were not part of their policy. According to the ADON, all employees are trained on the [MEDICATION NAME] maneuver, and CNAs can only do the [MEDICATION NAME] on a conscious person. If a person becomes unconscious, licensed staff is to take over and do chest thrusts. The ADON stated they have several staff members who are dining room staff that receive extra training. These dining room staff included CNA #1 who was the dining room coordinator and Medical Records worker #1 (who was not a CNA but passed out trays). One RN was to the dining room on [DATE] s/he left early to go to a doctor's appointment prior to the incident. When asked what the dining room staff had done to help Resident #2 (on [DATE]), the ADON stated they had probably just hit the resident on the back, but that s/he hadn't seen this. During an interview on [DATE] at 3:00 PM, the ADON was asked about how the chicken [MEDICATION NAME] had been expelled. According to the ADON, EMS had not gotten there yet when the resident expelled a 2nd chicken [MEDICATION NAME]. The ADON stated this occurred minutes after they had gotten the resident back into bed. The ADON said the head of the bed was up a little bit, with the resident on her/his back, when s/he had raised Resident #2's head up higher and leaned her/him onto the siderail and the chicken came up and the resident started coming back. During a phone interview on [DATE] at 3:40 PM, the Medical Director stated s/he heard about the choking incident with Resident #2 on [DATE] while in the facility, but had not reviewed the chart related to the incident and was not aware of the details of the events that occurred. The Medical Director stated that one of the typical issues is often simply recognizing if a situation exists. If it's obvious, then staff knows the protocol. After giving the Medical Director some of the details of the incident (from information from the above staff interviews), the Medical Director said that there may have been some confusion; and to his/her general recollection, someone choked and got "unchoked" and seemed fine. It sounded like there was a period of time they (staff) may not have recognized the situation and then they did. When asked about what should have been done for the resident, the Medical Director stated s/he was a little uncomfortable giving an opinion on the situation since s/he was unsure of all the details and timeline. When asked specifically about what staff should do when they witness resident choking, the Medical Director said that looking in hindsight, most reasonable people would try to assist a person who was choking; and, if you knew someone had been eating and had choked, then something should be done to help the person to relieve the obstruction. Review of the policy provided by the policy entitled "[MEDICATION NAME] Maneuver", revised [DATE], revealed the following: "...It is the policy of this facility that any staff member may perform the [MEDICATION NAME] MANEUVER provided they have been properly instructed and have completed a successful return demonstration. Objective To expel food or foreign body lodged in the throat, creating a blockage of the airway. Clinical Signs 1. Cannot speak or breathe 2. Turns blue 3. [MEDICATION NAME] sign: Hand to neck signals: "I am choking!" 4. Collapses- death occurs in four minutes. Procedure 1. If a person is choking on food or foreign body, act immediately. Key Points To save his life. 2. Stand behind the resident and wrap your arms around his waist... 3. Place your fist, thumb side against the victim's abdomen, slightly above the umbilicus and below the breastbone. 4. Grasp your fist with your other hand and press into the resident's abdomen with a quick, upward thrust. 5. Repeat several times, if necessary, until food or foreign body has been removed. 6. If resident is sitting, stand or kneel behind the chair and perform the maneuver in the same manner. Key Points- Pressure forces the diaphragm upward, compressing the air in the lungs and expelling the object blocking the breathing passage. 7. If the resident is lying on his back, kneel to the side. 8. With one hand on top of the other, place the heel of the bottom hand on the abdomen, slightly above the umbilicus and below the breastbone. 9. Press into the resident's abdomen with a quick, upward thrust. Key Points - Continue to give abdominal thrusts until the object is forced out and the resident can breathe, cough, or talk or until he/she stops responding. 10. Repeat several times, if necessary, until food or foreign body has been removed. 11. Notify physician immediately after the emergency maneuver... 12. Chart emergency procedure, time, nature of food or foreign body, and resident's response. Include all pertinent observations. Note: If the resident becomes unresponsive, immediately lower to floor face up (from sitting or standing position) and proceed to determine need for CPR." Review on [DATE] of information retrieved from an internet website, Mediline Plus, entitled "Trusted Health Information for You", from the U.S. National Library of Medicine, NIH National Institutes of Health, revealed under "Choking- adult or child over 1 year", that considerations included that "A choking person's airway may be completely or partially blocked, so that not enough oxygen reaches the lungs. A complete blockage is a medical emergency. A partial blockage can quickly become life threatening if the person cannot properly breathe in and out. Without oxygen, permanent brain damage can occur in as little as ,[DATE] minutes. Rapid first aid for choking can save a life. Occasionally an object will enter the lung. While the person may appear to improve and breathe normally, in a few days symptoms may develop such as: Persistent cough, Pneumonia, (and) Wheezing." Some danger signs of choking included "...Bluish skin color, Difficulty breathing, Inability to speak, Loss of consciousness if the blockage is not cleared, Noisy breathing or high pitched sounds while inhaling, (and) Weak ineffective coughing." First aid included the [MEDICATION NAME] maneuver. According to the information, "...DO NOT interfere if the person is coughing forcefully, able to speak, or is able to breathe in and out adequately. However, be ready to act immediately if the person's symptoms worsen...". An Allegation of Compliance dated [DATE] was developed by the facility and included the following: (The Facility) does provide staff members that meet professional standards of quality of care, and provide the highest practicable physical, mental, and psychosocial well-being in providing emergency care and maintaining the airway for a choking resident. On [DATE], Resident #2 was sent to and returned from the hospital emergency room with diet changes. The emergency room assessed Resident #2's diet and ordered chopped meats. Resident #2 returned to the facility on [DATE], reassessed, and the facility's attending physician ordered a mechanical soft diet with chopped meats. Resident #2 was placed on the list for residents that need assistance with eating. Resident #2's care plan was updated on [DATE] and Speech Therapy re-evaluated Resident #2 on [DATE]. On [DATE], the facility's Director of Nursing audited, reviewed, and identified other potential residents that may be affected by the type of diet (regular diet/chopped meats) they are on and who had the potential of choking. One resident was identified. The identified resident will be monitored during all meal intakes, and on [DATE] was placed on the list for residents that need assistance with eating. On [DATE], the identified resident's care plan was revised. For newly admitted residents and current residents, Speech Therapy will screen on admission, during any significant changes, and quarterly. On [DATE], the facility's Emergency Response policy was changed to perform an immediate assessment of a resident's airway following a witnessed and/or suspected choking event. All licensed nursing staff, nursing assistants, and all staff that assist the residents with dining experience and feeding will be in-serviced before they are able to work. Approximately 100 of 125 staff members have been inserviced by [DATE]. The inservice includes policy review of the [MEDICATION NAME] Maneuver, demonstration of the [MEDICATION NAME] Maneuver, and returned demonstration. The in-service emphasized during any acute episode during a resident feeding, licensed staff is to perform an immediate assessment of the residents' airway following a witnessed and/or suspected choking event. Observations, review of policies and procedures and interviews on [DATE] with 7 licensed nurses and 7 CNAs (Certified Nursing Assistants) revealed facility nursing staff were knowledgeable of the need for an assessment of the resident's airway for a choking event and/or the implementation of the [MEDICATION NAME] Maneuver if indicated. It was determined that the Allegation of Compliance submitted by the facility on [DATE] had been implemented by the facility and was in practice as of [DATE] removing the immediacy of the deficient practice. The citation at F-309 remained at a lower scope and severity of "D".

On the days of the Complaint and Extended survey, based on record reviews, interviews, review of the facility policy entitled "[MEDICATION NAME] Maneuver", and reviews of information from the National Institutes of Health and Perry and Potter's Clinical Nursing Skills & Techniques, the facility nursing staff failed to provide basic emergency medical care to maintain the airway for Resident #2, one of one sampled resident reviewed for choking. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set Assessment with an Assessment Reference Date of [DATE] revealed Resident #2 had a Brief Interview for Mental Status score of 9, indicating moderate cognitive impairment at the time of the assessment. According to the assessment, Resident #2 had clear speech, and usually made her/himself understood and usually had the ability to understand others. Resident #2 required limited assistance of one person for eating; and had no natural teeth. Review of the Care Plan revealed Resident #2 had upper and lower dentures, but did not always wear them. Record review on [DATE] at 1:45 PM revealed a Departmental Note dated [DATE] at 1:20 PM which stated, "12:15 PM-- Resident was eating in dining room and was witnessed choking by her/his family members and several staff members. When RNs (Registered Nurses), (the Staff Development Coordinator and Director of Nursing) arrived immediately thereafter, s/he was breathing, but appeared to be struggling with coughing something up. Some food was coughed up in the dining room, and resident was taken back to her/his room and placed in the bed. Resident appeared limp, and her/his tongue and mouth were blue at this time. Resident was breathing agonally. Pulse is still palpable. Family at bedside. Resident is a DNR (Do Not Resuscitate), but the RP (Responsible Party), ---, states over the phone that s/he wants all life saving measures taken at this time. EMS (Emergency Medical Services) called and is on the way. Resident coughed up a large piece of what appears to be chicken, and within 5 minutes, s/he is beginning to breathe normally, and is beginning to talk. Family continues to be at bedside. 12:45 PM-- EMS has arrived and is leaving facility with resident." During a phone interview on [DATE] at 1:35 PM, CNA #1 was asked about what happened in the dining room on [DATE] in regards to the choking incident with Resident #2. CNA #1 stated that Resident #2's family member grabbed her/him by the arm and pointed to Resident #2, s/he responded by hollering to get help. CNA #1 stated that s/he could not tell if the resident was moving air or not. CNA #1 stated s/he said the resident's name, and then told Medical Records worker #1 to go get help. When asked how the resident was looking, CNA #1 stated the resident was pale. When asked if either s/he or Medical Records worker #1 had patted the resident on the back, CNA #1 stated that s/he believed Medical Records worker #1 had patted the resident's back. According to CNA #1, "I made sure s/he wasn't choking". It was just a flash (in time). CNA #1 stated s/he did not see Resident #2 cough up any food or chicken and said that s/he had stayed in the dining room after the nurses took the resident to her/his room. When asked for specifics on what had been done for the resident, CNA #1 stated s/he had called the resident's name, the resident started coughing, and the DON was standing right there. CNA #1 stated s/he did not see any food come up or hear any congestion or rattling noises coming from the resident. CNA #1 stated, "If s/he hadn't coughed when s/he did, I would have done the [MEDICATION NAME]". When asked what training s/he had received on the [MEDICATION NAME] maneuver s/he stated s/he received an annual inservice in April or May of 2013. During an interview on [DATE] at 4:08 PM, Medical Records worker #1 stated that s/he didn't recall the exact date of the choking incident with Resident #2, but stated that the incident occurred at lunch time. According to Medical Records worker #1, CNA #1 told her/him that Resident #2 was choking, and that s/he needed help. Medical Records worker #1 went to Resident #2 and asked if s/he was alright, but all Resident #2 would do was nod, s/he wouldn't speak. Medical Records worker #1 stated s/he then patted the resident on the back and Resident #2 started coughing, at which time s/he ran and got the nurses out of the meeting. Medical Records worker #1 stated s/he did not witness any chicken or food coming out of the resident's mouth, but that after s/he patted the resident's back, the resident was able to cough. Medical Records worker #1 stated that Resident #2 sounded like s/he had congestion when s/he was breathing and that led her/him to believe something else was going on. Resident #2 was still not acting right. Medical Records worker #1 stated that s/he was scared the food would go back into the resident's airway, so s/he hollered, "help, someone choking". According to Medical Records worker #1, while s/he went to get help, CNA #1 stayed with Resident #2 and her/his family who was present in the dining room during the incident. When the RNs got to the dining room, they asked the resident if s/he was all right, and the resident shook her/his head "yes", but was still congested. Medical Records worker #1 stated the nurses rolled Resident #2's wheelchair back, because the resident was not able to pick up her/his feet, and took her/him to the room. Medical Records worker #1 and CNA #1 stayed behind in the dining room. When asked to demonstrate the pats applied to Resident #2's back, Medical Records worker #1 demonstrated open handed sideways facing firm pats to the back, and stated s/he did this 3 or 4 times. Medical Records worker #1 stated s/he did not want to do the [MEDICATION NAME]. When questioned further, Medical Records worker #1 stated that the resident was moving air after s/he patted her/him on the back, but before patting the resident's back, the resident was not moving air and was not making any sounds, no gurgling sounds or sounds of congestion. When asked why s/he did not perform the [MEDICATION NAME] maneuver, Medical Records worker #1 stated that s/he was afraid to do more damage, and said that s/he was unsure if the food was really lodged. When asked what CNA #1 was doing during all this, Medical Records worker #1 stated CNA #1 had been patting the resident on the back too. During an interview on [DATE] at 2:25 PM, the Assistant Director of Nursing (ADON) stated that 2 dining room staff (Medical Records worker #1 and Certified Nursing Assistant (CNA) #1) were present in the dining room for lunch on [DATE] when the choking incident happened. The Director of Nursing (DON) and Staff Development Coordinator (SDC) took Resident #2 from the dining room to the resident's room which took about ,[DATE] minutes, and placed the resident in the bed. According to the ADON Resident #2 was not responsive but gasping and passing some air with agonal stomach breathing The ADON stated that someone called EMS (Emergency Medical Services) and someone called the resident's family. The ADON stated that s/he raised the head of the bed and leaned the resident over to the side of the bed rail because it looked like the resident was going to vomit. It was at this time the resident went "blah" and a piece of chicken came up. The ADON stated the chicken was all balled up and looked like it had been chewed and swallowed. When asked about how long it took for the chicken [MEDICATION NAME] to pop out, the ADON stated that it was hard to tell the time frame but believed it was less than 5 minutes. According to the ADON, someone went to get Oxygen and someone went to call EMS. When asked if anyone attempted to perform the [MEDICATION NAME] maneuver, the ADON stated that if the resident was coughing and passing air, they were not supposed to do the [MEDICATION NAME]. The ADON stated the resident's eyes were open and that s/he had heard the resident breathing. When asked if anyone had performed an ABC (Airway, Breathing, and Circulation) assessment on the resident, the ADON stated that when they got the resident in bed, that s/he had rolled the resident's head up, listened (for breathing), and felt a good pulse. The ADON said that s/he could hear air passing through and had even wondered if they should suction the resident. The ADON could not remember if Oxygen was brought and/or administered before EMS arrived and stated that once the resident coughed up the chicken, s/he got better. According to the ADON, a grievance was filed by the resident's family related to the choking incident and the investigation into the grievance was handled by the Administrator. During an interview on [DATE] at 3:15 PM, Registered Nurse (RN) #1 stated that s/he had not initially responded to the dining room, but had been told the resident choked. In the resident's room s/he observed Resident #2 to have agonal breathing, struggling, and turning blue. RN #1 stated s/he could hear air passing. Another staff member had the resident's family on the phone and sat the resident up in bed at which time the resident coughed up a huge golf ball sized piece of chicken. Within 5 minutes after coughing up the chicken, the resident started breathing normally. RN #1 stated that initially upon going into the resident's room s/he thought about doing the [MEDICATION NAME] maneuver, but since the resident was passing air, did not. RN #1 stated that someone did check a pulse oximetry reading and it was low, possibly in the 60% range but that s/he was not sure of the exact reading. When asked what kind of treatment was done for the resident, RN #1 stated that s/he had not been one of the primary responders and that s/he had gone to check the resident's chart for a DNR status. RN #1 stated that the only thing s/he knew for a fact was that when the ADON sat the resident up, the resident moved more air and coughed or attempted to cough enough to get the meat up. RN #1 could not recall if Oxygen had been administered and stated that no one had attempted the [MEDICATION NAME] maneuver at the bedside. When asked if anyone had listened or checked the resident's ABC's- airway, breathing, and circulation, RN #1 stated that this had not been witnessed by her/him. RN #1 stated s/he had not witnessed staff attempting to give or giving any breaths; but added that s/he had not been there when the choking incident initially happened. According to RN #1, EMS was called when the resident was taken to her/his room, and then EMS was called off. RN #1 stated that one family member was in the hallway and this family member had called the RP while the SDC was trying to get a decision on whether to send the resident out. RN #1 stated, "It happened so quick". The DON did check the code status and returned stating the resident was a DNR. When asked what the DNR meant, RN #1 stated that it meant not to do CPR (Cardiopulmonary Resuscitation) or a chemical code. RN #1 stated that with a DNR, EMS could be called and that staff could still perform the [MEDICATION NAME] maneuver if necessary. During an interview on [DATE] at 3:25 PM, the SDC (staff development coordinator) stated that they had been in a meeting on [DATE] between 12:00 Noon and 12:30 PM when one of the dining room attendants came and said that Resident #2 was choking and that s/he needed help now. The SDC stated they arrived in the dining room within 10 seconds; at which time Resident #2 was in distress but was not choking. Resident #2 was able to cough, so they told her/him to keep coughing, which the resident did; and they removed her/him from the table. The SDC stated s/he went to the telephone in the break room and called 911 while the ADON and DON assisted the resident to her/his room. In the room, the SDC directed RN #1 to check the resident's DNR status because the resident had deteriorated and turned blue; but was still coughing and in the wheelchair. At that time, the ADON and SDC placed the resident in the bed. Two of the resident's family members were there, but not the RP. According to the SDC, Resident #2 was blue with agonal breathing, "like a fish out of water", with deep open mouthed breaths. The resident's eyes were open but s/he was not talking. The resident's eyes were moving but her/his extremities were not. The SDC stated that s/he raised the head of the bed up to assist/reposition the resident onto her/his pillow. By that time, they were told the resident was a DNR. The SDC stated s/he then told the family members that they could not resuscitate the resident because of the DNR status. According to the SDC, they tried to explain to the family members that since the person responsible for making decisions said that the resident should not be resuscitated, that they could not go against his/her wishes. One of the family members at the bedside said, "Let me call (another family member)". The SDC stated that s/he told them to call the RP instead, since s/he made the decisions and was the Power of Attorney. The family member at the bedside then left a message for the RP to call back and then called (the other family member). When the other family member got on the phone, s/he asked why the facility staff couldn't do anything for Resident #2. The SDC stated that s/he then told this family member that the resident was a DNR and that only the RP could make that decision. It was then that the RP called back and the SDC explained to the RP that Resident #2 was in the dying process. According to the SDC, there was no pulse that s/he could feel for about 2 minutes (guesstimate). The SDC stated s/he kept her/his hand on the resident's wrist as s/he was talking to the RP. The SDC stated that s/he told the RP that Resident #2 did not have a pulse that s/he could feel. The RP asked what happened. The SDC stated s/he told the RP what happened and that the resident had been coughing and was placed back in bed. The RP then told the SDC that s/he wanted the facility staff to do everything possible for Resident #2. The SDC asked the RP if s/he wished to rescind the resident's DNR status and the RP rescinded the DNR. When asked if any treatment had been provided to Resident #2, the SDC said no, that the resident had been a DNR, the DNR status had been rescinded, and then EMS was there. The SDC stated they were trying to follow the wishes for the DNR. When asked about the policy related to a DNR, the SDC stated that it meant no CPR or ventilations. Staff are allowed to do the [MEDICATION NAME] maneuver if a resident is choking, but no chest compressions or ambu-bag (ventilations). When asked when s/he first identified the resident as having no pulse, the SDC stated that it was soon after they got the resident in bed; the resident's pulse just faded away. The SDC added that if the resident was breathing, it was so shallow you couldn't tell. The SDC stated, "There was a time that I couldn't tell s/he was breathing". When asked how long this lasted, the SDC stated no more than 2 minutes. Once the RP rescinded the DNR, s/he felt the resident's radial pulse come back. The SDC stated that the resident's pulse came back before the resident expelled the chicken [MEDICATION NAME]. When asked what s/he thought had happened (for the resident's pulse to return), the SDC stated that by putting the resident in the bed, they may have dislodged what was partially blocking the resident's airway. The SDC stated that s/he then told the RP that the resident's pulse was getting stronger and asked the RP if s/he still wanted the resident sent out. According to the SDC, s/he called 911 after the DNR was rescinded; and by the time s/he hung up, EMS arrived and took over, placed the resident on a stretcher, and started Oxygen. The SDC did not know how the chicken [MEDICATION NAME] had been removed, and stated that the chicken [MEDICATION NAME] had been expelled after EMS arrived and s/he left the room. When asked if EMS had been called off because staff did not know what to do, the SDC stated that it wasn't because they didn't know what to do, but because the resident was a DNR. The SDC stated s/he called EMS from the break room not knowing the resident was a DNR. Once the SDC found that the resident was a DNR, s/he told RN #1 to go ahead and call EMS off. According to the SDC, the DON said the resident was a DNR, so they could not do resuscitative measures; that's when the family at the bedside said, "Why can't you do it?" When asked if RN #1 called EMS off, the SDC stated that RN #1 had; but once the RP wanted the DNR rescinded, EMS was called back. During an interview on [DATE] at 3:00 PM, the ADON was asked about how the chicken [MEDICATION NAME] was expelled. According to the ADON, EMS had not gotten there when the resident expelled a 2nd chicken [MEDICATION NAME]. The ADON stated this occurred minutes after they had gotten the resident back into bed. The ADON said the head of the bed was up a little bit, with the resident on her/his back, when s/he had raised Resident #2's head up higher and leaned her/him onto the siderail and the chicken came up and the resident started coming back. During an interview on [DATE] at approximately 3:50 PM, the DON stated that a staff member came and got them and said Resident #2 was choking. The resident was noted to be coughing. By the time they got Resident #2 to her/his room, the resident looked like s/he was going to pass. Some of the resident's family members were there, but not the RP. Because the resident looked so bad, they asked the family members to come into the room. The SDC spoke with another family member by phone and told her/him Resident #2 was going to die; since that was what Resident #2 looked like - with agonal respirations. The SDC then spoke with the RP who revoked the DNR, and by the time all this had transpired, Resident #2 started looking better. According to the DON, the resident initially expelled a piece of food in the dining room, then after the DON left the resident's room, the resident coughed up another piece of food, though s/he did not see what had come out of the resident's mouth. When asked if there was any Oxygen administered for the resident, the DON stated that it was so crazy that s/he was sure they had Oxygen going. The DON then stated that s/he couldn't say for sure. When asked about an assessment of the resident's ABC's (airway, breathing, and circulation); the DON stated Resident #2 was breathing and that was why the [MEDICATION NAME] was not done. The DON stated s/he spoke with the resident's RP later, after the incident, and informed him/her that they couldn't do the [MEDICATION NAME] maneuver when the resident was moving air. The DON stated that s/he explained to the RP that if the resident become unconscious, and if the resident's heart stopped, that they could not do anything because of the DNR status. When asked why they wouldn't have been able to do anything because of the DNR, the DON stated that they do not do rescue breathing or chest compressions if the heart stops. The DON stated Resident #2 was never without a pulse or respirations. The DON said that s/he thought Resident #2 was going to die; that the resident had agonal breathing. The DON was unsure if a pulse oximetry reading had been taken and said the resident just started getting better and better. According to the DON, if you are trying to dislodge food from a choking victim, then you can do the [MEDICATION NAME] maneuver; but once the person stops breathing and their heart stops; if the resident was a DNR, the facility staff would not be able to do anything. The DON stated that if a resident who is a DNR choked and lost their pulse or respirations, that facility staff do not do CPR, and that was just policy. For an acute episode, if the resident was sick and had a DNR status, then staff could send the resident out, but it would depend on what the family said and if the resident was near death. An instance of this would include an acute episode like a new stroke or something that could be reversed; then they would still send the resident out. When asked if anyone did any breaths to see if the airway was blocked or if the air would go through, the DON stated that the resident was a DNR, so they didn't. On [DATE] at 3:58 PM, a Concern/Grievance Report dated [DATE] for Resident #2 was reviewed with the DON. The grievance was filed by a family member and stated, "(Family member) was very upset abut choking episode with Resident #2 on Wed(nesday) [DATE]. Wants our policy when it comes to the staff following a "DNR" and wants to know if [MEDICATION NAME] is included on things not to perform..." Documentation on the concern form revealed the grievance had been received by the Administrator on [DATE]. Under "Investigation" was written, "DNR means Do Not resuscitate which means no chest compressions or rescue breathing. Back thrusts performed in Dining Room which was effective- resident coughed up piece of chicken. Became non-responsive on way to room and due to DNR chest compressions nor rescue breathing was initiated. Unable to do deep suctioning at facility- family called to see if they wanted to send to ER. Resident was passing air through airway and was able to cough up 2nd piece of chicken." Under "Action Taken" was written "Inservice to re-educate staff on choking procedures". According to documentation at the bottom of the report, the grievance had been received by Social Services on [DATE]. There was no documentation of a follow up with the family member, just a note stating "As of [DATE]- matter has been resolved. Family has not voiced any complaints regarding this matter." The resolution date was listed as [DATE] with no documentation that an expectation had been met or not. During the interview, the DON stated that s/he had not realized that back thrusts had been performed in the dining room. When asked for the facility's investigation into the incident to include statements, the DON stated s/he would check, but did not provide any other documentation. When asked about any inservices or staff training related to the incident, the DON stated that the ADON was working on doing an inservice. During a phone interview on [DATE] at 3:40 PM, the Medical Director stated s/he had heard about the choking incident with Resident #2 on [DATE] while there in the facility, but had not reviewed the chart related to the incident and was not aware of the details of the events that occurred. The Medical Director stated that one of the typical issues is often simply recognizing if a situation exists. If it's obvious, then staff know the protocol. After giving the Medical Director some of the details of the incident (from information from the above staff interviews), the Medical Director said that there may have been some confusion; and to his/her general recollection, someone choked and got unchoked and seemed fine. It sounded like there was a period of time they (staff) may not have recognized the situation and then they did. When asked about what should have been done for the resident, the Medical Director stated s/he was a little uncomfortable giving an opinion on the situation since s/he was unsure of all the details and timeline. When asked specifically about what staff should do for a resident that had been witnessed choking, the Medical Director said that looking in hindsight, most reasonable people would try to assist a person who was choking; and, if you knew someone had been eating and had choked, then something should be done to help the person to relieve the obstruction. Review of the policy provided by the policy entitled "[MEDICATION NAME] Maneuver", revised [DATE], revealed the following: "...It is the policy of this facility that any staff member may perform the [MEDICATION NAME] MANEUVER provided they have been properly instructed and have completed a successful return demonstration. Objective To expel food or foreign body lodged in the throat, creating a blockage of the airway. Clinical Signs 1. Cannot speak or breathe 2. Turns blue 3. [MEDICATION NAME] sign: Hand to neck signals: "I am choking!" 4. Collapses- death occurs in four minutes. Procedure 1. If a person is choking on food or foreign body, act immediately. Key Points To save his life. 2. Stand behind the resident and wrap your arms around his waist....3. Place your fist, thumb side against the victim's abdomen, slightly above the umbilicus and below the breast bone. 4. Grasp your fist with your other hand and press into the resident's abdomen with a quick, upward thrust. 5. Repeat several times, if necessary, until food or foreign body has been removed. 6. If resident is sitting, stand or kneel behind the chair and perform the maneuver in the same manner. Key Points- Pressure forces the diaphragm upward, compressing the air in the lungs and expelling the object blocking the breathing passage. 7. If the resident is lying on his back, kneel to the side. 8. With one hand on top of the other, place the heel of the bottom hand on the abdomen, slightly above the umbilicus and below the breast bone. 9. Press into the resident's abdomen with a quick, upward thrust. Key Points- Continue to give abdominal thrusts until the object is forced out and the resident can breathe, cough, or talk or until he/she stops responding. 10. Repeat several times, if necessary, until food or foreign body has been removed. 11. Notify physician immediately after the emergency maneuver....12. Chart emergency procedure, time, nature of food or foreign body, and resident's response. Include all pertinent observations. Note: If the resident becomes unresponsive, immediately lower to floor face up (from sitting or standing position) and proceed to determine need for CPR." Review on [DATE] of information retrieved from an internet website, Mediline Plus, entitled "Trusted Health Information for You", from the U.S. National Library of Medicine, NIH National Institutes of Health, revealed under "Choking- adult or child over 1 year", that considerations included that "A choking person's airway may be completely or partially blocked, so that not enough oxygen reaches the lungs. A complete blockage is a medical emergency. A partial blockage can quickly become life threatening if the person cannot properly breathe in and out. Without oxygen, permanent brain damage can occur in as little as ,[DATE] minutes. Rapid first aid for choking can save a life. Occasionally an object will enter the lung. While the person may appear to improve and breathe normally, in a few days symptoms may develop such as: Persistent cough, Pneumonia, (and) Wheezing." Some danger signs of choking included "...Bluish skin color, Difficulty breathing, Inability to speak, Loss of consciousness if the blockage is not cleared, Noisy breathing or high pitched sounds while inhaling, (and) Weak ineffective coughing." First aid included the [MEDICATION NAME] maneuver. According to the information, "...DO NOT interfere if the person is coughing forcefully, able to speak, or is able to breathe in and out adequately. However, be ready to act immediately if the person's symptoms worsen...". Review on [DATE] of Perry and Potter's Clinical Skills & Techniques, 7th Edition, page 721, revealed under Emergency Measures for Life Support; "Life is dependent on the adequacy of oxygen transport to the body's tissues. Oxygen transport depends on the health of the respiratory and cardiovascular systems that power three mechanisms: ventilation, diffusion, and perfusion. Ventilation is the movement of oxygen and carbon [MEDICATION NAME] into and out of the lungs. Diffusion is the movement of oxygen and carbon [MEDICATION NAME] into and out of cells and tissues. The final mechanism to ensure oxygen delivery is perfusion or blood flow to the tissues. Anytime one or more of these three mechanisms fail, a cardiopulmonary arrest may occur....Respiratory arrest, or cessation of ventilation, results in the absence of oxygen delivery to the alveoli. Causes of a respiratory arrest include airway obstruction...Early intervention in a respiratory arrest usually prevents a [MEDICAL CONDITION]." An Allegation of Compliance dated [DATE] was developed by the facility and included the following: (The facility) does provide staff members that meet professional standards of quality of care, and provide the highest practicable physical, mental, and psychosocial well-being in providing emergency care and maintaining the airway for a choking resident. On [DATE], Resident #2 was sent to and returned from the hospital emergency room with diet changes. The emergency room assessed Resident #2's diet and ordered chopped meats. Resident #2 returned to the facility on [DATE], reassessed, and the facility's attending physician ordered a mechanical soft diet with chopped meats. Resident #2 was placed on the list for residents that need assistance with eating. Resident #2's care plan was updated on [DATE] and Speech Therapy re-evaluated Resident #2 on [DATE]. On [DATE], the facility's Director of Nursing audited, reviewed, and identified other potential residents that may be affected by the type of diet (regular diet/chopped meats) they are on and who had the potential of choking. One resident was identified. The identified resident will be monitored during all meal intakes, and on [DATE] was placed on the list for residents that need assistance with eating. On [DATE], the identified resident's care plan was revised. For newly admitted residents and current residents, Speech Therapy will screen on admission, during any significant changes, and quarterly. On [DATE], the facility's Emergency Response policy was changed to perform an immediate assessment of a resident's airway following a witnessed and/or suspected choking event. All licensed nursing staff, nursing assistants, and all staff that assist the residents with dining experience and feeding will be in-serviced before they are able to work. Approximately 100 of 125 staff members have been inserviced by [DATE]. The inservice includes policy review of the [MEDICATION NAME] Maneuver, demonstration of the [MEDICATION NAME] Maneuver, and returned demonstration. The in-service emphasized during any acute episode during a resident feeding, licensed staff is to perform an immediate assessment of the residents' airway following a witnessed and/or suspected choking event. Observations, review of policies and procedures and interviews on [DATE] with 7 licensed nurses and 7 CNAs (Certified Nursing Assistants) revealed facility nursing staff were knowledgeable of the need for an assessment of the resident's airway for a choking event and/or the implemenation of the [MEDICATION NAME] Maneuver if indicated. It was determined that the Allegation of Compliance submitted by the facility on [DATE] had been implemented by the facility and was in practice as of [DATE] removing the immediacy of the deficient practice. The citation at F-281 remained at a lower scope and severity of "D".

On the days of the survey, based on limited record reviews and interviews, the facility staff failed to review and revise the care plan for one of one sampled residents reviewed for choking. Resident #2's care plan had not been updated to include interventions to prevent choking after the resident choked on a piece of chicken. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set Assessment with an Assessment Reference Date of 5/22/13 revealed Resident #2 required limited assistance of one person for eating; and had no natural teeth. The resident had not been marked for denture use. Record review on 7/30/13 at 1:45 PM revealed a Departmental Note dated 7/10/13 at 1:20 PM which stated, "12:15 PM-- Resident was eating in dining room and was witnessed choking by her/his family members and several staff members. When RNs (Registered Nurses), (the Staff Development Coordinator and Director of Nursing) arrived immediately thereafter, s/he was breathing, but appeared to be struggling with coughing something up. Some food was coughed up in the dining room, and resident was taken back to her/his room and placed in the bed. Resident appeared limp, and her/his tongue and mouth were blue at this time. Resident was breathing agonally. Pulse is still palpable. Family at bedside. Resident is a DNR (Do Not Resuscitate), but the RP (Responsible Party), ---, states over the phone that s/he wants all life saving measures taken at this time. EMS (Emergency Medical Services) called and is on the way. Resident coughed up a large piece of what appears to be chicken, and within 5 minutes, s/he is beginning to breathe normally, and is beginning to talk. Family continues to be at bedside. 12:45 PM-- EMS has arrived and is leaving facility with resident." Review of the care plan for Resident #2 on 7/30/13 revealed an entry dated 4/18/12 entitled "CNA (Certified Nursing Assistant) Care and Data Collection Guide" used to identify resident care needs. According to the entry, the resident fed her/himself, used dentures, and required set up for meal trays. An entry dated 10/13/10 for deficits in ADLs (Activities of Daily Living) revealed that Resident #2 would feed herself after meal tray set up, and that staff were to assist as needed. It included information that the resident had upper and lower dentures, but did not always wear them. An entry dated 2/8/12 included information that Resident #2 was at risk for signs and symptoms of GI (Gastrointestinal) distress related to Barrett's Esophagus; ie. nausea/vomiting, heartburn, abdominal distention and bloating, abdominal pain and decreased appetite; but did not include any information related to interventions for choking. The resident's care plan had not been updated to indicate the resident had a recent history of choking or that the staff were to feed the resident. An Allegation of Compliance dated 8/1/13 was developed by the facility and included the following: (The Facility) does provide staff members that meet professional standards of quality of care, and provide the highest practicable physical, mental, and psychosocial well-being in providing emergency care and maintaining the airway for a choking resident. On 7/10/13, Resident #2 was sent to and returned from the hospital emergency room with diet changes. The emergency room assessed Resident #2's diet and ordered chopped meats. Resident #2 returned to the facility on [DATE], reassessed, and the facility's attending physician ordered a mechanical soft diet with chopped meats. Resident #2 was placed on the list for residents that need assistance with eating. Resident #2's care plan was updated on 7/31/13 and Speech Therapy re-evaluated Resident #2 on 8/1/13. On 7/31/13, the facility's Director of Nursing audited, reviewed, and identified other potential residents that may be affected by the type of diet (regular diet/chopped meats) they are on and who had the potential of choking. One resident was identified. The identified resident will be monitored during all meal intakes, and on 7/31/13 was placed on the list for residents that need assistance with eating. On 7/31/13, the identified resident's care plan was revised. For newly admitted residents and current residents, Speech Therapy will screen on admission, during any significant changes, and quarterly. On 8/1/13, the facility's Emergency Response policy was changed to perform an immediate assessment of a resident's airway following a witnessed and/or suspected choking event. All licensed nursing staff, nursing assistants, and all staff that assist the residents with dining experience and feeding will be in-serviced before they are able to work. Approximately 100 of 125 staff members have been inserviced by 8/1/13. The inservice includes policy review of the [MEDICATION NAME] Maneuver, demonstration of the [MEDICATION NAME] Maneuver, and returned demonstration. The in-service emphasized during any acute episode during a resident feeding, licensed staff is to perform an immediate assessment of the residents' airway following a witnessed and/or suspected choking event. Observations, review of policies and procedures and interviews on 8/1/13 with 7 licensed nurses and 7 CNAs (Certified Nursing Assistants) revealed facility nursing staff were knowledgeable of the need for an assessment of the resident's airway for a choking event and/or the implementation of the [MEDICATION NAME] Maneuver if indicated. It was determined that the Allegation of Compliance submitted by the facility on 8/1/13 had been implemented by the facility and was in practice as of 8/1/13 removing the immediacy of the deficient practice. The citation at F-280 remained at a lower scope and severity of "D".

On the day of the complaint survey based on record review and interview the facility failed to ensure two of five residents reviewed with sliding scale insulin had their physician notified of a low blood sugar. Resident #2's physician was not notified for 10 days of low blood sugars. Resident #5's physician was not notified of a low blood sugar. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the closed medical record for Resident #2 revealed the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of Resident #2's June 2011 physician's orders [REDACTED]. Further review revealed, Resident #2 was prescribed [MEDICATION NAME] 8 units every night. On 5/26/2011 the sliding scale insulin coverage was discontinued, however the blood sugars were to be monitored twice daily. There was no evidence the physician was notified of the low blood sugars. No orders were written between 6/13 and 6/25 related to insulin or blood sugars. During an interview on 8/15/2011 at 10:50 AM, the Director of Nurses (DON) confirmed the low blood sugars. The DON also confirmed the physician was not notified of the low blood sugars and the nurses should have notified the physician for order changes and/or clarification orders. The DON also confirmed there were no orders or notes written regarding the low blood sugars. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of Resident #5's, August 2011 physician's orders [REDACTED].< 50 orange juice snack... for if blood sugar less than 50 give orange juice... call MD (medical doctor) if BS (blood sugars) < 60 > 500... Insta Glucose 40% Gel contents 1 tube po (by mouth) prn (as needed) BS <50..." Further review revealed none of the above orders were followed related to the blood sugar of 49. No interventions were implemented. There was no evidence the physician was notified of the low blood sugar. During an interview on 8/15/2011 at 1:10 PM the DON confirmed the low blood sugar on 7/3/2011 and confirmed that there were no interventions implemented and the physician was not notified.

On the day of the complaint survey based on record review and interview, the facility failed to ensure 2 of 5 residents receiving insulin had interventions implemented according to the physician's orders [REDACTED]. Resident #2's blood sugar was below 50 six times between 6/14 and 6/25/2011 without the ordered interventions implemented and on 6/25 had 100 Units of Regular Insulin administered in error. Resident #5 had a blood sugar below 50 without any interventions implemented. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the physician's orders [REDACTED]. No [MEDICATION NAME] was given for the low blood sugars between 6/13 and 6/24/2011. Further review revealed, Resident #2 was prescribed [MEDICATION NAME] 8 units every night. On 5/26/2011 the sliding scale insulin coverage was discontinued, however the blood sugars were to be monitored twice daily. Review of the Nurse's Notes revealed no documentation related to the low blood sugars until a note dated 6/25/2011 at 5:45 AM stated, "Res(ident) in bed c (with) eyes open. FS (finger stick) 36. 100 U (units) of Humalog (insulin) was given. Three Insta Glucose gel was given along c a snack. MD called made aware of what happened. Blood sugar was checked while on phone c MD- FS 61. (Physician) said to watch her it was coming up and that's what we want. Call back to be sure he didn't want anything else. No orders given. " At 7:05 AM, Resident #2 was sent to the emergency room for "low blood sugar". During an interview on 8/15/2011 at 10:50 AM, the Director of Nurses confirmed the low blood sugars. The DON also confirmed the physician was not notified of the low blood sugars and the nurses should have notified the physician for order changes and/or clarification orders. The DON confirmed the resident was on a long acting insulin at night, and there had not been any changes since May 2011. The DON also confirmed there were no orders or notes written regarding the low blood sugars. The DON confirmed that LPN #1 administered 100 U of Regular Insulin to Resident #2. She also confirmed that Resident #2 did not have orders for Insta Glucose. She also confirmed that Resident #2's orders were not followed related to low blood sugars. She confirmed that if the nursing staff could not not follow the physician's orders [REDACTED]. During an interview on 8/15/2011 at 12:30 PM, LPN #1 stated that she checked Resident #2's blood sugar on 6/25/2011 at 5:30 AM. She stated that she thought the glucometer read 336. LPN #1 stated that she had administered 35 U of regular insulin per the sliding scale coverage. (Review of the Sliding Scale Coverage revealed 35 U was not an ordered amount). She stated that after she administered the 35 U she realized that was wrong and double checked the glucometer and realized the blood sugar was 36. She stated that she gave Resident #2 three Insta Glucose, and a snack. LPN #1 then reported the incident to the Supervisor who informed her to give the IM [MEDICATION NAME] and call the doctor. LPN #1 stated that she did not give 100 U of Regular Insulin and that she must have "panicked " and that was why she had said that. LPN #1 also stated that Resident #2 was receiving Sliding Scale Insulin coverage and stated that Resident #2 had an order for [REDACTED]. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the physician's orders [REDACTED]. Further review revealed none of the above orders were followed related to the blood sugar of 49. No interventions were implemented. There was no evidence the physician was notified of the low blood sugar. During an interview on 8/15/2011 at 1:10 PM the DON confirmed the low blood sugar on 7/3 and confirmed that there were no interventions implemented.

On the day of the complaint survey based on record review and interview the facility failed to ensure one of six residents care plans were updated to reflect the current status of each resident. Resident #2's care plan did not include specific interventions related to high and low blood sugars. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Care Plan revealed a problem area related to Diabetes Mellitus and low blood sugar was identified however the approaches were to "monitor for s/s of [DIAGNOSES REDACTED]". No interventions were included on the care plan. During an interview on 8/15/2011 at 2:15 PM, the Resident Assessment Coordinator (RAC) confirmed there was a care plan related to Diabetes for Resident #2 and she confirmed there were no specific interventions or follow up related to low blood sugars.