complaint·June 26, 2025

Allegation: Staff did not ensure resident's dietary needs were met resulting in the resident choking. The complaint alleges that on 6/15/2025 during breakfast meal time Memory Care resident (R1) was served the wrong diet plate and choked on a piece of sausage. According to information obtained, at the time of the incident R1 was on mechanical soft diet, but was given a regular diet plate. A total of five (5) residents were interviewed. None of the residents reported issues with the facility not following their physician order diet. Based on staff interviews, a staff person observed the resident choking and gasping for air. Staff immediately performed Heimlich maneuver and inserted two fingers when the food item was not being expelled. After the piece of sausage was expelled the resident displayed shortness of breath, which resulted in need of emergency services. All staff interviewed confirmed the resident choked because they were served the wrong food diet plate. Staff interviews revealed the staff person who served R1 their plate was unaware the resident required a special diet. Record review confirmed R1 required a mechanical soft diet at the time of the incident. There is sufficient evidence to corroborate the allegaiton. Allegation: Staff did not provide resident's advance directive and/or request to emergency personnel. It is alleged that facility staff did not provide emergency personnel resident (R1's) "Do Not Resuscitate [DNR]" form and other necessary records. A total of five (5) residents were interviewed. None reported issues with POLST or DNR documents. Staff interviews revealed that on June 15, 2025, when 911 emergency services personnel arrived at the facility and determined the resident required transport to the hospital, staff were not able to print any of the residents documents that are normally provided to emergency personnel. Staff stated that the med-tech room computer broke the day before, and the computer used the day of the incident had printing issues. Therefore, emergency personnel were not provided necessary documents i.e., Face Sheet, medication list, POLST/DNR, and medical assessment. Staff stated they asked paramedics to take a picture of the records. It is unknown which documents the paramedics took pictures of. Advance directive and/or request regarding resuscitative measures forms shall be presented to the responding emergency medical personnel. Therefore, there is sufficient evidence to corroborate the allegation. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . An exit interview was conducted with Human Resources Director Nadia Batista. A copy of the report and appeal rights were issued. Allegation: Staff did not report resident's incident to appropriate parties . It is alleged that on Sunday, June 15, 2025, during breakfast time resident (R1) choked on a piece of sausage, and staff called 911 for emergency services. The complaint alleges that R1’s responsible party was notified via text at 10:27 AM requesting a call back, and hospice nurse received a call at 10:32 AM. Information obtained revealed that emergency personnel evaluated the resident and transported R1 to a local community hospital at approximately 9:48 AM. Staff interviews revealed that the choking incident occurred at approximately 9:00 AM, and a call to 911 emergency was made at 9:14 AM. After the incident staff called R1’s responsible party and immediately after the hospice nurse was notified of the incident and medical transport. According to staff interviews, at 10:25 AM, R1’s responsible party did not answer the call, a voice message was left, and a text was sent. The responsible party returned the call at 11:22 AM and finally spoke to them at 11:44 AM. Based on interviews conducted and copies of text and phone screen shots provided by facility, the findings indicate staff notified appropriate parties i.e., responsible party and hospice agency within a reasonable time. Therefore, there is insufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations is Unsubstantiated . Exit interview conducted with Human Resources Director Nadia Batista. A copy of the report was issued.