Health inspection·March 30, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #2) reviewed for NPO status. Residents Affected - Few The facility failed to intervene timely and appropriately when Resident #2 obtainted food and began to choke. On 3/25/2024, during lunch service about 12:00 p.m., Resident #2 obtained access to Resident #1's food, staff did not provide timely interventions which led to Resident #2 choking and expiring. Resident #2 had a g-tube and was on NPO status. An IJ was identified on 03/28/24. The IJ templates were provided to the facility on [DATE] at 5:30 PM. While the IJ was removed on 3/30/24 at 7:18PM. The facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure could place residents at risk of choking or death. Findings included: Record review on 3/26/24 of self-reported incident report dated 3/25/24 revealed Resident #2 was up and wheeling around as normal. He saw another patient eating some pie at the table near the nursing station and grabbed it from him and put it in his mouth. CNA went to get it (the pie) and he started to have difficulty breathing. Director of Nursing took him to the room and suctioned, performed the Heimlich maneuver, and provided Oxygen. Family did not want him sent out but rather stay here since he was a DNR. Record review of Resident #2's face sheet dated 3/26/24, revealed he was a [AGE] year-old male, admitted on [DATE]. Resident #2 had a medical dx of OTHER SEQUELAE FOLLOWING NONTRAUMATIC SUBARACHNOID HEMORRHAGE (bleeding in the space between the brain and the tissue covering the brain), DYSPHAGIA (difficulty swallowing), COGNITIVE COMMUNICATION DEFICIT (difficulty thinking and how someone uses language), BIPOLAR DISORDER (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), SCHIZOPHRENIA (serious mental illness that affects how a person thinks, feels, and behaves), AND DEMENTIA (a group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #2's admission MDS assessment dated [DATE], revealed Resident #2 had a Page 1 of 18 675637 675637 03/30/2024 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few BIMS score of 09 which indicated Resident #2 was moderately cognitively impaired and needed help at times with indoor mobility. MDS indicates Resident #2 coughs and chokes during meals or when swallowing medication and has a feeding tube, Record review of Resident #2's care plan dated 3/26/24, stated Resident requires tube feeding with an initiated date of 2/16/24. Interventions for this tube feeding included anticipating Resident #2's needs, assisting Resident #2 to develop appropriate methods of coping and interacting. Encourage Resident #2 to express feelings appropriately. Record review of Resident #2's physician orders revealed an order for an NPO diet with an initiated date of 2/15/24. Record review of Resident #1's face sheet dated 3/26/24, revealed he was a [AGE] year old, admitted on [DATE] for Coronary Hear Disease, Hypertension, Dementia, Glaucoma, and Depression. Record review of Resident #1's admission MDS assessment dated [DATE], revealed Resident #1 had a BIMS score of 03 which indicated Resident #1 was severely cognitively impaired. Resident #1 was able to use suitable utensils to bring food and liquid to the mouth and swallow food/liquid once without assistance once the meal is placed before the resident. During an interview on 3/26/24 at 11:45a.m., the Administrator and the Director of Nursing stated, Resident #2 was seen at a table with another resident. Resident #2 was on NPO status. Resident #2 was seen with a pie plate with pie from the other resident at the table. CNA A removed the pie plate and informed the nurse at the nurse's station. LVN B (nurse at nurses' station) instructed CNA A to mov. Resident #2 from the table. CNA A was moving Resident #2 when she noticed he had changed in his demeanor and informed LVN B. LVN B then instructed CNA A to take Resident #2 to his room for an assessment. The Director of Nursing states I was called to Resident #2's room to assist LVN B with Resident #2. Resident #2 was unresponsive but still breathing when we transferred him to his bed. I did the Heimlich maneuver while sitting on the bed behind him. We did suction him with no residual. The Hospice nurse walked in while Resident #2 was being suctioned. Resident #2 did eventually expire, and the Hospice nurse called the time and date of 3/25/2024 at 12:38p.m. During an interview on 3/27/2024 at 11:45 a.m., with CNA D she stated she placed Resident #1 at a table in front of the nurse's station for monitoring of his food intake. CNA D stated she did not see anyone at the nurse's station at the moment she placed the tray of food in front of Resident #1 and left to pass the other trays for her hall. During a phone interview on 3/26/2024 at 1:18 p.m., with CNA A she stated she saw Resident #1 and Resident #2 sitting at a table together. CAN A stated Resident #2 was seen with a pie plate from Resident #1. CNA A stated He did have crumbs on his clothes CNA A stated the plate was removed from Resident #2 due to his NPO status. CNA A stated she informed LVN B of Resident #2 having wheeled himself to a table and getting a pie plate with pie. Resident #2 got the pie by being at the table while Resident #1 has his lunch tray and LVN B instructed CNA A to move Resident #2 away from the table. Immediately after informing LVN B of Resident #2 having the pie, CNA A stated she was moving Resident #1 and noticed he was pale in color and was not responding to her. CNA A stated after informing LVN B, LVN B instructed CNA A to take the Resident #2 to his room. CNA A stated she is unsure how much time passed because it happened so quickly. During an Interview on 3/26/2024 at 12:53 p.m., LVN B stated she instructed CNA A to escort 675637 Page 2 of 18 675637 03/30/2024 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #2 to his room for an assessment. LVN B stated she called out for RN to assist in Resident #2's room. LVN B stated she is unsure how much time passed because it all happened so quickly. During an interview on 3/26/2024 at 12:30 p.m., RN C stated she entered the room of Resident #2 and when he stopped breathing, she initiated the Heimlich maneuver and eventually suctioned Resident #2. RN C stated Resident #2 was on Hospice and the family did not want emergency services called. Resident #2 did expire with the Hospice nurse in the room and the Hospice nurse pronounced time of expiration. During a phone interview on 3/28/24 at 5:34pm, the Hospice Nurse said, Resident #2 was lying in his bed with the head of the bed elevated upright to what appeared to be the highest position, there were four to five nurses surrounding patients' bed, patient is noted with the pulse ox monitor to his right hand and electronic blood pressure monitor to right arm. At this time the nurse (unknown which nurse) tells me the patient who has a dx of dysphagia grabbed a pie from another patient and ate it. Resident #2's skin is cyanotic, and eyes are partially open, patient had an oxygen mask on and one of the floor nurses was attempting to perform deep oral suction. I then grabbed my phone to attempt to call patients sister from my work phone but was unable to find her number at this time one of the nurses states she was going to call the patient's family member and inform her of the situation, I then called Nurses on wheels office to get the caregivers number but at this time the nurse reentered the room and stated that the patients sister did not want to revoke the Do Not Resuscitate order and refused to have patient sent to the hospital. I did see some particles in the suction machine canister. At 12:37pm - 12:38pm I attempted to obtain a manual BP reading. I was unable to auscultate a BP reading or an apical pulse. Pupils assessed and were fixed and dilated. I then waited 1 full minute to obtain a second set of vitals, upon second attempt no BP, no pulse and no respirations. I then pronounced Resident #2 at 12:38pm. During an interview on 3/30/2024 at 12:15 p.m., CNA C stated when she arrived yesterday (3/29/24), she was told of the choking event that led to Resident #2 expiring at the facility and stated that Resident #2 consistently would ask to eat food, however CNA C stated she would redirect Resident #2 to participate in activities during mealtimes. During an interview on 03/30/2024 at 12:31 p.m., RN C stated the facility has provided education on abuse and neglect, Heimlich maneuver, time management, and during emergent situations do not waste time and must immediately call 911. During an interview on 3/30/2024 at 12:56 p.m., CNA E stated she had worked with Resident #2 prior and saw a tube feeding pump and would monitor him and stated Resident #2 would ask for food consistently in a form of hand gesture and this resident could self-propel his wheelchair. Record review of facility policy titled, Removing Foreign Body Airway Obstruction-Heimlich Maneuver and dated 07/07/20 included verbiage that stated, If severe airway obstruction develops, quick intervention is necessary to relieve the obstruction. Anoxia resulting from such obstruction may cause brain damage and death. There was no policy provided regarding residents on NPO status. This was determined to be an Immediate Jeopardy (IJ) on 03/28/24. The Administrator and the Director of Nursing were notified. The IJ template was provided to the facility on [DATE] at 5:30 PM. The following Plan of Removal submitted by the facility was accepted on 3/29/2024 at 6:27 p.m. The following plan of action outlines immediate interventions employed by the facility to remove 675637 Page 3 of 18 675637 03/30/2024 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0684 any further concerns surrounding the alleged issue of professional standards of practice. Level of Harm - Immediate jeopardy to resident health or safety Identification of other residents having the potential to be affected: Residents Affected - Few o The facility has a binder at the nurse's station that identifies residents that have an NPO status. o Audit completed of all residents' diets and NPO status. o Residents who are identified to be at risk for potential hazards related to NPO status will be monitored for potential risk of harm. Measures/Systemic Changes to ensure the deficient practice does not recur: All licensed staff will be re-educated on responding timely to emergent situations by DON and/or IP nurse. DON was reeducated by the Regional Director of Clinical Services on 3/26/2024. In-servicing by administrative nursing staff on Heimlich Maneuver per policy to be done facility wide. NPO book will be reviewed and updated as needed by DON and /or IP nurse Monday - Friday. In-servicing by administrative nursing staff (DON and/or IP nurse) on resident assessment and response to emergencies in a timely manner. Ongoing Monitoring: Daily rounding during mealtimes by administrative staff to ensure dining room supervision until compliance is achieved. All components of this plan of correction will be submitted to the facility QAPI committee meeting for three months and additional recommendations will be made until substantial compliance has been achieved. The Medical Director was notified and agrees with the plan of correction. The Admin Nursing Staff to include, Don, Infection Prevention Coordinator, Regional Director of Clinical Services, Executive Director, or designee are responsible for the corrections and continued monitoring. Verification of the facility's Plan of Removal Included: Record review, the facility conducted 100% review of all residents identified with gastric tubes and NPO status, as well as reviewed all residents with modified/restrictive diets. Record review of Resident #1's physician dietary orders, audited on 03/29/2024, revealed order dated 2/22/2024 for Resident #1 to receive regular diet, easy to chew texture, thin consistency. There 675637 Page 4 of 18 675637 03/30/2024 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0684 were no concerns noted. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #3's physician dietary orders, audited on 03/29/2024, revealed order dated 3/14/2024, enteral feeding documented Resident #3 to receive Glucerna 1.2, 55 ml/ hour for 22 hours. 100mL water flush Q4hr - There were no concerns noted. Residents Affected - Few Record review of Resident #4's physician dietary orders, audited on 03/29/2024, order dated 07/25/2023, regarding enteral feeding documented Resident #4 to receive Fibersource at 70 ml/hour x 20 hours via pump, with 150mls water flush Q4 hours. There were no concerns noted. Record review of Resident #5's physician's dietary modification orders was audited on 03/29/2024, order dated 02/29/2024, documented Resident #5 to receive sodium restricted diet, regular texture, thin consistency. There were no concerns noted. During an observation and interview on 03/30/2024 at 4:47PM observed Resident #3's tube feeding. Resident #3 had Glucerna 1.2 infusing at 55mL/HR, with a scheduled 100ml water flush Q4hr. Resident #3 stated she did not have any concerns regarding her tube feedings. Resident #3 stated she knew why she was receiving tube feedings, and that the clinical staff attend to her needs when she requests assistance. During an observation on 03/30/2024 at 5:13PM Resident #1 was in the dining room eating his easy to chew meal which consisted of chicken, mashed potatoes, carrots, a slice of bread and tea. Resident #1 was able to ingest his food with no issues observed. No observable concern. During an observation on 03/30/2024 at 5:23PM, Resident #4 was receiving tube feeding. Resident #4 had Fiber source infusing at 70 ml/hour via pump with 150mL water flush Q4hr. Resident #4 did not exhibit any signs of distress. No concerns observed. During an interview on 03/30/2024 at 12:15PM, CNA C CNA C stated if she were to encounter a person with a change in color, she has been educated to call immediately for assistance, and will stay with patient until nurse arrives. CNA C stated if she were to experience a resident choking, she will initiate a Heimlich maneuver, and position her hands within the abdomen area and thrust upward. CNA C stated she has been also taught another way to alarm the nursing staff was to call for help loudly, to signify that a person was in distress and needs emergency assistance, that could potentially lead to death. CNA C stated the CNAs were usually supervising residents eating and observe how they eat and how much they eat and will report to the nurses any irregularities with eating/ eating behaviors. CNA C stated she has been instructed to set up a tray properly, which would involve cutting the proteins in bite size measurements, and will continue to observe residents eating, however if she must vacate area, she will return immediately to ensure the resident's safety, and will make sure the resident eats a good percentage of their meal. CNA C stated when she arrived yesterday (3/29/24), she was told of the choking event that led to Resident #2 expiring and stated that Resident #2 consistently would ask to eat food, however CNA C stated she would redirect Resident #2 to participate in activities during mealtimes. CNA C stated she has been educated on types of abuse which would encompass forcefully inflicting pain, and would report to the charge nurse, DON, and Administrator. CNA C stated she was last in-serviced about Code Blue, Heimlich Maneuvers, Abuse and Neglect, and Falls on 03/29/2024. During an interview on 03/30/2024 at 12:31PM, RN Charge Nurse; RN C stated the facility has provided education on abuse and neglect, and Heimlich maneuver, time management, and during emergent 675637 Page 5 of 18 675637 03/30/2024 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few situations do not waste time and must immediately call 911. RN C stated for a full code blue, she has been educated on the proper procedures on how to conduct CPR and to always notify the chain of command. RN C stated Resident #2 was her patient on 03/25/2024 and she was on break when choking/expiration happened. RN C stated she was very sad about event. RN C stated Resident #2 was NPO due to dysphagia and had difficulty swallowing. RN C stated that Resident #2 was mobile via wheelchair and was able to wheel himself throughout the facility. RN C stated Resident #2 never requested food, and when she would ask if he was hungry, once the tube feeding was complete, he would state he was full. RN C stated Resident #2 was not impulse and enjoyed counting monopoly money. RN C said while she was on break, LVN A and the floor CNAs were the ones who were watching her residents. RN C stated Resident #2's behavior never made her believe that he would take something that was not his. RN C stated she administered Resident #2's gastric tube feed at 10AM on 03/25/2024. RN C stated once she returned Resident #2 had passed away. RN C stated family had already been notified. RN C stated she has been educated to initiate Heimlich maneuver immediately and call out for help, the helpers would be the ones contacting chain of command as well as calling for Emergency assistance, while she continues to attempt to dislodge any particles or foreign substances out of the resident's oral cavity. RN C stated that she will begin the Heimlich maneuver to ensure resident's safety followed by then assessing the oral cavity, all as preventative measure to maintain the resident's safety and wellbeing. RN C stated in her professional opinion, the treatment nurse was wrong, and should have acted immediately because time was very important. RN C stated privacy can be maintained later, life is what is important. During an interview on 03/30/2024 at 12:56PM, CNA D, CNA E, both stated they were in-serviced about abuse, neglect, when to report abuse and neglect, NPO definition, change in condition, and to report any immediate changes. Both stated they performed the Heimlich maneuver. Both stated to perform the Heimlich maneuver will situate hands under rib cage, and in an upward motion will thrust. Both stated they were comfortable with performing the Heimlich maneuver on heavier set people. CNA D stated she observed to her left Resident #1, crumbs on chest, thighs, and plate right in front of him. CNA D stated she knew that Resident #1 was NPO and there was nothing on the plate. CNA D notified the Treatment nurse, who instructed CNA D to take the plate away from him, and foot was caught in wheelchair and saw resident leaning to right side, and picked up his hat and his eyes were drifted to the right. The treatment nurse instructed CNA D to take to his room, and CNA D asked LVN A and Resident #1 was breathing lightly slow breathes, and while in front of an office and LVN A looked at him, then instructed to take Resident #1 into his room which was position 3 room down in 106A. CNA D stated the treatment nurse, LVN A, MDS Coordinator, and DON entered Resident #2's room. CNA D stated it could not be more than 2 minutes between the time she returned Resident #2 from the table to his room. CNA E stated that fall risk patients were positioned near the nurse's station to ensure there were people watching. CNA E stated she had worked with Resident #2 prior and saw a tube feeding pump and would monitor him and would ask for food consistently in a form of hand gesture. CNA E stated she was in his room on the day in question, and hospice nurse had just bathed Resident #2, and Resident #2 had wheeled himself out of his bedroom. Both stated they have been educated to stay with the patient and yell out for help from all clinical staff and have also been instructed to perform the Heimlich maneuver immediately. Both stated types of abuse they have been educated on were emotional, physical, and mental, if they notice a new bruise, abrasions, skin tears, and color will notify charge nurse and administrator if they suspect abuse. Both stated they attended in-services 03/29/2024- 03/30/2024. During an interview on 03/30/2024 at 1:28PM, CNA F, CNA G, CNA H, CNA I; all have stated they have been educated on Abuse and Neglect and NPO precautions, Heimlich maneuver. All 675637 Page 6 of 18 675637 03/30/2024 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few stated NPO precautions were implemented for those residents that have gastric tubes that do not allow them to eat through their oral cavities. All stated they will advocate for a nurse to intervene by calling out for help and would initiate the Heimlich maneuver immediately if a resident was witnessed choking and knows that it may be due to eating/choking issue. All stated to position hands above the gastric tubes and as close to the rib cage/abdomen area and will conduct an upward thrust and will stay with the resident until the nurse arrives and will await their instructions. Resident #1was CNA I's resident and was able to eat by himself and was in the front so that there were more eyes to watch him. All stated Resident #2 had dementia but was able to eat on his own and does not allow people to eat from his tray. All stated facility has implemented that all residents that need assistance to eat will be assisted in the dining room area, snack cart was now put behind nurses' station, as well as coffee station was now served only in dining area. CNA E stated she had seen Resident #2use a hand to mouth gesture that indicated he was hungry and wanted to eat. All stated, types of abuse they have been educated on were physiological, physical, sexual, verbal, abandonment, and misappropriation of property. All stated, signs and symptoms of abuse could be sad, crying, grimacing of pain, skin coloration, bruises, behavioral abnormalities, or resident verbalizes allegation. All stated if they do suspect abuse, they will report immediately to the charge nurse and administrator. During an interview on 03/30/2024 at 1:55PM, LVN A stated on 03/25/2024 around lunch time, she was at the nurse's station, on the phone getting a surgery date for another resident, when she was alerted by CNA D that help was needed. LVN A stated she then got her pulse oximeter and saw Resident #2 in distress in his room. LVN A stated she also saw the DON, MDS Coordinator, and CNA D. LVN A saw the DON performing the Heimlich maneuver. LVN A stated the treatment nurse was at the nurse's station conducting some form of documentation on the computer. LVN A stated she did not see anything going on, and once CNA D alerted her, she then reacted and went to Resident #2's room. LVN A stated she was focused on her trying to get her own resident a follow up appointment for surgery, she did not hear CNA D speak with the treatment nurse. LVN A stated it was no more than a minute from when LVN A was alerted to the time she entered Resident #2's room. LVN A stated, while the Director of Nursing was performing the Heimlich maneuver, saw some particles come out of Resident #2's mouth, but nothing else was coming up. LVN A stated the MDS Coordinator went to get a suction. LVN A stated she felt Resident #2's pulse and was gasping for air, and multiple times tried to get a blood pressure on Resident #2 but was not reading, and the pulse oximeter oxygen reading was in the 70's and administered oxygen through a simple mask, not a non-rebreather mas. LVN A stated the MDS Coordinator then returned and suctioned some particles with yanker and deeper suctioned, but nothing was working. LVN A stated they actively tried to suction and could hear Resident #2's heartbeat and was told by an unknown staff member that Resident #2's family member did not want to send Resident #2 into the hospital. LVN A stated she was positioned on the right side of Resident #2 and the hospice nurse was in the room standing to the further part of the room. LVN A stated she asked/told the hospice nurse to check pulse, and throughout the incident Resident #2's face would turn blue then return to normal skin color. LVN A stated Resident #2 was not exhibiting signs of choking. LVN A stated for sure the Heimlich maneuver should have been conducted as well as an assessment on scene, as opposed to having the resident taken to their room because maintaining the life of a patient was more important than maintaining their privacy for emergent situations. LVN A stated Resident #2 was sitting at the edge of bed and the DON performed Heimlich maneuver for approximately 5-10minutes, nothing substantial came out, followed by the staff member placing him back in bed with the head of the bed raised, eyes were not open, and body would sporadically jerk and when performing sternal rub Resident #2's body would jerk 675637 Page 7 of 18 675637 03/30/2024 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few but then stop. LVN A stated Resident #2's breathing was light/labored breathing, then stop and then would twitch/jerk sporadically. LVN A stated she has been educated to perform an assessment immediately once it was known there was cause of an emergent situation as well as to begin a Heimlich maneuver immediately when a resident was choking. During an interview on 03/30/2024 at 2:36PM, Laundry Attendant A, Laundry Attendant B; Both stated that if they witness a resident actively choking and were standing up, they will immediately perform the Heimlich maneuver, or if they were in a wheelchair, they will call out for help from the clinical. Both stated they were in-serviced about abuse, neglect, reporting of abuse/neglect reporting, where the NPO book was located and the definition of NPO which means nothing by mouth. Both stated they were also in-serviced about the Heimlich maneuver and how to perform the Heimlich maneuver by placing both hands under the rib cage and thrusting in an upwards motion. During an interview on 03/30/2024 at 2:45P, CNA J, CNA K, CNA L, CNA M, all stated if they were to encounter a resident that was showing signs of pallor or change in condition they will call out for the nurses' help. All stated that they will immediately commence the Heimlich maneuver, would perform the Heimlich maneuver by placing their hands on the resident's abdomen and performing a forceful upward thrust. All stated, as a collaborative effort if a resident needed to be observed while eating, the CNAs were primarily the people to do the observation, and if they must leave for any reason the nurses will take over. All stated, those residents that need assistance eating were now located in the dining room area. All stated, the snack carts were located behind the nurse's station now, and coffee station was now behind the nurses' stations as well. All stated, those residents that were NPO were now updated according in the POC as well as inputted in the NPO book that was located at the nurse's station. All stated, they were in-serviced about NPO definition, abuse and neglect, Heimlich maneuver. All stated, the facility has instructed to be more observant of the NPO residents that were mobile. All stated, abuse and neglect, encompass verbal, mental, physical, isolation, and emotional abuse. All stated, if they suspect abuse, they will report suspicion to the charge nurse and administrator. All stated they were in-services from 03/27/2024-03/30/2024. During an interview on 03/30/2024 at 3:02PM, LVN B stated she was (8YEARS) full time: LVN B stated she worked the second shift (3-11PM) on 03/25/2024. LVN B stated Resident #2 was impulsive and would consistently ask to eat actual food and would also exhibit frustration when told he was not allowed to eat via oral cavity due to swallowing issues. LVN B stated Resident #2's mental compacity could have limited him in understanding why he could not eat through oral cavity. LVN B stated she has been educated that if she were to see a resident actively choking, she would immediately perform the Heimlich maneuver, and stated she would immediately assess the resident if the resident was exhibiting signs of distress, change in condition, or change in skin coloration. LVN B stated as a nurse, she will always prioritize the safety and well-being of a resident before maintaining their privacy because she believes, in her professional opinion, that keeping her residents' lives and thriving was the most important reason, the well-being of her residents come before maintaining their privacy because resident's lives were more important. LVN stated she was educated that a nurse needs to always stay in the dining room while residents were in the dining room, also on abuse, neglect, NPO definition (make sure no foods available to them for their safety), and Heimlich maneuver. LVN stated the facility has instructed the clinical staff to be more vigilant, LVN B caught Resident #1 walking and was very mobile and stressed that Resident #1 was impulsive. LVN stated Resident #2 was very determined. LVN stated there are all types of abuse including physical, sexual, verbal, monetary. LVN stated she was looking out for signs of symptoms of abuse by being observant of bruises, behavioral abnormalities, and family hostile dynamics, 3/27/2024 and 3/29/2024. 675637 Page 8 of 18 675637 03/30/2024 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an interview on 03/30/2024 at 3:36PM, LVN C stated she worked here for8years; (3-11PM) LVN C stated that Resident #2 would state he was hungry all the time. LVN C stated Resident #2 was active and would administer bolus feeds 5 times a day. LVN C stated she worked on 03/25/2024 the evening shift (3-11PM). LVN C stated the facility implemented a new process of the medication aides will be observing residents eat/assisting residents to eat within the dining room area solely. LVN C stated that the event with Resident #2 on 03/25/2024 potentially was avoidable, and continued by stating the nursing staff should have reacted immediately to render aide to Resident #2, not remove Resident #2 from the table area, in front of the nurse's station, to his room. LVN C stated the time it took for Resident #2 to be transported to his room, the clinical staff could have assessed the resident and immediately started to perform the Heimlich maneuver. LVN C stated in NPO residents should be given multiple diverting activities during mealtimes as a preventative measure to keep them from being around others that were eating actual food. LVN C stated she would in her professional opinion, as a nurse, if she were to encounter a choking resident, she would immediately assess the residents, perform vital signs and begin an investigation immediately to advocate for the residents' health and well-being. LVN C stated that residents' lives were more important than maintaining a resident's privacy. LVN C stated she was educated/in-serviced about NPO definition, NPO book, abuse, neglect, Heimlich maneuver. LVN C stated all residents that need feeding assistance will be assisted in the dining room, and all snack carts will be positioned in the nursing station. During an interview on 03/30/2024 at 4:06PM, LVN D (11PM-7PM) LVN D stated he was educated on the importance of reporting abuse and neglect, reporting any allegation of abuse, completing incident reports, specialized diets, NPO status, and Heimlich maneuver. LVN D stated if resident was actively exhibiting signs of distress including choking, he would act upon the concern immediately. LVN D stated a resident's life was more important than maintaining privacy during an emergent situation. LVN D stated if he were to be notified of a resident's change of condition, he would immediately assess the resident, attain vital signs, and if it determined they are choking, he would immediately perform the Heimlich maneuver. LVN D stated the tables that were initially in the front of the nurses' station were used for residents to eat at when the dining room was overly loud and stimulating. LVN D stated the facility has now instructed the clinical staff that residents that need to be assisted to eat, will now be solely done in the dining room. LVN D stated the facility has implemented 1 nurse will be in the dining room during mealtimes and will stay till the last resident finishes. LVN D stated he was in-serviced on the multiple topics yesterday, 03/29/2024. During an interview on 03/30/2024 at 4:21PM, (10PM-7A night shift) CNA M stated she was educated/in-serviced about if there was an incident, she must notify the [TRUNCATED] 675637 Page 9 of 18 675637 03/30/2024 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure residents receive adequate supervision to prevent accidents for 1 of 3 residents reviewed for NPO status. Residents Affected - Few The facility failed to ensure Resident #1 was adequately supervised while eating lunch. On 3/25/2024, during lunch service about 12:00 p.m., CNA D did not ensure adequate supervision of Resident #1 while eating. Resident #2 obtained access to Resident #1's food, choked and died. Resident #2 had a g-tube and was on NPO status. An IJ was identified on 03/28/24. The IJ templates were provided to the facility on [DATE] at 5:30 PM. While the IJ was removed on 3/30/24 at 7:18PM. The facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure could place residents at risk of choking or death. Findings included: Record review on 3/26/24 of self-reported incident report dated 3/25/24 revealed Resident #2 was up and wheeling around as normal. He saw another patient eating some pie at the table near the nursing station and grabbed it from him and put it in his mouth. CNA went to get it (the pie) and he started to have difficulty breathing. Director of Nursing took him to the room and suctioned, performed the Heimlich maneuver, and provided Oxygen. Family did not want him sent out but rather stay here since he was a DNR. Record review of Resident #2 face sheet revealed he was a [AGE] year-old male, admitted on [DATE], Resident #2 had a medical dx of OTHER SEQUELAE FOLLOWING NONTRAUMATIC SUBARACHNOID HEMORRHAGE (bleeding in the space between the brain and the tissue covering the brain), DYSPHAGIA (difficulty swallowing), COGNITIVE COMMUNICATION DEFICIT (difficulty thinking and how someone uses language), BIPOLAR DISORDER (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), SCHIZOPHRENIA (serious mental illness that affects how a person thinks, feels, and behaves), AND DEMENTIA (a group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #2's admission MDS assessment dated [DATE], revealed Resident #2 had a BIMS score of 09 which indicated Resident #2 was moderately cognitively impaired and needed help at times with indoor mobility. MDS indicates Resident #2 coughs and chokes during meals or when swallowing medication and has a feeding tube, Record review of Resident #2's care plan dated 3/26/24, stated Resident requires tube feeding with an initiated date of 2/16/24. Interventions for this tube feeding included anticipating Resident #2's needs, assisting Resident #2 to develop appropriate methods of coping and interacting. Encourage Resident #2 to express feelings appropriately. Record review of Resident #2's physician orders revealed an order for an NPO diet with an initiated date of 2/15/24. 675637 Page 10 of 18 675637 03/30/2024 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of Resident #1's face sheet dated 3/26/24, revealed he was a [AGE] year old, admitted on [DATE] for Coronary Hear Disease, Hypertension, Dementia, Glaucoma, and Depression. Record review of Resident #1's admission MDS assessment dated [DATE], revealed Resident #1 had a BIMS score of 03 which indicated Resident #1 was severely cognitively impaired. Resident #1 was able to use suitable utensils to bring food and liquid to the mouth and swallow food/liquid once without assistance once the meal is placed before the resident. During an interview on 3/26/24 at 11:45a.m., the Administrator and the Director of Nursing stated, Resident #2 was seen at a table with another resident. Resident #2 was on NPO status. Resident #2 was seen with a pie plate with pie from the other resident at the table. CNA A removed the pie plate and informed the nurse at the nurse's station. LVN B (nurse at nurses' station) instructed CNA A to mov. Resident #2 from the table. CNA A was moving Resident #2 when she noticed he had changed in his demeanor and informed LVN B. LVN B then instructed CNA A to take Resident #2 to his room for an assessment. The Director of Nursing states I was called to Resident #2's room to assist LVN B with Resident #2. Resident #2 was unresponsive but still breathing when we transferred him to his bed. I did the Heimlich maneuver while sitting on the bed behind him. We did suction him with no residual. The Hospice nurse walked in while Resident #2 was being suctioned. Resident #2 did eventually expire, and the Hospice nurse called the time and date of 3/25/2024 at 12:38p.m. During an interview on 3/27/2024 at 11:45 a.m., with CNA D she stated she placed Resident #1 at a table in front of the nurse's station for monitoring of his food intake. CNA D stated she did not see anyone at the nurse's station at the moment she placed the tray of food in front of Resident #1 and left to pass the other trays for her hall. During a phone interview on 3/26/2024 at 1:18 p.m., with CNA A she stated she saw Resident #1 and Resident #2 sitting at a table together. CAN A stated Resident #2 was seen with a pie plate from Resident #1. CNA A stated He did have crumbs on his clothes CNA A stated the plate was removed from Resident #2 due to his NPO status. CNA A stated she informed LVN B of Resident #2 having wheeled himself to a table and getting a pie plate with pie. Resident #2 got the pie by being at the table while Resident #1 has his lunch tray and LVN B instructed CNA A to move Resident #2 away from the table. Immediately after informing LVN B of Resident #2 having the pie, CNA A stated she was moving Resident #1 and noticed he was pale in color and was not responding to her. CNA A stated after informing LVN B, LVN B instructed CNA A to take the Resident #2 to his room. During an Interview on 3/26/2024 at 12:53 p.m., LVN B stated she instructed CNA A to escort Resident #2 to his room for an assessment. LVN B stated she called out for RN to assist in Resident #2's room. During an interview on 3/26/2024 at 12:30 p.m., RN C stated she entered the room of Resident #2 and when he stopped breathing, she initiated the Heimlich maneuver and eventually suctioned Resident #2. LVN E stated she did see the suctioning process produce some residual particles of something. RN C stated Resident #2 was on Hospice and the family did not want emergency services called. During a phone interview on 3/28/24 at 5:34pm, the Hospice Nurse said, Resident #2 was lying in his bed with the head of the bed elevated upright to what appeared to be the highest position, there were four to five nurses surrounding patients' bed, patient is noted with the pulse ox monitor to his right hand and electronic blood pressure monitor to right arm. At this time the nurse (unknown which nurse) tells me the patient who has a dx of dysphagia grabbed a pie from another patient and ate 675637 Page 11 of 18 675637 03/30/2024 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few it. Resident #2's skin is cyanotic, and eyes are partially open, patient had an oxygen mask on and one of the floor nurses was attempting to perform deep oral suction. I then grabbed my phone to attempt to call patients sister from my work phone but was unable to find her number at this time one of the nurses states she was going to call the patient's family member and inform her of the situation, I then called Nurses on wheels office to get the caregivers number but at this time the nurse reentered the room and stated that the patients sister did not want to revoke the Do Not Resuscitate order and refused to have patient sent to the hospital. I did see some particles in the suction machine canister. At 12:37pm - 12:38pm I attempted to obtain a manual BP reading. I was unable to auscultate a BP reading or an apical pulse. Pupils assessed and were fixed and dilated. I then waited 1 full minute to obtain a second set of vitals, upon second attempt no BP, no pulse and no respirations. I then pronounced Resident #2 at 12:38pm. During an interview on 3/30/2024 at 12:15 p.m., CNA C stated when she arrived yesterday (3/29/24), she was told of the choking event that led to Resident #2 expiring at the facility and stated that Resident #2 consistently would ask to eat food, however CNA C stated she would redirect Resident #2 to participate in activities during mealtimes. During an interview on 03/30/2024 at 12:31 p.m., RN C stated the facility has provided education on abuse and neglect, Heimlich maneuver, time management, and during emergent situations do not waste time and must immediately call 911. During an interview on 3/30/2024 at 12:56 p.m., CNA E stated she had worked with Resident #2 prior and saw a tube feeding pump and would monitor him and stated Resident #2 would ask for food consistently in a form of hand gesture and this resident could self-propel his wheelchair. Record review of facility policy titled, Removing Foreign Body Airway Obstruction-Heimlich Maneuver and dated 07/07/20 included verbiage that stated, If severe airway obstruction develops, quick intervention is necessary to relieve the obstruction. Anoxia resulting from such obstruction may cause brain damage and death. There was no policy provided regarding residents on NPO status. Record review of facility dining, and meal service policy titled, Meal Service and Resident Dining Services dated 8/24/2023 and 4/26/2023 does not indicate monitoring or supervision of residents during mealtimes. This was determined to be an Immediate Jeopardy (IJ) on 03/28/24. The Administrator and the Director of Nursing were notified. The IJ template was provided to the facility on [DATE] at 5:30 PM. The following Plan of Removal submitted by the facility was accepted on 3/29/2024 at 6:27 p.m. The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the alleged issue of professional standards of practice. Identification of other residents having the potential to be affected: o DON updates NPO book in morning meeting which is shared with all staff. o 675637 Page 12 of 18 675637 03/30/2024 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0689 This will be reviewed Monday - Friday and updates as needed. Level of Harm - Immediate jeopardy to resident health or safety o Residents who are identified to be at risk for potential hazards related to NPO status will be monitored for potential risk of harm. Residents Affected - Few Measures/Systemic Changes to ensure the deficient practice does not recur: Daily rounding during mealtimes by administrative staff to ensure adequate dining room supervision. Supervision will be done by nursing staff with direct over-sight while feeding assistants assist with feeding patients that will need it. In-services and education for all staff will be completed by 3-29-24 by Admin Nursing Staff to include, DON, , Infection Prevention, , , Regional Director of Clinical Services, , RN. In-service topics will include the following: Specialized Diets/NPO Binder Abuse and Neglect DON/ADON re-in serviced nursing staff of supervisory schedule of one dining room for all three meals on 3-28-24. Meal assignments Ongoing Monitoring: Department heads making dining room rounds ensuring supervision in dining area. All components of this plan of correction will be submitted to the facility QAPI committee meeting for three months and additional recommendations will be made until substantial compliance has been achieved. The Medical Director was notified and agrees with the plan of correction. The Admin Nursing Staff to include, Don, Infection Prevention Coordinator, Regional Director of Clinical Services, Executive Director, , LNFA, are responsible for the corrections and continue monitoring. Verification of the facility's Plan of Removal Included: Record review, the facility conducted 100% review of all residents identified with gastric tubes and NPO status, as well as reviewed all residents with modified/restrictive diets. Record review of Resident #1's physician dietary orders, audited on 03/29/2024, revealed order dated 2/22/2024 for Resident #1 to receive regular diet, easy to chew texture, thin consistency. There were no concerns noted. 675637 Page 13 of 18 675637 03/30/2024 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of Resident #3's physician dietary orders, audited on 03/29/2024, revealed order dated 3/14/2024, enteral feeding documented Resident #3 to receive Glucerna 1.2, 55 ml/ hour for 22 hours. 100mL water flush Q4hr - There were no concerns noted. Record review of Resident #4's physician dietary orders, audited on 03/29/2024, order dated 07/25/2023, regarding enteral feeding documented Resident #4 to receive Fibersource at 70 ml/hour x 20 hours via pump, with 150mls water flush Q4 hours. There were no concerns noted. Record review of Resident #5's physician's dietary modification orders was audited on 03/29/2024, order dated 02/29/2024, documented Resident #5 to receive sodium restricted diet, regular texture, thin consistency. There were no concerns noted. During an observation and interview on 03/30/2024 at 4:47PM observed Resident #3's tube feeding. Resident #3 had Glucerna 1.2 infusing at 55mL/HR, with a scheduled 100ml water flush Q4hr. Resident #3 stated she did not have any concerns regarding her tube feedings. Resident #3 stated she knew why she was receiving tube feedings, and that the clinical staff attend to her needs when she requests assistance. During an observation on 03/30/2024 at 5:13PM Resident #1 was in the dining room eating his easy to chew meal which consisted of chicken, mashed potatoes, carrots, a slice of bread and tea. Resident #1 was able to ingest his food with no issues observed. No observable concern. During an observation on 03/30/2024 at 5:23PM, Resident #4 was receiving tube feeding. Resident #4 had Fiber source infusing at 70 ml/hour via pump with 150mL water flush Q4hr. Resident #4 did not exhibit any signs of distress. No concerns observed. During an interview on 03/30/2024 at 12:15PM, CNA C CNA C stated if she were to encounter a person with a change in color, she has been educated to call immediately for assistance, and will stay with patient until nurse arrives. CNA C stated if she were to experience a resident choking, she will initiate a Heimlich maneuver, and position her hands within the abdomen area and thrust upward. CNA C stated she has been also taught another way to alarm the nursing staff was to call for help loudly, to signify that a person was in distress and needs emergency assistance, that could potentially lead to death. CNA C stated the CNAs were usually supervising residents eating and observe how they eat and how much they eat and will report to the nurses any irregularities with eating/ eating behaviors. CNA C stated she has been instructed to set up a tray properly, which would involve cutting the proteins in bite size measurements, and will continue to observe residents eating, however if she must vacate area, she will return immediately to ensure the resident's safety, and will make sure the resident eats a good percentage of their meal. CNA C stated when she arrived yesterday (3/29/24), she was told of the choking event that led to Resident #2 expiring and stated that Resident #2 consistently would ask to eat food, however CNA C stated she would redirect Resident #2 to participate in activities during mealtimes. CNA C stated she has been educated on types of abuse which would encompass forcefully inflicting pain, and would report to the charge nurse, DON, and Administrator. CNA C stated she was last in-serviced about Code Blue, Heimlich Maneuvers, Abuse and Neglect, and Falls on 03/29/2024. During an interview on 03/30/2024 at 12:31PM, RN Charge Nurse; RN C stated the facility has provided education on abuse and neglect, and Heimlich maneuver, time management, and during emergent situations do not waste time and must immediately call 911. RN C stated for a full code blue, she has been educated on the proper procedures on how to conduct CPR and to always notify the chain of command. 675637 Page 14 of 18 675637 03/30/2024 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few RN C stated Resident #2 was her patient on 03/25/2024 and she was on break when choking/expiration happened. RN C stated she was very sad about event. RN C stated Resident #2 was NPO due to dysphagia and had difficulty swallowing. RN C stated that Resident #2 was mobile via wheelchair and was able to wheel himself throughout the facility. RN C stated Resident #2 never requested food, and when she would ask if he was hungry, once the tube feeding was complete, he would state he was full. RN C stated Resident #2 was not impulse and enjoyed counting monopoly money. RN C said while she was on break, LVN A and the floor CNAs were the ones who were watching her residents. RN C stated Resident #2's behavior never made her believe that he would take something that was not his. RN C stated she administered Resident #2's gastric tube feed at 10AM on 03/25/2024. RN C stated once she returned Resident #2 had passed away. RN C stated family had already been notified. RN C stated she has been educated to initiate Heimlich maneuver immediately and call out for help, the helpers would be the ones contacting chain of command as well as calling for Emergency assistance, while she continues to attempt to dislodge any particles or foreign substances out of the resident's oral cavity. RN C stated that she will begin the Heimlich maneuver to ensure resident's safety followed by then assessing the oral cavity, all as preventative measure to maintain the resident's safety and wellbeing. RN C stated in her professional opinion, the treatment nurse was wrong, and should have acted immediately because time was very important. RN C stated privacy can be maintained later, life is what is important. During an interview on 03/30/2024 at 12:56PM, CNA D, CNA E, both stated they were in-serviced about abuse, neglect, when to report abuse and neglect, NPO definition, change in condition, and to report any immediate changes. Both stated they performed the Heimlich maneuver. Both stated to perform the Heimlich maneuver will situate hands under rib cage, and in an upward motion will thrust. Both stated they were comfortable with performing the Heimlich maneuver on heavier set people. CNA D stated she observed to her left Resident #1, crumbs on chest, thighs, and plate right in front of him. CNA D stated she knew that Resident #1 was NPO and there was nothing on the plate. CNA D notified the Treatment nurse, who instructed CNA D to take the plate away from him, and foot was caught in wheelchair and saw resident leaning to right side, and picked up his hat and his eyes were drifted to the right. The treatment nurse instructed CNA D to take to his room, and CNA D asked LVN A and Resident #1 was breathing lightly slow breathes, and while in front of an office and LVN A looked at him, then instructed to take Resident #1 into his room which was position 3 room down in 106A. CNA D stated the treatment nurse, LVN A, MDS Coordinator, and DON entered Resident #2's room. CNA D stated it could not be more than 2 minutes between the time she returned Resident #2 from the table to his room. CNA E stated that fall risk patients were positioned near the nurse's station to ensure there were people watching. CNA E stated she had worked with Resident #2 prior and saw a tube feeding pump and would monitor him and would ask for food consistently in a form of hand gesture. CNA E stated she was in his room on the day in question, and hospice nurse had just bathed Resident #2, and Resident #2 had wheeled himself out of his bedroom. Both stated they have been educated to stay with the patient and yell out for help from all clinical staff and have also been instructed to perform the Heimlich maneuver immediately. Both stated types of abuse they have been educated on were emotional, physical, and mental, if they notice a new bruise, abrasions, skin tears, and color will notify charge nurse and administrator if they suspect abuse. Both stated they attended in-services 03/29/2024- 03/30/2024. During an interview on 03/30/2024 at 1:28PM, CNA F, CNA G, CNA H, CNA I; all have stated they have been educated on Abuse and Neglect and NPO precautions, Heimlich maneuver. All stated NPO precautions were implemented for those residents that have gastric tubes that do not allow them to eat through their oral cavities. All stated they will advocate for a nurse to intervene by calling 675637 Page 15 of 18 675637 03/30/2024 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few out for help and would initiate the Heimlich maneuver immediately if a resident was witnessed choking and knows that it may be due to eating/choking issue. All stated to position hands above the gastric tubes and as close to the rib cage/abdomen area and will conduct an upward thrust and will stay with the resident until the nurse arrives and will await their instructions. Resident #1was CNA I's resident and was able to eat by himself and was in the front so that there were more eyes to watch him. All stated Resident #2had dementia but was able to eat on his own and does not allow people to eat from his tray. All stated facility has implemented that all residents that need assistance to eat will be assisted in the dining room area, snack cart was now put behind nurses' station, as well as coffee station was now served only in dining area. CNA E stated she had seen Resident #2use a hand to mouth gesture that indicated he was hungry and wanted to eat. All stated, types of abuse they have been educated on were physiological, physical, sexual, verbal, abandonment, and misappropriation of property. All stated, signs and symptoms of abuse could be sad, crying, grimacing of pain, skin coloration, bruises, behavioral abnormalities, or resident verbalizes allegation. All stated if they do suspect abuse, they will report immediately to the charge nurse and administrator. During an interview on 03/30/2024 at 1:55PM, LVN A stated on 03/25/2024 around lunch time, she was at the nurse's station, on the phone getting a surgery date for another resident, when she was alerted by CNA D that help was needed. LVN A stated she then got her pulse oximeter and saw Resident #2 in distress in his room. LVN A stated she also saw the DON, MDS Coordinator, and CNA D. LVN A saw the DON performing the Heimlich maneuver. LVN A stated the treatment nurse was at the nurse's station conducting some form of documentation on the computer. LVN A stated she did not see anything going on, and once CNA D alerted her, she then reacted and went to Resident #2's room. LVN A stated she was focused on her trying to get her own resident a follow up appointment for surgery, she did not hear CNA D speak with the treatment nurse. LVN A stated it was no more than a minute from when LVN A was alerted to the time she entered Resident #2's room. LVN A stated, while the Director of Nursing was performing the Heimlich maneuver, saw some particles come out of Resident #2's mouth, but nothing else was coming up. LVN A stated the MDS Coordinator went to get a suction. LVN A stated she felt Resident #2's pulse and was gasping for air, and multiple times tried to get a blood pressure on Resident #2 but was not reading, and the pulse oximeter oxygen reading was in the 70's and administered oxygen through a simple mask, not a non-rebreather mas. LVN A stated the MDS Coordinator then returned and suctioned some particles with yanker and deeper suctioned, but nothing was working. LVN A stated they actively tried to suction and could hear Resident #2's heartbeat and was told by an unknown staff member that Resident #2's family member did not want to send Resident #2 into the hospital. LVN A stated she was positioned on the right side of Resident #2 and the hospice nurse was in the room standing to the further part of the room. LVN A stated she asked/told the hospice nurse to check pulse, and throughout the incident Resident #2's face would turn blue then return to normal skin color. LVN A stated Resident #2 was not exhibiting signs of choking. LVN A stated for sure the Heimlich maneuver should have been conducted as well as an assessment on scene, as opposed to having the resident taken to their room because maintaining the life of a patient was more important than maintaining their privacy for emergent situations. LVN A stated Resident #2 was sitting at the edge of bed and the DON performed Heimlich maneuver for approximately 5-10minutes, nothing substantial came out, followed by the staff member placing him back in bed with the head of the bed raised, eyes were not open, and body would sporadically jerk and when performing sternal rub Resident #2's body would jerk but then stop. LVN A stated Resident #2's breathing was light/labored breathing, then stop and then would twitch/jerk sporadically. LVN A stated she has been educated to perform an assessment immediately once it 675637 Page 16 of 18 675637 03/30/2024 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few was known there was cause of an emergent situation as well as to begin a Heimlich maneuver immediately when a resident was choking. During an interview on 03/30/2024 at 2:36PM, Laundry Attendant A, Laundry Attendant B; Both stated that if they witness a resident actively choking and were standing up, they will immediately perform the Heimlich maneuver, or if they were in a wheelchair, they will call out for help from the clinical. Both stated they were in-serviced about abuse, neglect, reporting of abuse/neglect reporting, where the NPO book was located and the definition of NPO which means nothing by mouth. Both stated they were also in-serviced about the Heimlich maneuver and how to perform the Heimlich maneuver by placing both hands under the rib cage and thrusting in an upwards motion. During an interview on 03/30/2024 at 2:45P, CNA J, CNA K, CNA L, CNA M, all stated if they were to encounter a resident that was showing signs of pallor or change in condition they will call out for the nurses' help. All stated that they will immediately commence the Heimlich maneuver, would perform the Heimlich maneuver by placing their hands on the resident's abdomen and performing a forceful upward thrust. All stated, as a collaborative effort if a resident needed to be observed while eating, the CNAs were primarily the people to do the observation, and if they must leave for any reason the nurses will take over. All stated, those residents that need assistance eating were now located in the dining room area. All stated, the snack carts were located behind the nurse's station now, and coffee station was now behind the nurses' stations as well. All stated, those residents that were NPO were now updated according in the POC as well as inputted in the NPO book that was located at the nurse's station. All stated, they were in-serviced about NPO definition, abuse and neglect, Heimlich maneuver. All stated, the facility has instructed to be more observant of the NPO residents that were mobile. All stated, abuse and neglect, encompass verbal, mental, physical, isolation, and emotional abuse. All stated, if they suspect abuse, they will report suspicion to the charge nurse and administrator. All stated they were in-services from 03/27/2024-03/30/2024. During an interview on 03/30/2024 at 3:02PM, LVN B stated she was (8YEARS)full time: LVN B stated she worked the second shift (3-11PM) on 03/25/2024. LVN B stated Resident #2 was impulsive and would consistently ask to eat actual food and would also exhibit frustration when told he was not allowed to eat via oral cavity due to swallowing issues. LVN B stated Resident #2's mental compacity could have limited him in understanding why he could not eat through oral cavity. LVN B stated she has been educated that if she were to see a resident actively choking, she would immediately perform the Heimlich maneuver, and stated she would immediately assess the resident if the resident was exhibiting signs of distress, change in condition, or change in skin coloration. LVN B stated as a nurse, she will always prioritize the safety and well-being of a resident before maintaining their privacy because she believes, in her professional opinion, that keeping her residents' lives and thriving was the most important reason, the well-being of her residents come before maintaining their privacy because resident's lives were more important. LVN stated she was educated that a nurse needs to always stay in the dining room while residents were in the dining room, also on abuse, neglect, NPO definition (make sure no foods available to them for their safety), and Heimlich maneuver. LVN stated the facility has instructed the clinical staff to be more vigilant, LVN B caught Resident #1 walking and was very mobile and stressed that Resident #1 was impulsive. LVN stated Resident #2 was very determined. LVN stated there are all types of abuse including physical, sexual, verbal, monetary. LVN stated she was looking out for signs of symptoms of abuse by being observant of bruises, behavioral abnormalities, and family hostile dynamics, 3/27/2024 and 3/29/2024. During an interview on 03/30/2024 at 3:36PM, LVN C stated she worked here for8years; (3-11PM) LVN C stated that Resident #2 would state he was hungry all the time. LVN C stated Resident #2 was active 675637 Page 17 of 18 675637 03/30/2024 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and would administer bolus feeds 5 times a day. LVN C stated she worked on 03/25/2024 the evening shift (3-11PM). LVN C stated the facility implemented a new process of the medication aides will be observing residents eat/assisting residents to eat within the dining room area solely. LVN C stated that the event with Resident #2 on 03/25/2024 potentially was avoidable, and continued by stating the nursing staff should have reacted immediately to render aide to Resident #2, not remove Resident #2 from the table area, in front of the nurse's station, to his room. LVN C stated the time it took for Resident #2 to be transported to his room, the clinical staff could have assessed the resident and immediately started to perform the Heimlich maneuver. LVN C stated in NPO residents should be given multiple diverting activities during mealtimes as a preventative measure to keep them from being around others that were eating actual food. LVN C stated she would in her professional opinion, as a nurse, if she were to encounter a choking resident, she would immediately assess the residents, perform vital signs and begin an investigation immediately to advocate for the residents' health and well-being. LVN C stated that residents' lives were more important than maintaining a resident's privacy. LVN C stated she was educated/in-serviced about NPO definition, NPO book, abuse, neglect, Heimlich maneuver. LVN C stated all residents that need feeding assistance will be assisted in the dining room, and all snack carts will be positioned in the nursing station. During an interview on 03/30/2024 at 4:06PM, LVN D (11PM-7PM) LVN D stated he was educated on the importance of reporting abuse and neglect, reporting any allegation of abuse, completing incident reports, specialized diets, NPO status, and Heimlich maneuver. LVN D stated if resident was actively exhibiting signs of distress including choking, he would act upon the concern immediately. LVN D stated a resident's life was more important than maintaining privacy during an emergent situation. LVN D stated if he were to be notified of a resident's change of condition, he would immediately assess the resident, attain vital signs, and if it determined they are choking, he would immediately perform the Heimlich maneuver. LVN D stated the tables that were initially in the front of the nurses' station were used for residents to eat at when the dining room was overly loud and stimulating. LVN D stated the facility has now instructed the clinical staff that residents that need to be assisted to eat, will now be solely done in the dining room. LVN D stated the facility has implemented 1 nurse will be in the dining room during mealtimes and will stay till the last resident finishes. LVN D stated he was in-se[TRUNCATED] 675637 Page 18 of 18