Health inspection·January 8, 2021

F656 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40.

F726 §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. §483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. §483.35(c) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

F805 §483.60(d) Food and drink Each resident receives and the facility provides- §483.60(d)(3) Food prepared in a form designed to meet individual needs. § 72311. Nursing Service - General. (a)Nursing service shall include, but not be limited to, the following (1) Planning of patient care, which shall include at least the following (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (B) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (C) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (D) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient’s condition. On 11/9/2020, the Department received a complaint alleging a 56-year-old resident (Resident 1) died at the hands of the facility. The complainant included an autopsy report which indicated the resident choked to death on a large piece of meat. The complaint indicated the resident had missing and loose teeth and the staff were supposed to cut her meat into smaller pieces. On 11/10/2020, an unannounced investigation was conducted at the facility. The facility failed to: 1. Serve Resident 1 a finely chopped diet as prescribed by the physician, by not ensuring the tray was checked by the staff before it was served as per the facility’s policy and procedures. 2. Supervise Resident 1 while eating and observe for pocketing of food in the cheeks. 3. Encourage Resident 1 to take small bites and swallow, as indicated by the Speech Therapist recommendations and the resident plan of care. 4. Adhere to its “Choking-Obstructive Airway Clearance” policy and immediately and correctly perform the Heimlich maneuver (emergency rescue procedure for application to someone choking on a foreign object, in which the rescuer places a fist between the victim's lower ribs or upper abdomen from behind and exerts sudden pressure in the form of thrusts of sufficient force to help eject the object from the windpipe) on Resident 1. As a result, Resident 1 had a choking (severe difficulty breathing because of an object or food lodged in the throat blocking airflow) episode during dinner and went into cardiac arrest (sudden, unexpected loss of heart function, breathing, and consciousness). Resident 1 was subsequently transferred to a general acute care hospital (GACH) emergency department (ED) and pronounced deceased within 30 minutes. A review of Resident 1’s Admission Face Sheet indicated Resident 1, a 56-year-old female, was originally admitted to the facility on 12/28/18 and last readmitted on 11/22/19. A review of Resident 1’s admission History and Physical (H/P) dated 12/18/18 indicated Resident 1 did not have the capacity to understand and make decisions. The H/P indicated Resident 1 had diagnoses of schizoaffective disorder (mental disorder in which a person interprets reality abnormally and may exhibit hallucinations, delusions, and extremely disordered thinking and behavior that impair daily functioning), and hypertension (high blood pressure). A review of Resident 1’s Minimum Data Set (MDS), a resident assessment and care screening tool, dated 8/7/2020 indicated Resident 1 had severe memory problems and impaired decision-making, but was usually able to understand and sometimes understood by others. The MDS indicated Resident 1’s diagnosis included non-Alzheimer’s dementia (progressive deficits in behavior, executive function, or language), Parkinson’s disease (disorder of the central nervous system that affects movement, often including tremors), and disorientation (condition of having lost one's sense of direction). The MDS indicated Resident 1 required a one-person physical setup of trays and did not have missing teeth. A review of Resident 1’s care plan titled “Pocketing Food in Cheeks,” dated 6/2/2020, indicated the goal was for Resident 1 to chew and swallow food with no difficulty for the next 90 days. The staff’s interventions were to encourage small, frequent feedings and rest in between periods, provide diet as ordered, observe for pain when swallowing, and observe Resident 1 during mealtimes. A review of Resident 1’s Progress Note, dated 6/4/2020 and timed at 11:37 p.m., indicated an order was received from the Medical Director (MD) to change Resident 1’s diet to pureed (cooked food, usually vegetables, fruits or legumes, that has been ground, pressed, blended or sieved to the consistency of a creamy paste or liquid), nectar thickened liquids (easily pourable and comparable to apricot nectar, thicker cream soups), and to provide supervision during meals. A review of the Interdisciplinary Team ([IDT] group of health care professionals with various areas of expertise working together toward the goals of their residents) conference note dated 6/19/2020 indicated Resident 1 was noted pocketing food in the left side of the jaw during feeding and required extra prompting during meals to chew and swallow food. The IDT recommendations were to refer Resident 1 to a speech therapist (ST) for evaluation of the ability to swallow and for staff to aid during meals. A review of Resident 1’s Speech and Language Evaluation dated 6/29/2020 indicated Resident 1 was referred for a swallowing evaluation due to increased pocketing of food. The ST evaluation indicated Resident 1 had been downgraded from regular diet to a regular finely chopped diet with nectar thickened liquids and required some assistance with feeding. The evaluation indicated Resident 1 was missing upper right and lower left molars (tooth with a rounded or flattened surface adapted for grinding specifically) which impacted her ability to effectively masticate (chew) food. The ST evaluation indicated Resident 1 had mild to moderate oral phase dysphagia (problems with using the mouth, lips and tongue to control food or liquid), reduced oral strength, coordination, and sensation, and mastication inefficiency. The ST recommended for Resident 1 to have mechanical soft foods with finely chopped meats, extra gravy, thin liquids, no corn, salad, or raw vegetables, upper partial dentures to be on prior to meals, verbal cues to take single bites, swallow all the food in Resident 1’s mouth and then proceed to take the next bite, take sips of liquid between bites, and ensure the mouth is clear of food after the meal. A review of Resident 1’s physician order dated 6/29/2020 indicated a regular diet finely chopped texture (food, especially meat, cut into very small pieces roughly the size of kernel of corn), thin consistency, with no added salt (NAS), small portion at breakfast and lunch, finely chopped with extra gravy with no corn, coleslaw or raw vegetables and salads. A review of the facility’s document titled “Mechanical Soft Diets and Mechanical Soft Finely Chopped Diet,” revised 1/2020, indicated mechanical soft diets and soft finely chopped diets were designed for residents with chewing or swallowing limitations. The document indicated all mechanical soft finely chopped diet were soft and cut into ¼ inch pieces. On 11/12/2020 at 11:20 a.m., during a concurrent interview and record review of Resident 1’s Change of Condition (COC) and care plans, the Director of Nursing (DON) stated on 6/1/2020 Resident 1 was observed unable to chew her food and on 6/3/2020, her diet was changed to puree texture by the Registered Dietician (RD). The DON stated that on 6/18/2020, Resident 1 had a follow-up COC indicating Resident 1 required help with feeding and redirection to chew and swallow food. The DON stated finely chopped food was best described as small cuts of food. The DON stated Resident 1’s care plan for nutrition was updated and the interventions included for staff to encourage Resident 1 to slowly swallow her food and avoid pocketing. The DON stated staff were responsible for supervising residents during dining. On 11/12/2020 at 12:20 p.m., during a dining observation of the North dining room, no staff members were observed supervising the residents having lunch. Four (4) staff members were observed standing by the tray carts waiting for the residents to bring their empty trays, not assisting or providing prompts to the residents. On 11/12/2020 at 1:33 p.m., during an observation of the facility’s surveillance video of the South dining area dated 9/1/2020 in the presence of the DON and the Administrator (ADM), the following events were observed: At 4:52 p.m., Certified Nurse Assistant 1 (CNA 1) provided Resident 1 with a dinner tray. At 4:54 p.m., CNA 1 was observed picking up a dark color object with a fork and giving it to Resident 1 to eat and then walking away to continue passing food trays. Resident 1 was observed putting the object in her mouth and a few seconds later, Resident 1 was observed covering her mouth with a napkin and then placing it on the tray. At 4:56 p.m., Resident 1 got up and walked to the other room of the South side dining room and stood facing CNA 1 for a few seconds. The resident was seen gesturing by pointing to her face and then CNA 1 was observed putting her hand on Resident 1’s shoulder and guiding her back to her table. Once at the table, Resident 1 was gesturing toward her mouth to indicate she was choking. CNA 1 was observed rubbing and tapping Resident 1’s back and neck while Resident 1 was leaning forward on the table. At 4:58 p.m., Resident 1 was observed leaning forward towards the table and CNA 1 was observed grabbing Resident 1 by the front of the neck and pressing on the resident’s neck while another staff member was punching Resident 1 on the breast area. At 4:59 p.m., Registered Nurse 1 (RN 1) was observed performing the Heimlich maneuver three times and stopping to hit Resident 1 multiple times on the back. CNA 1 was observed grabbing Resident 1 by the neck again and applying pressure to the resident’s neck with her right arm. At 5:01 p.m., Licensed Vocational Nurse 1 (LVN 1) attempted the Heimlich maneuver on Resident 1 and then placed Resident 1 on the floor to initiate cardiopulmonary resuscitation (CPR). At 5:10 p.m., the paramedics entered the facility’s dining area and continued with CPR. At 5:31 p.m., Resident 1 was placed on a gurney and removed from the dining area by the paramedics. On 11/12/2020 at 2:39 p.m., during an interview, the Director of Staff Development (DSD) stated the staff were to do three checks to ensure the correct diets were being provided to the residents. The DSD stated the first check was done by the Food Services Staff ([FSS] in the kitchen), the second check by the licensed nurses, and the final check by the CNAs prior to the food tray being given to each resident. The DSD stated the staff was responsible for checking food trays, passing trays, assisting residents requiring assistance to eat, monitoring the residents and documenting percentage of meal consumed. The DSD stated licensed nurses and CNAs were in-serviced at the beginning of the year on how to perform the Heimlich maneuver when a resident is seen choking. On 11/12/2020 at 2:48 p.m., during an interview, the Dietary Supervisor (DS) stated the charge nurses were in charge of checking the food trays and comparing them with the resident’s orders to ensure the correct diet was provided to the residents. On 11/12/2020 at 3:40 p.m., during an interview, Registered Nurse 1 (RN 1) stated on 9/1/2020 during dinnertime, she heard a page for Code Blue (a medical emergency code for cardiac or respiratory arrest) in the South dining area. RN 1 stated she could not remember which LVN was responsible for being in the dining room that day but stated she did not check the trays that day as she was on the floor and not in the dining room. RN 1 stated CNA 1 told her Resident 1 was choking and noticed food particles coming from Resident 1’s mouth. RN 1 stated she was not able to perform the Heimlich maneuver because Resident 1 was sitting down [sic]. RN 1 stated the only time she was in-serviced on the Heimlich maneuver by the facility was after Resident 1’s choking incident in 9/2020. On 11/12/2020 at 5:40 p.m., during a telephone interview, FSS 1 was unable to recall the last time she received an in-service regarding food textures. FSS 1 stated FSS 2 was terminated from the facility for not following Resident 1’s diet orders and ensuring that the resident received the appropriate diet as ordered. On 11/13/2020 at 4:07 p.m., during an interview, CNA 1 stated on 9/1/2020 during dinnertime she placed a food tray on Resident 1’s table and then left to get juice for the resident. CNA 1 stated minutes later Resident 1 got up from her chair and showed her the food she had in her mouth CNA 1 stated she saw Resident 1 leaning forward as though she was tired and then falling face forward towards the table unconscious and unable to wake up. CNA 1 stated Resident 1 was to receive a “chopped” diet, but stated she did not check Resident 1’s food card to ensure Resident 1 received the correct diet as recommended by the ST. CNA 1 stated a finely chopped diet would have to be scooped because the pieces were small and could not be pierced with a fork. On 11/13/2020 at 4:33 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated on 9/1/2020 he responded to a Code Blue over page to the South dining room. LVN 1 stated he was informed by a staff member (did not remember who) of Resident 1 having food in her mouth. LVN 1 stated he unsuccessfully performed the Heimlich maneuver on Resident 1 and performed CPR because Resident 1 had no pulse. On 11/13/2020 at 4:44 p.m., during an interview, CNA 2 stated Resident 1 was to receive a chopped diet and required assistance when eating and constant reminders to chew and swallow her food. CNA 2 state