Based on interview and record review, the facility failed to ensure services for bed mobility were provided with two staff members present to a dependent resident who required total assistance of two staff for bed mobility for 1 of 3 residents reviewed for falls. (Resident 99) This deficient practice resulted in Resident 99 falling from the bed and sustaining a fracture left knee joint. Findings include: Resident 99's clinical record was reviewed on 12/13/14 at 11:29 a.m. Diagnoses included, but were not limited to, quadriplegia (a severe medical condition characterized by the partial or total loss of function in all four limbs and the torso), left elbow contracture, left shoulder contracture, left wrist contracture, left hand contracture, right shoulder contracture, right wrist contracture, right hand contracture, major depressive disorder, bipolar disorder, restless leg syndrome, and generalized anxiety disorder. A current care plan, dated 3/1/24, revised on 5/28/24, and reviewed on 12/2/24, indicated Resident 99 required assistance with activities of daily living (ADLs) related to quadriplegia. Interventions included a total assist of two staff members with bed mobility. She required a total assist of 1-2 staff when toileting and required a total assist of one to two staff members with bathing. A quarterly Minimum Data Set (MDS) assessment, dated 8/20/24, indicated she had upper and lower extremity impairment on both sides. She was dependent on toileting hygiene, shower/bathing, upper and lower body dressing, eating, and rolling to the left and right in bed. She was cognitively intact. The resident did not have any falls since the prior assessment. A Significant Change MDS assessment, dated 11/18/24, indicated she had upper and lower extremity impairment on both sides. She was dependent on toileting hygiene, shower/bathing, upper and lower body dressing, eating, and rolling to the left and right in bed. She was cognitively intact. An MDS progress note, dated 11/18/24 at 3:40 p.m., indicated Resident 99 had complaints of frequent neck pain and overall generalized discomfort in the past five days. The worst pain was a five on a 0-10 pain scale. The resident received routine and as needed pain medications which she stated was effective. The resident voiced occasional shortness of breath with exertion and at rest. The resident was non-ambulatory and used a mechanical lift for transfers. The resident was totally incontinent of bowel and bladder and utilized incontinence products and moisture barrier cream. A nursing progress note, dated 11/29/24 at 8:30 p.m., indicated the CNA reported assisting Resident 99 in her bed without assistance. He rolled her to the left side of the bed to adjust the bed sheets and incontinence pad, when the residents right leg went over the side of the bed. The resident stated she went onto the floor and hit her head. The resident ended up developing a skin tear to her sacrum that was 2 centimeters (cm) long by 0.2 cm width with no depth. Range of motion was normal per resident's current physical condition. Neurological checks were initiated, within defined limits, and she was alert and oriented times four. Four staff members assisted in getting the resident off the floor and back into her bed. There were no progress notes documented between 11/29/24 at 8:30 p.m., when the fall occurred, and 11/30/24 at 6:36 a.m., when the resident had complaints of pain. A nursing progress note, dated 11/30/24 at 6:36 a.m., indicated the CNA notified the nurse that the resident was experiencing 10/10 pain following her fall the previous night. Her left leg and back caused the majority of her pain. Upon assessment, the resident's left leg was extremely swollen and painful to touch. The nurse spoke with both the resident and family who indicated they wanted her sent to the emergency room (ER) for evaluation A nursing progress note, dated 11/30/24 at 7:08 a.m., indicated the resident's representative arrived at the facility and Emergency Medical Services (EMS) was contacted for transport. A hospital imaging service report, dated 11/30/24 at 10:03 a.m., indicated findings of a depressed medical tibial plateau fracture. A nursing progress note, dated 11/30/24 at 12:37 p.m., indicated the resident returned from the emergency room with a diagnosis of medial tibial plateau (concave part of the tibial plateau, which is the flat top of the tibia bone in the knee) fracture and a urinary tract infection (UTI). A nursing progress note, dated 12/2/24 at 1:11 p.m., indicated the resident requested for her bed to be put back the way it was prior to her fall, so she could see out the window and watch her television. The DON was notified. An Interdisciplinary Team (IDT) note, dated 12/2/24 at 1:52 p.m., indicated the root cause of her fall was that the resident's leg rolled over further than the staff member expected. Since the resident had no control over her body, the momentum pulled her to the floor. Other contributing factors included quadriplegia, other cord compression, chronic pain syndrome, muscle spasms, spinal stenosis, chronic obstructive pulmonary disease, major depression, anxiety, sick sinus syndrome, critical illness myopathy, and contractures. Interventions in place prior to fall included her call light and personal items were within reach and to remind the resident to change position slowly. New education included proper ADL care of the resident and resident requested to have her bed moved up against the wall to make her feel safer. The fall care plan had been reviewed and updated. Current physician orders, on 12/13/24, included amitriptyline (antidepressant) 25 milligram (mg) daily, aripiprazole (atypical antipsychotic) 10 mg daily, Eliquis (anticoagulant) 5 mg daily, gabapentin (anticonvulsant) 200 mg twice daily, and oxycodone-acetaminophen (narcotic) 7.5-325 mg every six hours. A current care plan, dated 9/6/24 and revised on 12/2/24, indicated the resident was at risk for falls related to immobility, use of narcotics, use of psychotropics, and pain. An intervention, dated 9/6/24, indicated the resident would have her personal items within reach. An intervention, dated 9/6/24, indicated her call light would be within reach. An intervention, dated 9/6/24, indicated she needed to be reminded to change her position slowly. A post fall intervention, dated 12/1/24, indicated she would have her bed against the wall as it made her feel safe. The resident had chosen to move her bed away from the wall in order for her to look out of her window, dated 12/1/24. A post fall intervention, dated 12/2/24, indicated the resident was to wear proper footwear or non-slip footwear when she was up. A current care plan, initiated 11/30/24 and revised on 12/6/24, indicated the resident had a traumatic fracture to her left depressed medical tibial plateau due to fall. An intervention, dated 11/30/24, indicated the implementation of her pain care plan. A current care plan, initiated 3/1/24 and revised on 12/6/24, indicated the resident has chronic pain syndrome, osteoarthritis right knee, and osteoporosis. She was at risk for acute pain related to surgical site left lower quadrant abdominal and left umbilicus, muscle spasm, Chronic Obstructive Pulmonary Disease (COPD), spinal stenosis, constipation, and urinary retention, irritable bowel syndrome, gastroesophageal reflux disease (GERD), depression and left depressed medical tibial plateau fracture on 11/30/24. Interventions, dated 3/1/24, indicated her pain medication would be administered as ordered, observe for increased sedation, constipation, and respiratory depression, staff would observe to determine if she was experiencing non-verbal signs of pain, and when she was experiencing pain to check for decrease external stimulation as much as possible. A current care plan, initiated 3/6/24 and revised on 7/3/24, indicated the resident was totally incontinent and not a candidate for a bowel program due to irritable bowel syndrome. Interventions included applying barrier cream as indicated, receive medications as ordered, check for incontinence every two hours, and more frequently as needed and assist the resident with incontinence care. During a random observation, on 12/11/24 at 10:54 a.m., Resident 99 was lying in bed on her back, covered with a sheet. A small travel pillow was around her neck for support. The bed was located away from the wall. During a random observation, on 12/11/24 at 2:36 p.m., Resident 99 was lying on her back in bed with her eyes closed, covered with a sheet. A small travel pillow was around her neck for support. The bed was located away from the wall. During a random observation, on 12/12/24 at 10:49 a.m., Resident 99 was lying on her back in bed, covered with a sheet. The bed was located away from the wall. During a random observation, on 12/12/24 at 2:17 p.m., Resident 99 was lying on her back in bed with her eyes closed. The bed was elevated and a touch call pad was within reach. A small travel pillow was around her neck for support. The bed was located away from the wall. During an interview, on 12/13/24 at 2:08 p.m., Resident 99 indicated, on 11/29/24, that CNA 4 had changed her bed sheets and incontinence pad. The resident advised CNA 4 that he needed to have a second staff member help with changing her incontinence pad and bedding. CNA 4 assured her that he could do it by himself. CNA 4 rolled her back and forth a few times. She was lying on her left side at the edge of the bed, her right leg went forward off the bed, causing her to roll off the bed. She hit her head and upper back on the chair beside her bed. During an interview, on 12/13/24 at 2:30 p.m., Resident 99 indicated, on 11/29/24, she had been lying flat in bed during incontinence care. Her bed was away from the wall. She was on her left side, on the edge of the bed. She felt like both of her legs ended up sliding off the bed, which caused the rest of her body to fall off the bed. It happened so fast she didn't have time to say anything to the staff member before falling off the bed. Her upper bed rails were up, and she flipped over the top bedrail. She hit the back of her head and the top part of her back on the chair at her bedside. She had back pain after the fall occurred. The following morning, she was sent out to the hospital where she was diagnosed with a left knee fracture. She saw the orthopedic physician today, and he would see her back in 4 weeks for a follow-up appointment. When provided care, she usually scrunched up in a ball, as she was contracted in her extremities. Being rolled around in bed caused her to be in pain. During an interview, on 12/13/24 at 2:40 p.m., LPN 3 indicated facility staff knew to use two people when assisting the resident with care. However, if they were familiar with her, one person could provide care for her. Everyone who worked for this facility used two people for her care. During an interview, on 12/13/24 at 3:33 p.m., CNA 4 indicated, on 11/29/24, he had assisted Resident 99 when she needed cleaned up and her bedding changed. CNA 4 had rolled the resident onto her left side, which was on the opposite side of the bed from the CNA. When he rolled Resident 99 over to change her brief, her right leg went over the side of the bed where he was standing. He had his hand on her side, near her waist, and was able to keep her from fully falling off the bed. He was able to run around the bed, get behind the resident, and lowered her to the ground. He didn't feel like the resident's knees touched the floor. He was able to get right up behind her and lowered her to the ground. He was unsure how she hurt her knee. He was told by other staff members that it was easy to provide incontinence care to the resident, but just to be careful as she was contracted. The resident was not scrunched up or contracted while he was providing care. The nurse was right outside her door when the fall occurred. Resident 99 was not hollering or calling out. He denied the resident hit her head or back on anything. The nurse assisted him with lowering the resident to the floor. He indicated he did not have access to the facility's computer system. During an interview, on 12/13/14 at 4:04 p.m., RN 5 indicated, on 11/29/24, she was outside the resident's door when the fall occurred. She heard the resident scream. When she entered the room, Resident 99 was already on the floor. The resident was a two-person physical assist during care. CNA 4 was from another facility, and they had informed him that the resident was a two-person physical assist before providing care. RN 5 didn't feel CNA 4 could have lowered the resident to the floor by himself. RN 5 felt the resident slid out of the bed. The resident preferred to have her bed elevated. RN 5 did not see any swelling or redness to the resident's knee during the assessment after her fall. Later that next morning, the resident was sent out to the ER for complaints of knee pain. She was diagnosed with a fracture of her left knee. A point of care task, retrieved on 12/13/24 at 4:25 p.m., indicated staff members documented Resident 99 required one person assist with bed mobility 10 out of 11 days prior to her fall from 11/18/24 to 11/29/24, and 10 out of 14 days after her medial tibial plateau fracture, from 12/1/24 to 12/13/24. During an interview, on 12/16/24 at 8:40 a.m., CNA 6 indicated Resident 99 was a two-person physical assist for bed mobility and incontinence care due to her contractures. During an interview, on 12/16/24 at 8:41 a.m., CNA 7 indicated Resident 99 was a two-person physical assist with care. One person could do it on their own, but CNA 7 wouldn't recommend it due to the resident being a quadriplegic and contracted. During an interview, on 12/16/24 at 9:53 a.m., the DON indicated, on 11/29/24, she interviewed Resident 99 and CNA 4 once the resident returned from the hospital. The resident indicated that CNA 4 was trying to turn Resident 99 over in bed and that the resident was close to the edge of the bed. CNA 4 had his hand on Resident 99's waist. CNA 4 indicated Resident 99's knees went off the bed and the momentum pulled Resident 99 to the ground. CNA 4 tried to stop the resident from falling. The DON talked to the resident regarding an intervention of moving her bed against the wall so she would feel safe during care. Resident 99 was agreeable, but later wanted her bed moved back to where it was originally located. The DON provided education to all staff members that Resident 99 was a two-person physical assist with bed mobility. CNA 4 had access to the facility computer system. She verified that the resident was a two-person assist for bed mobility, and it did show that information on the care plan. During an interview, on 12/16/24 at 1:30 p.m., the Corporate Nurse provided documentation of CNA 4 accessing the clinical record from November 11, 2024 through December 5, 2024. During an interview, on 12/17/24 at 10:23 a.m., the DON indicated that CNA 4 was toileting (incontinence care) Resident 99 at the time of her fall. Her care plan indicated she was a 1-2 staff member assistance for toileting (incontinence care) and bathing. She was unsure why she was marked as a two-person assist for bed mobility. She was in the process of changing the resident's care plan to two-person assist for toileting (incontinence care) and bathing. During an interview, on 12/17/24 at 10:37 a.m., CNA 9 indicated Resident 99 was a two person assist with bed mobility. Bed mobility included rolling from left to right and providing During an interview, on 12/17/24 at 10:49 a.m., the DON indicated all staff members have been educated that Resident 99 was a two person assist for incontinence care and that Resident 99 was agreeable with using bolsters while in bed. During an interview, on 12/17/24 at 10:58 a.m., Resident 99 indicated she was incontinent and used a brief. When staff toileted her, they changed her brief and bed pad. During an interview, on 12/17/24 at 11:00 a.m., LPN 10 indicated Resident 99 was incontinent and unable to use the bedpan due to quadriplegia with contractures. The resident did not have any feeling from her upper chest down to her toes. She could move her arms enough to hit her call light, but she was unable to grasp or pull. During an interview, on 12/17/24 at 11:24 a.m., CNA 9 indicated Resident 99 was fully paralyzed and unable to tell when she needed to use the restroom. They used a disposable bed pad for her. She was unable to wear briefs due to her contractures. When they were providing toileting care, they were rolling her to either side of the bed. A current policy, titled Fall Investigation and Risk Evaluation, provided by the Corporate Nurse, on 12/16/24 at 3:52 p.m., indicated the following: .It is the policy of the facility to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assisted devices to prevent avoidable accidents 3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure urinary catheter outputs were monitored and documented for 3 of 3 residents reviewed for urinary catheters (Residents D, H, and J), resulting in Resident D being transferred to the hospital with a large amount of urine retained from a blocked urinary catheter. Findings include: 1. Resident D's clinical record was reviewed on 5/2/24 at 1:22 p.m. Diagnoses included, but were not limited to, neuromuscular dysfunction of bladder, unspecified focal traumatic brain injury (TBI) with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, and need for assistance with personal care. The physician's orders included, but were not limited to, cefdinir (antibiotic to treat urinary tract infections) 300 mg via gastrostomy tube for five days, change catheter bag every 30 days and as needed, flush catheter with 30 ml (milliliters) daily and as needed (1/31/24), and flush catheter with 100 cc (cubic centimeter) daily and as needed for sediment (3/7/24). A 1/30/24, admission, Minimum Data Set (MDS) assessment indicated Resident D was rarely/never understood, and was dependent on staff for personal care and toileting. He had a urinary catheter. A current care plan indicated a problem of an indwelling catheter related to neurogenic bladder related to TBI (1/27/24). Interventions included change catheter system when clinically indicated or ordered (1/27/24), staff would care for his catheter, personal hygiene needs and proper positioning of the drainage bag (1/27/24), and staff to observe for changes in the color, consistency, and odor of urine, changes in mental status, changes in amount of urine produced, and pain in lower back or lower abdomen (1/27/24). Resident D's February and March 2024 urinary output documentation indicated the following: On 2/27/24 at 3:33 a.m., 250 cc (cubic centimeters)[a unit of measure] urine output and at 9:59 p.m., 500 cc urine output, totaling 750 cc of urine output for the day. On 2/29/24 at 5:16 a.m., 200 cc urine output. The clinical record lacked documentation of additional urine output. On 3/1/24 at 4:41 a.m., 300 cc urine output. The clinical record lacked documentation of additional urine output. On 3/3/24, the clinical record lacked urine output documentation. On 3/4/24, the clinical record lacked urine output documentation. On 3/5/24, the clinical record lacked urine output documentation. On 3/6/24 at 5:29 a.m., 650 cc urine output and at 1:59 p.m., 750 cc urine output, totaling 1400 cc of urine output for the day. The history and physical note from a local hospital, dated 3/4/24 at 10:08 p.m., indicated Resident D was in the hospital with respiratory failure and was agitated. In the emergency department, it was discovered that Resident D's urinary catheter was clogged and upon changing the catheter, over a liter and a half (1500 cc) of urine had came out and Resident D felt a lot more comfortable. He would be admitted to the hospital with a urinary tract infection and started on Rocephin (antibiotic). The hospitalist impression/plan was (1) acute hypoxic respiratory failure, this was transient in nature and likely secondary to urine backup. (2) urinary tract infection (UTI), initiated Rocephin intravenously twice daily. (3) pressure ulcer, this was a known chronic entity. (4) encephalomacia (damaged brain tissue due to inflammation or bleeding); Resident D was chronically aphasic (unable to speak) secondary to TBI and subsequent encephalomalacia. The clinical record lacked indication of reason for transfer to the hospital on 3/4/24. During an interview with the DON, while reviewing Resident D's urinary output documentation, on 5/3/24 at 1:26 p.m., she indicated there was no documented urinary output for Resident D on 3/3/24. Resident D went out to the hospital on 3/4/24 at 5:30 a.m., and returned to the facility on 3/5/24 at 1:00 p.m. Sometimes, staff did not document the resident's urinary outputs. Resident D was non-responsive, but moaned at times during care. He tracked staff with his eyes at times. He had been in and out of the hospital for UTIs and respiratory problems. 2. Resident H's clinical record was reviewed on 5/6/24 at 10:31 a.m. Diagnoses included quadriplegia and retention of urine. The current physician's orders included 16 French Foley catheter (urinary catheter) with 30 cc balloon change once every 30 days, change catheter bag as needed every 30 day(s), change catheter as needed for occlusion and/or dislodgement every 24 hours as needed for replace catheter (2/29/24), change catheter bag as needed for if leaking (3/1/24), and urine output every shift at end of shift (5/6/24). A quarterly MDS assessment, dated 4/1/24, indicated Resident H was moderately cognitively impaired and required from substantial/maximal assistance to total dependence on staff for personal care. A current care plan indicated a problem of an indwelling catheter related to urinary retention/wounds (3/1/24). Interventions included change catheter system when clinically indicated or ordered (3/1/24), she would receive teaching on how to care for my catheter, personal hygiene needs, and proper positioning of the drainage bag (3/1/24), she would report and would observe for changes in the color, consistency, and odor of urine, changes in mental status, changes in amount of urine produced, and pain in the lower back or lower abdomen (3/1/24). Resident H's April and May 2024 urinary output documentation indicated the following: On 4/21/24 at 11:34 a.m., 600 cc urine output. On 4/22/24 at 3:40 a.m., 1000 cc urine output and at 9:58 p.m., 800 cc output, totaling 1800 cc of urine output for the day. On 4/23/24 at 5:23 a.m., 150 cc urine output and at 9:03 p.m., 1400 cc output, totaling 1550 cc of urine output for the day. The clinical record lacked urine output documentation for 4/24/24 through 4/27/24. On 4/28/24 at 7:03 a.m., 900 cc urine output and at 4:49 p.m., 1000 cc output, totaling 1900 cc of urine output for the day. On 4/29/24 at 12:20 p.m., 600 cc urine output and at 9:59 p.m., 725 cc output, totaling 1325 cc of urine output for the day. On 4/30/24 at 5:09 a.m., she had 950 cc urine output and at 8:16 p.m., she had 1000 cc output totaling 1950 cc of urine output. The clinical record lacked urine output documentation for 5/1/24 through 5/4/24. On 5/5/24 at 5:59 a.m., she had 950 cc urine output and at 1:52 p.m., she had 600 cc output totaling 1550 cc of urine output. 3. Resident J's clinical record was reviewed on 5/6/24 at 1:15 p.m. Diagnoses included, but were not limited to, other artificial openings of urinary tract status, neuromuscular dysfunction of bladder, benign prostatic hyperplasia without lower urinary tract symptoms, retention of urine, calculus of kidney, and hydronephrosis with renal and ureteral calculous obstruction. The current physician's orders included change catheter bag monthly and as needed, maintain suprapubic catheter 20 French/10 cc bulb and urine output every shift at end of shift (5/6/24). An admission MDS assessment, dated 3/7/24, indicated she was cognitively intact and was dependent on staff for personal care. Resident J had a care plan problem of a suprapubic catheter related to neurogenic bladder and urinary obstruction (6/22/22). Interventions included change catheter system when clinically indicated or ordered (8/7/23), consult with MD/NP as indicated (11/14/23), he would have extra fluids offered with medications (8/7/23), and he would report and staff would observe for changes in the color, consistency, and odor of urine, changes in mental status, changes in amount of urine produced, and pain in lower back or lower abdomen (6/11/22). Resident J's urinary output documentation indicated the following: On 4/21/24 at 5:59 a.m., he had 1700 cc urine output and at 10:44 p.m., he had 600 cc output totaling 2300 cc of urine output. On 4/22/24 at 3:28 a.m., he had 1200 cc urine output and at 5:17 p.m., he had 550 cc output totaling 1750 cc of urine output. On 4/23/24 at 5:21 a.m. he had 700 cc urine output. The clinical record lacked urine output documentation for the remainder of the day. The clinical record lacked urinary output documentation for 4/24/24 and 4/25/24. On 4/26/24 at 5:50 a.m., he had 675 cc urine output. The clinical record lacked urine output documentation for the remainder of the day. On 4/28/24 at 4:48 a.m., he had 900 cc urine output and at 9:59 p.m., he had 800 cc output totaling 1700 cc of urine output. On 4/30/24 at 5:59 a.m., he had 2650 cc urine output and at 12:53 p.m., he had 600 cc output totaling 3250 cc of urine output. On 5/1/24 at 4:29 a.m., he had 900 cc urine output and at 1:59 p.m., he had 500 cc output totaling 1400 cc of urine output. The clinical record lacked urinary output documentation for 5/2/24 and 5/3/24. On 5/4/24 at 5:57 a.m., he had 650 cc urine output and at 9:59 p.m., he had 900 cc output totaling 1550 cc of urine output. On 5/5/24 at 5:59 a.m., he had 2000 cc urine output and at 11:55 a.m., he had 1100 cc output totaling 3100 cc of urine output. During an interview with LPN 34, on 5/3/24 at 3:36 p.m., she indicated the urinary catheters were to be emptied and the output amount documented every eight hours by the CNAs. The CNAs would notify the nurse if there was a concern with little to no output or if the urine was dark or foul smelling. The nurses checked to see if outputs were documented. During an interview with QMA 15, on 5/3/24 at 4:00 p.m., she indicated anyone could empty a catheter. The CNAs documented the outputs, and the catheters were emptied every shift and as needed. She would report discoloration, smell, or blood in the urine and if there was no to low urine output, to a nurse. During an interview with LPN 13, on 5/6/24 at 3:35 p.m., she indicated she forgot how to check the charting for urinary output, but Unit Manager 5 checked the charting to make sure it was completed. During an interview with RN 27, on 5/6/24 at 3:45 p.m., she indicated CNAs emptied the catheter bags and documented the urinary outputs. The nurses checked to make sure the documentation was completed and thought when it was not documented it will turn up red on the charting. During an interview with Unit Manager 5, on 5/6/24 at 3:39 p.m., she indicated herself and the nurses checked the CNAs' documentation. She checked day shift while she was working and then checked the other shifts' charting the following morning. If the urinary outputs were not documented, she would go to the resident's room first to make sure the catheter drainage bag wasn't full so it wasn't backing up into the resident's bladder, then she would counsel the staff for not documenting the outputs. A current facility policy, titled Catheter Care, provided by the DON on 5/6/24 at 12:33 p.m., indicated the following: .Policy Explanation .8. Empty drainage bag every shift .Document care and report any concerns noted to the nurse on duty This citation relates to Complaint IN00432308. 3.1-41(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure supervision during dining for 1 of 4 residents reviewed for accidents. (Resident B) This deficient practice resulted in the resident choking and requiring placement on a ventilator at the hospital. Findings include: Review of a facility self-reportable to the State Agency, dated 8/5/23 at 7:01 p.m., indicated Resident B had an episode of choking at dinner time. The resident had a diet of pureed, and mechanical soft upon request, and was currently receiving speech therapy. During dinner, a table mate gave the resident a sandwich, which the resident began eating, and staff noticed the resident began choking. The nurse was notified and the resident required the Heimlich maneuver and suctioning to be done in the dining room. He was sent to the hospital. Resident B's clinical record was reviewed on 8/10/23 at 11:08 a.m. His diagnoses included chronic obstructive pulmonary disease (COPD), vascular dementia, oropharyngeal dysphagia, and hoarding disorder. A Minimum Data Set (MDS) assessment, dated 7/22/23, indicated he was severely cognitively impaired and required extensive assistance of one staff member for eating. Current physician orders, dated 4/6/22, indicated his diet was regular, pureed texture, with thin consistency liquids, and may have mechanical soft food items upon request with close supervision. A current careplan, dated 8/2/19, indicated his eating ability was at risk for decline related to his dementia diagnosis. Intervention approaches included to alternate solids and liquids: 3 to 1, cue me to pick up glass/cup and take a drink, cue me to pick up utensil and take a bite, cue me to take small bites/sips, lingual sweep and swallow, swallow completely before taking next bite, and finish meal with a liquid wash. An activities of daily living (ADL) careplan, dated 8/31/15, indicated he required assistance related to his dementia diagnosis. Intervention approaches included requiring supervision with set up for eating. A current cognition care plan, dated 7/12/22, indicated he would eat food off other people's trays. A current Discharge summary, dated [DATE], indicated Resident B was hospitalized after a choking incident. The pulmonologist note included the diagnosis of acute left mainstem bronchus occlusion with food particle or foreign body (food stuck in his lung). The resident remained intubated (tube placed to assist with breathing) and transferred to a secondary hospital for further care and possible surgery options to remove the food obstruction. During an interview, on 8/11/23 at 10:15 a.m., QMA 2 indicated staff had been told multiple times to watch Resident B while eating. He would take food from other people's tray and hide food items in his pockets to eat. She had caught him before with food that did not follow his diet order. The dining room assignment was supposed to be filled out daily so staff would be able to assist both in the dining room and with the residents remaining on the hall for meals. There should be two CNAs and one QMA from [NAME] Lane, and one CNA from [NAME] Lane, at lunchtime in the dining room. Review of an 8/11/23 at 12:22 p.m. incident report and investigation of Resident B's choking, provided by the DON, indicated three staff members in the dining room during the meal service - CNA 3, CNA 4 and RN 5. The DON's interview with CNA 4 indicated he had transported residents back to their rooms and was not present in the dining room when Resident B choked. The investigation report lacked interviews with the two remaining employees present in the dining room at the time of the resident's choking. During an interview, on 8/11/23 at 12:26 p.m., the DON indicated she had confirmed the meal tray served to Resident B was pureed. The kitchen staff had served a ham sandwich to another resident, per request, who was sitting at the same table during dinner. During an interview, on 8/11/23 at 12:37 p.m., the DON indicated the care plan interventions requiring supervision during eating for Resident B were old and he no longer required those interventions. Resident B's speech therapy evaluation, dated for certification period 7/21/23-8/19/23, provided by the DON on 8/11/23 at 1:19 p.m., indicated the following recommendations: close supervision of oral intake, cues to slow rate of eating, and to alternate bites/sips frequently. During a phone interview, on 8/11/23 at 1:00 p.m., CNA 3 indicated she was assisting someone at the table for dependent residents, and had a view of Resident 14's profile at another table across the room. She did not remember what was on the tray in front of Resident B, but he had been seated with his roommate and another resident, or maybe two. CNA 4 and RN 5 had left the dining room prior to the resident choking. There were no staff members sitting at the table with Resident 14. CNA 4 and RN 5 were not available for interview during the survey. The National Dysphagia Diet, reviewed on 8/14/23 at 2:30 p.m., at https://www.[NAME]-[NAME].org/health-library/tests-and-procedures/d/dysphagia-diet-level-1.html., indicated that patients with dysphagia diagnosis should eat only pureed food and avoid coarse foods. This Federal tag relates to Complaint IN00414590. 3.1-45(a)(2)