**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R5 R5's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), orthostatic hypotension, and a history of falls. It further indicated impairment on bilateral lower extremities (LE), independent with toileting and mobility, was occasionally incontinent of urine and always continent of bowel. Shortness of breath (SOB) when laying flat, had a fall within the last 2-6 months prior to admission/entry or reentry, and received an antidepressant and diuretic on a routine basis. R5's Care Area Assessment (CAA) triggered for falls from the MDS (11/27/25) for the following reasons: -new admit -advanced age -history of falls -impaired mobility (uses a wheelchair and was able to self-transfer with walker) -COPD with oxygen use as needed (PRN), CHF, bilateral (both sides) LE edema, morbid obesity, chronic pain, Benign Prostatic Hyperplasia (BPH) with occasional urinary incontinence, hypertension (HTN), atrial fibrillation (A-fib), depression, insomnia, restless leg syndrome (RLS), and cerebral aneurysm, non-ruptured. -medications (that may contribute to falls) Trazadone, Cymbalta, and Bumex. He hasn't had had any falls since entry/admission. Proceed to the plan of care that resident will remain safe in environment with interventions in place as evidenced by no falls during the quarter. R5's Care plan indicated R5 was at risk for falls related to medical diagnoses and history of falls prior to admission. admitted following transitional care unit (TCU) stay for strengthening following two falls on 12/27/24 (scalp laceration) and 12/30/24 (left clavicle fracture). Spasmodic torticollis. Bilateral lower extremities (BLE) edema with ready wraps daily. All staff to observe and identify for possible hazards in environment to prevent avoidable accidents/falls. It further indicated the following interventions along with the dates they were developed and implemented: -Call light within reach of resident when in room (11/27/24) -Encourage resident to call for assist with transfers and ambulation (1/31/25) -Ensure that resident has proper and non slip footwear (11/27/24) -Need to assist with evacuation in case of emergency (11/27/24) -Offer pharmacological and non-pharmacological interventions for pain when noted (11/27/24) -Physical therapy (PT)/Occupational therapy (OT) referral as needed/ordered (11/27/24) R5's progress note dated 12/27/2024, indicated R5 had an unwitnessed fall at 3:45 a.m. He slid off the commode and struck his head on the floor which resulted in a 6 centimeter (cm) laceration on the left side of his head. He was sent to the ER. R5's progress note lacked indication of a root cause analysis indicating how the fall may have occurred. R5's fall risk management dated 12/27/24, indicated R5 was found lying on his left side in his bathroom beside the commode with a 6 centimeter (cm) long laceration to the left side of his head. He was sent to the ER via non-emergency ambulance. Decreased range of motion (ROM) and gait imbalance were predisposing factors. R5's interdisciplinary team (IDT) note dated 12/30/2024, indicated resident reported that he lost his balance and fell while in the bathroom. Resident was at risk for falls due to impaired gait. Physical Therapy (PT) to evaluate and treat resident due to fall. Care plan reviewed. R5's care plan dated 11/27/24, lacked any new interventions following his fall on 12/27/24, in which he sustained a head laceration, went to the hospital, and received 7 staples in his head. During interview on 4/29/25 at 9:49 a.m., the director of therapy: (DOT) stated they had received a referral for R5 on 11/22/24 for PT. He was enrolled in PT from 12/4/24-12/31/24. The DOT further stated R5 was referred (for PT and OT) after a fall on 12/30/24, and was discharged to the Care View side for increased care on 12/31/24. R5's PT progress note dated 12/27/24, indicated R5 had seen progress since start of care (SOC) with reducing bilateral edema. Resident had a fall this morning and sustained a laceration to the head, returned from ER the same day. After education on wraps, resident continued to refuse wraps. Will continue current plan of therapy (POT) for manual lymph drainage and working on strengthening to reduce risk of falls. Resident in agreement. Today hold on exercise due to recent fall and fatigue/headache and hold on manual due to redness noted bilateral and nursing confirmation that patient appears to have cellulitis bilateral. R5's progress notes dated 12/30/24, indicated R5 had an unwitnessed fall at 4:15 p.m. The resident was found on the bathroom floor on his back with his left side against the wall. He was sent to the emergency room (ER) for evaluation. R5 was soaking wet and appeared like he used the toilet before and the floor was wet with urine. The root cause of the fall was R5 was unstable and the new intervention put in place was for him to start PT/OT. R5's risk management dated 12/30/24, indicated R5 was found on the bathroom floor on his back. He had extreme left shoulder/upper neck pain and was sent to the hospital. A wet floor, decreased ROM, gait imbalance, and previous falls were listed as predisposing factors. R5's after visit summary dated 12/30/24, indicated R5 had a fractured left clavicle (collarbone) as a result of a fall and was treated in the ER. R5's IDT note dated 12/31/2024, indicated resident reported that he fell asleep in the chair in his bathroom and fell. Resident has been re-educated to lie down in bed whenever he's tired to prevent falls/injuries. Resident will be transferred to Care View (CV)-TCU for rehab due to fracture of left clavicle. During interview on 4/29/25 at 8:58 a.m., licensed practical nurse (LPN)-A stated when a fall occured, nurses were responsible for trying to figure out why the fall happened and putting in an immediate intervention. Then the nurse managers were responsible for putting in follow up interventions in order to prevent another fall. During interview on 4/29/25 12:46 p.m. the nurse manager registered nurse (RN)-A stated when a fall occurred, the nurses were responsible for filling out an official fall progress note indicating what happened, and putting in an immediate intervention. Then the nurse managers were responsible for coming up with a root cause analysis (RCA). RN-A further stated there should be a new intervention put into place after each fall in order to determine what interventions are working or if there was anything else they could be doing to prevent the fall. RN-A also verified there wasn't a root cause analysis or any new interventions following R5's fall on 12/27/24. RN-A was unable to answer as to how the facility was able to determine whether R5 was safe to transfer and toilet himself following the fall. During interview on 4/30/25 at 10:40 a.m., the director of nursing (DON) stated there was no documentation that a RCA for R5's fall on 12/27/24 had been completed or that a new intervention had been added. This was important in order to prevent another fall. The facility's policy regarding falls dated 1/24/23, indicated the purpose of the policy was to identify and monitor residents at high risk for falls, minimize the incidence and potential for injury from falls, and ensure that proper assessment, intervention and documentation of incidents are completed. It further indicated all incidents should be assessed for the root cause and care plan modified if possible to prevent further incidents. R79 R79's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses including dementia, intellectual disabilities, and epilepsy. It further indicated R79 was independent with most activities of daily living (ADL) and mobility. R79's medical record lacked documentation an elopement risk assessment had been completed. During interview on 4/29/25 at 12:46 p.m. the nurse manager registered nurse (RN)-A stated they don't fill out elopement risk assessments for residents on the 2nd and 4th floors because they are able to come and go independently. RN-A stated they determine whether a resident can leave the facility independently or not upon admission and by asking the resident's responsible party. During interview on 4/30/25 at 9:02 a.m. the receptionist (RC) who sits at the front desk by the entrance door stated if a resident tried to leave the facility by themselves she would look in the book of photos at her desk that contained pictures of residents who were not able to safely leave the facility by themselves and would not unlock the door to let them out. She would then try to redirect them and call the nurse. The receptionist showed the surveyor the book of photos and there was a picture of R79 in the book. R79's progress note dated 4/27/25, indicated resident attempted to leave the facility without family, was stopped by the receptionist, and educated. During interview on 4/30/25 at 8:37 a.m licensed practical nurse (LPN)-A stated they do not fill out elopement assessments on the 4th floor but if a resident tried to elope, then they would complete one, notify the provider, family member, and supervisor. The surveyor showed LPN-A the progress note from 4/27/25 for R79 and she stated there should've been an elopement risk assessment filled out for R79 and notifications should have been made. During interview on 4/30/25 at 10:40 a.m., the DON stated elopement risk assessments were built into their admission data base, but R79's was not filled out and was unable to find any elopement risk assessments for him and there should have been . A facility policy regarding wandering and elopement dated 11/2022, indicated on admission, each resident will be assessed for elopement risk via completion of admission Database Assessment. Based on observation, interview and record review, the facility to ensure interventions were implemented for 2 of 2 residents (R83, R5) and a root cause analysis was completed for 1 of 2 residents (R5) after a fall. This lead to actual harm for both R83 and R5 when R83 fell and sustained a right hip fracture that required hospitalization and surgery and when R5 fell and sustained a right clavicle fracture that required hospitalization. In addition, the facility failed ensure an elopement risk assessment was completed for 1 of 1 residents (R79) who had attempted to elope and failed to provide monitoring for 1 of 1 residents (R47) who had complaints of coughing during meals. Findings include: R83 R83's quarterly Minimum Data Set (MDS) dated [DATE], indicated R83 had severe cognitive impairment and diagnoses of Alzheimer's Disease and osteoporosis (disease that causes weak bones). R83 required moderate assistance with toileting and supervision or touching assist when walking at least 10 feet and was at risk for falls. R83'S nursing progress note dated 10/4/24 at 9:26 a.m., indicated R83 had an unwitnessed fall at 7:30 a.m. The root cause was R83 slid out of bed onto the floor when trying to get out of bed. The intervention implemented was a perimeter mattress. R83's fall risk management dated 10/4/24, indicated R83 had slid out of bed. R83 was found with one sock on and one barefoot. R83 had impaired memory and was confused. A predisposing factor to the fall was improper footwear. R83's interdisciplinary (IDT) note dated 10/4/24 at 1:35 p.m., indicated R83 slid off the side of her bed onto the floor. Mattress was changed to perimeter and staff to assist R83 to place gripper sock on at bedtime as R83 allows. R83's care plan was reviewed and updated. R83's care plan revised 10/4/24, lacked indication the gripper socks at bedtime was initiated after this fall. R83's electronic medical record (EMR) lacked indication R83 had refused or took off the gripper socks at bedtime. R83's nursing progress note dated 10/30/24 at 7:23 a.m., indicated R83 was found on the floor at 1:00 a.m. The note identified the root cause was R83 slipped out of bed and was wearing slippery socks. R83 had severe pain to their right hip and was sent to the hospital. R83's fall risk management dated 10/30/24, indicated R83 was found on the floor next to their bed. R83 had severe pain and was guarding their right hip. R83 was sent to the emergency room for evaluation. R83's IDT note dated 10/30/24 at 10:30 a.m., indicated R83 sustained a fall while transferring out of bed. R83 was sent to the emergency room for evaluation. R83's emergency room provider note dated 10/30/24 at 3:54 a.m., indicated R83 was transferring out of their bed and slipped on their socks. R83 sustained a right femur fracture and required surgical intervention. R83's discharge physical therapy note dated 12/11/24, indicated R83 required assist of one and supervision for all mobility. R83's discharge occupational therapy note dated 12/11/24, indicated R83 required supervision for toileting, peri-cares and clothing management and directed R83 to have assistance with nursing. R83's fall Care Area Assessment (CAA) dated 12/18/24, indicated R83 recently had a right hip hemiarthroplasty (partial right hip replacement) due to a fall with fracture and had continued impaired mobility. Staff were to walk with resident with gait belt and wheelchair to activities and dining. R83's falls assessment dated [DATE], indicated R83 had impaired mobility and used a walker and wheelchair for ambulation. R83's care plan revised on 4/24/25, indicated R83 was at risk for falling due to cognitive impairment, history of falls, weakness and recent hip surgery. Interventions included to keep call light in reach, perimeter mattress, keep walker at bedside when resting, and ensure R83 has proper footwear. R83's care plan further indicated R83 required assistance with mobility due to hip surgery. Interventions included ambulation with supervision/touch assist. Walking in hallway to and from meals required staff assist of 1, gait belt, and a wheelchair to follow. R83's Kardex as of 4/29/25, directed staff R83 required supervision/touch and use of 2 wheeled walker for ambulation and walk resident in hallway with wheelchair to follow with meals. R83 also required supervision with toileting with assist of one. During an observation on 4/28/25 at 4:59 p.m., R83 was standing in the doorway shouting for help. R83 had no walker and one pant leg was pulled up to their knee and the other one was on the floor. R83 was yelling for someone to help them. Registered nurse (RN)-F was seated at the computer across from R83's room and stated I will be there in a minute without looking up from the computer. R83 then said what nobody around to help? RN-F then stood, saw the situation, and got up to assist R83. During an observation on 4/29/25 at 9:03 a.m., R83 was seated in the television area. At 9:36 a.m., activity aide (AA) asked R83 if they wanted to go for a walk in the hallway. AA walked R83 down to the dining room and then back, past the television room towards the birds. AA walked R83 without the transfer belt or a wheelchair behind them. About halfway down to the birds, R83 stated they needed to use the bathroom. AA turned back to go into R83's room and stopped at the bathroom door. At the bathroom door, R83 told AA to stay out. AA closed R83's bathroom door and room door when exiting. At 8:58 a.m., AA told nursing assistant (NA)-B, who was sitting at the desk across from R83's room charting, R83 was in the bathroom. NA-B continued charting and at 10:12 a.m., got up and walked down the hallway towards the dining room and returned at 10:14 a.m., knocked and entered R83's room. R83 was now in bed. R83's walker was in the bathroom and R83 had walked back to bed. NA-B stated oh, she must have already went back to bed. When interviewed at 4/29/25 at 10:16 a.m., NA-B stated the Kardex let staff know what kind of assistance residents need. NA-B further said, the nurses will report off who was at risk of falling and stated R83 was a fall risk. R83 was unsteady at times and was confused and still thinks she is independent. NA-B verified R83 required staff to be in with her for the bathroom, but often R83 doesn't want anyone in. NA-B stated usually, they stood right outside the door and listened. When R83 got up or the toilet flushed, then would enter and assist but had not done that this time. NA-verified R83 required a walker for ambulation and walked without it back to their bed. NA-further stated using a wheelchair behind them was more of a therapy thing, and it was an option if R83 was feeling weak. When interviewed on 4/29/25 at 10:28 a.m., AA stated they check with staff and the NA's to know how much an assistance a resident needed. AA further stated as you work with the residents- usually get to know them. When interviewed at 4/29/25 at 10:33 a.m., RN-E sated when a resident falls, an assessment of the resident is completed. Once the resident was deemed ok, a risk management report was completed. The report walks through the situation and what the root cause was and there should be an intervention placed. Nurse managers will put any new interventions in the Kardex and care plan. RN-E verified R83 was a fall risk and further stated R83 transferred independently and used a walker to ambulate. R83 doesn't always use the wheelchair, but maybe for longer distances. RN-E stated if there were any changes in mobility assistance or devices, therapy was usually involved. When interviewed on 4/29/25 at 12:38 p.m., the Director of Therapy (DOT) stated R83 discharged from therapy when they signed up for hospice on 12/11/24. At the time of discharge, R83 was transferring with assistance of one person and ambulating with assist of one with a two wheeled walker. Walking directions to follow with a wheelchair was from therapy and verified that was communicated to nursing on 11/18/24. Nursing could evaluate and change the mobility status if no longer needing the wheelchair or transfer belt. When interviewed on 4/29/25 at 1:43 p.m., RN-B stated when a fall happens, the resident was assessed for injuries and questions asked as to what happened. The nurse will complete a fall risk management report and this was where the root cause of the fall would be listed and any interventions needed. Any nurse can update the care plan or Kardex, however typically the nurse manager would complete. The IDT reviews the fall and will ensue any interventions added were appropriate and ensure the care plan was updated. RN-B verified R83's care plan had not included gripper socks at bedtime. RN-B expected that intervention to be included on the care plan and Kardex so staff were aware of it. Furthermore, RN-B verified R83's care plan and Kardex directed staff to use a walker, transfer belt and a wheelchair to follow for mobility to the dining room. RN-B expected staff to follow those directions. When interviewed on 4/29/25 at 2:52 p.m., the Director of Nursing (DON) expected staff to assess the resident, complete a risk management form to start the fall investigation, contact family, provider. The risk management form asks about the description of what happened, immediate actions, environment, and any pre-disposing factors. If the nurse knew what the root cause of the fall was, that would also be added. Then IDT meets and reviews the fall. The nurse will implement the immediate intervention, and IDT will determine if that is enough or if more investigation or interventions were needed. The nurse managers are then responsible to implement the interventions into the Kardex and care plan. DON expected R83's identified interventions for a perimeter mattress and gripper socks to be implemented and would need to review these. DON further expected staff to follow the interventions on the care plan and Kardex for mobility. If there were changes, therapy or nursing would evaluate and then update the interventions. A follow up interview at 4/30/25 at 8:51 a.m., the DON stated R83 never had the gripper socks implemented after the fall on 10/4/24. DON stated discussion with staff on the unit, R83 would not keep them on and always took them off and therefore not implemented. DON verified there was no documentation to support this. R47 R47's annual MDS dated [DATE], indicated R47 did not have signs or symptoms of a swallowing disorder, did not have coughing or choking during meals or when swallowing medications. R47's Optional State Assessment (OSA) dated 4/8/25, indicated intact cognition, did not reject cares, was independent with bed mobility, transfers, eating, and required supervision support with eating. R47's quarterly MDS dated [DATE], indicated intact cognition, did not have physical or verbal behaviors, did not reject care, had anxiety, depression, and mild cognitive impairment, was independent with ambulation, had coughing or choking during meals or when swallowing medications, was not on a therapeutic diet, mechanically altered diet, and did not have parenteral, IV feeding, or a feeding tube. R47's Medical Diagnosis form indicated R47 had the following diagnoses: mild cognitive impairment, major depressive disorder, other anxiety disorders, gastro-esophageal reflux disease (GERD) (a digestive disorder where stomach acid flows back up into the esophagus) without esophagitis, and disease of digestive system unspecified. R47's Physician's Orders form indicated the following orders: • 12/9/19, regular diet, regular texture, and thin liquids consistency. • 9/14/22, omeprazole (a medication that reduces the amount of acid your stomach makes) delayed release give 20 milligrams (MG) by mouth. R47's care plan dated 1/15/25, indicated R47 had a history of verbal aggression towards staff and other residents and did not like anyone sitting in her dining room chair and placed notes on the chair to remind other residents not to sit in her chair and because other residents ignored her request, preferred to eat in her room. R47's care plan revised 2/3/25, indicated R47 could feed herself independently and required as needed set up assist. R47's care plan revised on 4/30/25, indicated R47 had an altered nutrition and hydration status due to GERD, depression, anxiety and reported occasional discomfort with swallowing and declined speech therapy at this time. Further, R47 continued to express preferences to eat in her room and was educated on the risks and benefits of eating in the room versus the main dining room and verbalized understanding. Interventions included a regular diet, regular texture, thin liquids, notify dietary professional of changes in oral intake, weight, chew/swallowing, abnormal labs and skin integrity, and the dietician was to follow up as needed. R47's Kardex dated 4/30/25, indicated R47 had a regular diet, regular texture, and thin liquids. Further, R47 ate independently with as needed setup assistance. The Kardex lacked information R47 had difficulty swallowing or that R47 required any supervision. R47's physician progress note dated 4/4/25, indicated R47 had a history of GERD and diverticulitis, had no cough, was known to be lactose intolerant, and had been taking her meals in her room lately. R47's dietitian progress notes dated 4/8/25 at 8:12 a.m., indicated R47 ate in her room, had moved tables a few times due to not liking who was sitting with her. Further, R47 noticed when swallowing, sometimes things went down the wrong way, mostly with liquids and reported it was not painful, but more uncomfortable and reported food went down the wrong way and R47 coughed for it to come back up. The dietician explained speech therapy (ST) and R47 did not feel she needed ST and the note indicated to monitor for dysphagia (difficulty swallowing) signs and symptoms, gastrointestinal issues, and weight changes and the dietician would monitor R47's feeding ability and chewing and swallowing ability to provide further interventions as warranted. The note lacked information R47's provider was updated, or whether safety was assessed due to R47 eating in her room. R47's Nutrition Assessment form dated 1/21/25, indicated R47 ate in her room, was on a regular diet, regular textures with thin liquids, occasionally required set up help and did not have any chewing or swallowing difficulties. The note further indicated the dietician would continue to monitor R47's nutritional status including weight trends, meal intakes, labs, gastrointestinal status, feeding ability, and chewing and swallowing ability to provide further interventions as warranted. R47's Nutrition Assessment form dated 4/8/25, indicated R47 was on a regular diet, had regular textures with thin liquids, ate in her room and occasionally required set up help, had coughing or choking during meals or when swallowing medications. The form indicated R47 reported noticed when swallowing, liquids went down the wrong way and reported it was not painful, but more uncomfortable. R47 reported food went down the wrong way and R47 coughed for it to come back up and speech therapy was explained to R47 who did not feel she needed speech therapy and R47 would watch and see if it was needed in the future. Further, no nutritional interventions were in place. A heading, Goals/Recommendations, indicated to monitor for dysphagia signs and symptoms, gastrointestinal issues, and weight changes. During interview and observation on 4/29/25 at 12:33 p.m., R47 was in her room and stated she had not yet had lunch. During interview and observation on 4/29/25 at 1:01 p.m., nursing assistant (NA)-C brought R47's meal tray into her room and stated R47 was having a turkey Swiss wrap for lunch per R47's request. During observation on 4/30/25 at 12:26 p.m., R47 was in her room and stated lunch was served between 12:00 p.m., and 12:30 p.m., downstairs and then food was plated and brought up to rooms. R47 wanted her door closed. During observation on 4/30/25 at 12:21 p.m., a paper sign was located at the nursing station that directed staff regarding meals to ask residents their choice of meals before each meal and indicate the meal choice on the meal ticket. When serving check that the meal tray has condiments, utensils, and other items for the resident and check to make sure all food items are accessible and with in reach of the resident and ask the resident if there was anything else needed before leaving the room. Return to the resident's room shortly after tray pass to make sure they have everything they need, check to make sure all tray items are accessible and within reach and offer refills on drinks, re-warm or replace food as needed and at the end of the meal return to the resident's room to check if they are done eating collect the tray and return to the culinary cart. During observation on 4/30/25 at 12:51 p.m., the meal cart was observed coming down the hallway. During interview and observation on 4/30/25 at 12:52 p.m., NA-C stated R47 was going to have chicken salad and knocked on R47's door and introduced herself. NA-C stated they looked at the Kardex to know what cares a resident required and if a resident refused, staff reapproached and the nurse would try and document refusals. NA-C stated a nurse would have to answer what to do if a resident had trouble swallowing and stated therapy worked with residents and did not know whether residents should eat in their rooms if they had difficulty swallowing. NA-C stated R47 was independent and did not complaint of difficulty swallowing and stated her Kardex did not indicate R47 required monitoring with meals. During interview on 4/30/25 at 1:07 p.m., licensed practical nurse (LPN)-A stated they used the care plan to know what cares a resident required and if a resident refused would document. LPN-A stated if a resident reported difficulty swallowing would assess the resident, call the nurse practitioner or the doctor and residents would have speech therapy. LPN-A stated they first had to assess and then call the provider and if they received an order would fax it to the therapy department and further would add to the care plan and Kardex. LPN-A stated residents could not eat in their room if they had a swallowing problem and did not do a risk versus benefits form and added they couldn't force residents, but at the same time they encouraged them. LPN-A stated R47 did not have difficulty swallowing, was alert and oriented, and used to eat in the dining room but somebody sat in her spot and chose not to go down. LPN-A viewed R47's Kardex and verified it lacked information R47 had difficulty swallowing. LPN-A stated she hadn't heard R47 had difficulty swallowing and stated if R47 had difficulty, they had to assess and could not eat in her room. LPN-A viewed R47's nutrition assessment and verified R47 had coughing or choking during meals and stated if the physician was updated, it was documented in the progress notes and added it would be important for nursing to know if R47 had difficulty swallowing because they had to monitor her and was not monitored eating in her room. During interview on 4/30/25 at 1:27 p.m., RN-D stated they would document if a resident had difficulty swallowing and wanted to eat in their rooms the risk versus benefits and would order speech therapy to evaluate and treat and offer a recommendation. If the resident declined speech therapy (ST), ST would document the attempted evaluation and the nurse would update the doctor and stated ST had a waiver if ST saw a resident and the resident declined recommendations. RN-D stated it was a resident's preference if they wanted to eat in their room would tell them the risks versus the benefits of eating in the room and stated R47 did not have difficulty swallowing and had not exhibited the symptoms or reported any symptoms of trouble swallowing. RN-D viewed R47's nutrition assessment and stated he could have the dietician amend the note because he was not aware of any swallowing problems and would follow up with the dietician along with R47 and stated the dietician should have mentioned R47 had difficulty swallowing. RN-D later documented a progress note on 4/30/25 at 1:54 p.m., that indicated the progress note was a follow up note to the dietitian progress note dated 4/8/25 at 8:12 a.m., R47 reported occasional discomfort with swallowing and did not want a speech evaluation, but would let RN-D know if symptoms worsened. R47 continued to express preferences to eat in her room, was educated on risks and benefits of eating in the room versus in the main dining room, and R47's family and primary care provider were updated. Further, the note indicated the care plan was reviewed and updated. During interview on 4/30/25 at 1:39 p.m., dietician (D)-J stated if a resident reported difficulty swallowing would talk to the nurse manager and get ST in place and if the resident didn't want ST, would still follow up with the nurse manager to find a solution. During interview on 4/30/25 at 2:41 p.m., RN-D brought D-I to the conference room. D-I stated RN-D had updated D-I regarding inquiries on R47's swallowing. D-I stated she asked if a resident had difficulty swallowing on every assessment and R47 mentioned she noticed it happened and brought up ST because R47 stated sometimes things went down the wrong way and expected staff monitor R47 and watch for foods and fluids going down the wrong way. When asked how resident would be monitored for choking when eating in her room, D-I stated that could happen and they encouraged everyone to eat in the dining room and R47 preferred to eat in her room. D-I stated she would document if a risk versus benefits was completed and stated she did not discuss with R47 the risks versus benefits of eating in her room and stated she discussed what ST could help with and expected monitoring to be on the care plan and Kardex and verified information was not on the Kardex and stated it w[TRUNCATED]