See deficiency cited at Event ID #172413 Based on interview and record review, staff failed to implement a system to ensure facility staff communicated a report on residents' conditions to agency staff prior to their shifts and failed to direct agency staff where to find the binder containing instructions on residents' care needs. The facility failed to ensure one resident's (Resident #18) care plan instructions for staff reflected the resident's assessed needs, including use of mechanical lift for transfers. On 12/17/24 around 12:00 P.M., an unknown nurse directed Certified Nurse Aide (CNA) C to transfer the resident from his/her bed without communication of the resident's need for mechanical lift transfer. CNA C utilized a gait belt, instead of using a Hoyer lift (mechanical lift). The resident fell during the transfer and sustained fractures to his/her ribs, legs, and left ankle. The resident's physician said staff failed to notify him/her of the incident until later in the evening. EMS did not transfer the resident to the hospital until 10:08 P.M. and reported the resident was hard to arouse. Additionally, the facility failed to appropriately respond to a resident's (Resident #17) change of condition and failed to contact the resident's physician. The resident had multiple falls between 12/6/24 and 12/10/24. The sample was 2. The census was 96.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, staff failed to implement a system to ensure facility staff communicated a report on residents' conditions to agency staff prior to their shifts and failed to direct agency staff where to find the binder containing instructions on residents' care needs. The facility failed to ensure one resident's (Resident #18) care plan instructions for staff reflected the resident's assessed needs, including use of mechanical lift for transfers. On 12/17/24 around 12:00 P.M., an unknown nurse directed Certified Nurse Aide (CNA) C to transfer the resident from his/her bed without communication of the resident's need for mechanical lift transfer. CNA C utilized a gait belt, instead of using a Hoyer lift (mechanical lift). The resident fell during the transfer and sustained fractures to his/her ribs, legs, and left ankle. The resident's physician said staff failed to notify him/her of the incident until later in the evening. EMS did not transfer the resident to the hospital until 10:08 P.M. and reported the resident was hard to arouse. Additionally, the facility failed to appropriately respond to a resident's (Resident #17) change of condition and failed to contact the resident's physician. The resident had multiple falls between 12/6/24 and 12/10/24. The sample was 2. The census was 96. The Administrator was notified on 1/14/25 at 5:32 P.M., of an immediate jeopardy (IJ) which began on 12/17/24. The IJ was removed on 1/16/25 as confirmed by surveyor on-site verification. Review of the facility's Change in Condition and When to Notify the Physician policy (undated), showed: -Purpose: To provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a resident's condition; -When there is a change in condition, the physician must be notified. Below are examples of what is considered a change in condition: -Altered mental status: Includes sudden change in mental status or loss of consciousness; -Edema: Abrupt onset or increased amount; -Falls: All falls; -Nurses must assess residents frequently for change in condition. If a change is observed, check vital signs and note anything different with the resident. Relay the information to the physician.; -Make sure to document physician called, signs and symptoms observed, family notification and all interventions taken. Review of the facility's Fall programs policy and procedure, reviewed 1/2023, showed: -Purpose: To identify all resident who have a high risk for falls and to ensure adequate interventions are in place to prevent major injury; -Policy: An investigation of all falls will be completed by the Director of Nursing (DON)/designee and submitted to the interdisciplinary team (IDT) committee for review; -Fall risk evaluation (UDA) will be completed on every resident upon admission/re-admission by the nurse on shift the resident is admitted on ; -When a resident is identified as being at a high risk for falls, this will be identified on the baseline care plan upon admission and the fall intervention notes on the [NAME] (gives a brief overview of each resident); -When a resident within the facility falls, the nurse will assess/evaluate the resident and document in the electronic medical record. Neuro checks will be initiated for all un-witnessed falls, residents who hit their head. 1. Review of Resident #18's PT Discharge summary, dated [DATE], showed: -Total assistance/Hoyer (mechanical transfer) on 6/6/23, resident refused on 6/19/23, and unable to complete on 6/29/23; -Instructed nursing caregivers in positioning maneuvers and safety precautions. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/17/24, showed: -admitted [DATE]; -Moderate cognitive impairment; -Diagnoses included stroke, major depressive disorder and repeated falls; -Upper and lower extremity impairment on one side; -Substantial to maximum assistance with mobility; -Transfers: Dependent on staff for lying to sitting on the side of the bed. Sit to stand not attempted due to medical condition or safety concerns; -No falls since admission. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident had an activities of daily living (ADL) self-care performance deficit due to activity intolerance; -Interventions: The resident required extensive assistance by one staff to turn and reposition in bed and move between surfaces; -Focus: The resident was at risk for falls due to deconditioning, stroke, and right-side weakness; -Interventions: Anticipate and meet the resident's needs. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs; -The care plan did not instruct staff to utilize the Hoyer lift for transfers. Review of the resident's progress notes, showed: -On 12/9/24 at 7:12 P.M., resident seen by physician for chronic pain. New order for tramadol (used for short term relief of chronic pain) 50 milligram (mg), twice daily (BID) given; -On 12/17/24 at 5:30 P.M., staff monitored the resident for pain to ankle. He/She complained of pain to ankle this morning. At 8:40 P.M., the resident said his/her ankle was hurting. He/She was being assisted from bed and heard a pop. Oncoming nurse notified. At 8:56 P.M., the nurse received report the CNA on day shift attempted to transfer the resident and heard a pop. The resident had been in severe pain in bilateral lower extremities. The areas were painful to touch, and right leg appeared swollen. He/She complained of pain to left leg, but no bruising present in either extremities. The resident rated pain ten out of ten. Resident's physician notified of events. He/She gave orders to increase tramadol 50 mg BID to 100 mg BID and obtain three view x-ray of right ankle to rule out fracture/dislocation. X-ray technician said he/she would come out on 12/18/24. The resident remained in bed. His/Her vitals were stable with no acute distress noted. At 9:40 P.M., order received from physician to send resident to hospital. The resident responded to painful stimuli but did not answer questions. Resident transported to hospital by Emergency Medical Services (EMS). Review of the resident's EMS report, dated 12/17/24, showed: -At 10:08 P.M., EMS responded to the facility for a resident with an altered mental status. The resident was laying in his/her bed. Staff said the resident heard a loud pop during a transfer earlier in the day. He/She had been lethargic since. The resident was lethargic and hard to arouse. The resident was very large and an additional EMS personnel were called to transfer resident from bed. The resident was given oxygen. He/She became hypotensive (having low blood pressure) during transport to hospital. At 10:43 P.M., the resident's blood pressure was 58/33. Review of the resident's hospital records, showed -admitted on [DATE] at 10:46 P.M.; -According to EMS, the resident had a history of stroke, alert and oriented times three and almost completely bedbound; -The resident was given vasopressor (used to treat low blood pressure shock); -The resident said he/she fell. He/She could not remember what happened before or after the fall; -Right and left lower extremity range of motion decreased due to pain; -X-rays revealed both femurs (thigh bones) were fractured in the wider part, near the middle of the bone. The bone was broken in multiple pieces due to significant trauma. Fractures of the distal left tibia and fibula (break in the lower leg bone which requires immediate medical attention. Usually caused by a fall or hard blow to the leg, or sudden twist of the leg). Fracture of left calcaneal (heel bone), bruise on right thigh and rib fractures of the left first rib, right third, fifth and sixth ribs; -The resident had brittle bones; -The resident was admitted to the intensive care unit until blood pressure stabilized. Review of the facility's investigation dated 12/20/24, showed: -On 12/17/24 at approximately 12:00 P.M., agency CNA C reported he/she went into the resident's room to provide incontinence care. He/She changed the resident and cleaned him/her up. CNA C put the gait belt on the resident and sat him/her up on the side of the bed. The wheelchair was adjacent to the bed. CNA C told the resident he/she was going to stand him/her up. The resident said okay. They stood for a split second and CNA C heard a pop from down below. He/She thought it was the resident's knee or ankle. CNA C helped the resident back into bed with the gait belt; -The resident was transferred to the hospital later in the evening; -The resident was diagnosed with multiple bone fractures; -Nursing staff was in-serviced on safe transfers; -No documented conclusion to the investigation. During an interview on 1/10/25 at 12:00 P.M., CNA C said the nurse (he/she didn't know the nurse's name) told him/her to get the resident out of bed on 12/17/24. The nurse said the resident was going to say he/she could not walk or stand, but get him/her up anyway. The nurse did not provide the agency CNA with instruction on the appropriate method to transfer the resident. CNA C entered the resident's room around 12:00 P.M. The resident said he/she did not get out of bed. He/She did not want to get up. CNA C told the resident the nurse said he/she had to get up. CNA C lowered the resident's bed then put the wheelchair next to it. He/She used the gait belt to sit the resident up on the side of the bed. The resident stood up and said Oh. CNA C heard a pop and used the gait belt to sling the resident back on the bed. CNA C retrieved a Hoyer pad and was going to get help to transfer the resident. The resident did not want to be transferred. He/She was complaining of pain in his/her legs. CNA C went to get the nurse. The Assistant Director of Nursing (ADON) and Licensed Practical Nurse (LPN) F assessed the resident's legs. They said they would wait and see how it looked later. CNA C was transferred to another hall. The nurse did not tell CNA C if the resident was a one or two person assist. CNA C did not ask anyone how the resident should be transferred. Agency staff are supposed to get report from the Charge Nurse at the start of their shift. Sometimes the facility is short staffed, and they do not give report. He/She did not get report on the day of the incident. LPN F asked the resident why he/she did not tell CNA C he/she was a Hoyer lift transfer. The resident's legs buckled when he/she stood up. CNA C grabbed the resident with the gait belt, quickly. The resident's legs did not look out of place. CNA C did not know about the binder at the nurse's station. During an interview on 1/9/25 at 2:27 P.M., LPN A said he/she was assisting another resident when CNA C told him/her he/she was transferring the resident and heard a pop. The resident was complaining of pain. He/She told CNA C to ask the ADON to assist him/her. The ADON and LPN F said the resident did not need x-rays. They instructed the Certified Medication Technician (CMT) to give the resident pain medication. The ADON and LPN F said they notified the physician. LPN A assessed the resident. He/She is not sure what time he/she assessed the resident. During shift change, the evening nurse and LPN A assessed the resident for pain. He/She complained of pain in his/her left and right ankle. His/Her pain was a ten. The oncoming nurse contacted the physician. The physician increased the resident's tramadol to 100 mg and ordered an x-ray. The x-ray technician could not come out until the following day. The physician gave an order to send the resident to the hospital. He/She was bedbound. The resident was a two person assist with a Hoyer lift. During an interview on 1/10/25 at 11:11 P.M., the ADON said CNA C said he/she sat the resident up on the side of the bed. When the resident stood up, CNA C heard a pop. The resident complained of pain in his/her right ankle. When the ADON entered the resident's room, the resident was laying in bed and LPN F was assessing his/her right ankle. He/She had range of motion (ROM) in his/her right ankle. The ADON left the room to get the charge nurse. She is not sure if the physician was notified immediately after the incident. She is certain he was contacted later in the evening. The physician ordered an x-ray. She thinks the resident was a two person assist with a Hoyer lift. She did not see a Hoyer lift in the resident's room when she entered. She remembered seeing a gait belt on the bed or in CNA C's hand. She is not sure if the resident could bear weight prior to this incident. Agency staff are supposed to get report prior to shift change. Review of the binder containing care instructions for residents, dated 1/14/25, showed for Resident #18: -Transfer: The resident required extensive assist by 1 staff to move between surfaces. Upon return from hospital, use mechanical lift and two staff assist (updated 12/19/24). During an interview on 1/10/25 at 12:55 P.M., LPN F said he/she was stopped in the hall by CNA C. He/She entered the resident's room and the resident was laying in the bed. The resident complained of pain in his/her right ankle. He/She had ROM in his/her right ankle. The CNA attempted to transfer the resident by him/herself. LPN F did not ask the resident if he/she fell. He/She cannot remember if the resident was a one or two person assist. He/She did not remember seeing a gait belt or Hoyer lift in the resident's room. He/She does not remember if the resident's physician was notified. The nurse assigned to the resident would have been responsible for notifying the physician. The facility used agency staff often. Agency staff were supposed to view the binder at the nurse's station. The binder contained information about the residents. There was not a system in place to verify if they reviewed the binder. During an interview on 1/10/25 at 1:33 P.M., the resident's physician said staff notified him of the incident later in the evening. He/She gave an order to increase pain medication to 100 mg and obtain an x-ray. Staff said the resident was still complaining of pain and he/she told them to send the resident to the hospital. He/She is not sure what time staff contacted him/her. He/She tried to figure out severity based on the report from the staff. Staff said the resident was in pain. He/She was not aware of the severity of the injuries. He/She did not think a simple fall would cause the resident's injuries. The gait belt could have caused the rib fractures. Maybe he/she fell, twisted his/her legs, causing the femur fractures. The resident's injuries are not consistent with the CNA's story. He/She expected staff to give him a thorough report. The resident was bedbound and he/she did not know why they got him/her up. During an interview on 1/13/25 at 9:51 A.M., the Staffing Coordinator said CNA C was sent to another hall, because someone was sick and had to leave. Agency staff are supposed to get report from the Charge Nurse at the start of their shift. She does not know if they receive any training. During an interview on 1/13/25 at 10:23 A.M., the DON said agency staff are supposed to get a verbal report from the Charge Nurse about their assignments. There is a binder at each nurse's station with the residents' [NAME], which includes the residents' ADL needs. It is updated as needed or with a change of condition. There is not a system in place to ensure agency staff are getting report and reviewing the binder. During an interview on 1/13/25 at 1:04 P.M., the Administrator and ADON said the fractures occurred when CNA C attempted to transfer the resident. The resident stayed in bed most of the time. Agency staff should get report prior to their shift. 2. Review of Resident #17's admission MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included rectal cancer, cirrhosis of the liver, depression and muscle weakness; -History of falls; -No falls in two-six months prior to admission; -Independent with transfers; -Supervision with personal hygiene and toileting; -Partial to moderate assistance with showers; -He/She used a walker. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: The resident had an ADL self-care performance deficit due to impaired mobility, weakness, chronic health conditions. He/She was often non-compliant with asking for assistance prior to moving about; -Interventions: Staff discussed with resident/family/power of attorney any concerns related to loss of independence, decline in function. Encouraged the resident to discuss feelings about self-care deficit. Encouraged the resident to participate to with each interaction. Encouraged the resident to use call light for assistance. Monitored/documented/reported as needed (PRN) any changes, potential for improvement, reasons for self-care deficit, expected course, and declines in function; -Focus: The resident is at risk for falls due to cirrhosis, cancer, non-compliance, incontinence with generalized weakness, impulsivity, and impaired safety awareness; -Interventions: Resident educated on proper use of call light for assistance. Resident educated on rising slowly and using grab bars when transitioning from sitting to standing. Educated the resident/family/caregivers about safety reminders and what to do if fall occurred. Reviewed information on past falls and attempted to determine cause of falls. Recorded possible root causes. Altered/removed any potential causes if possible. Review of the resident's post fall evaluation, dated 12/6/24, showed: -Fall details: The fall occurred on 12/06/2024 at 5:30 A.M. in the resident's bathroom. The fall was unwitnessed. The resident was in a hurry to grab something to get back on the toilet. The resident had a skin tear and said his/her head hurt. The resident's physician notified on 12/6/24; -Contributing Factors: The lighting was poor and there was fluid spilled on floor. He/She was not using cane/walker as instructed; -Vitals: Temperature 97.9, blood pressure 118/71, pulse 80, respirations 18; -Pain: The resident complained of head pain. Pain indicated via facial expressions and non-verbal sounds. Pain level was an eight out of ten. Review of the resident's progress notes, showed: -On 12/6/24 at 8:38 A.M., the resident fell in his/her bathroom. He/She had a skin tear to left front knee with head injury and pain to left side of head. Family notified. At 9:43 A.M., the resident refused vital signs. He/She said he/she was fine. He/She denied pain to head and/or knee. Skin tear cleansed and dressing applied. His/Her knee was slightly swollen. No shortening noted. He/She was able to move his/her knee without discomfort; -On 12/7/24 at 6:00 A.M., the resident was continued on incident follow up (IFU). His/Her vital signs were stable and strong at baseline. He/She was neurologically alert and oriented. He/She was educated to ask for help when moving around; -On 12/8/24 at 6:08 P.M., the resident was on IFU following a fall. He/She fell to left side had a skin tear to his/her left knee. He/She denied pain. Discoloration noted to area near left eye. He/She said it happened a while ago; -On 12/9/24 at 10:37 A.M., the resident denied pain and discomfort related to fall. The resident was assessed. Both eyes were black in color. Neuro checks and hand grips were equal. He/She continued to be on the toilet. At 12:57 P.M., the resident refused peri care and clothes change. At 3:13 P.M., staff assisted the resident to bed. He/She remained in bed for 45 minutes, then got up and sat on the toilet all shift; -On 12/10/24 at 5:20 A.M., resident on IFU due to fall. Both eyes were almost swollen shut. He/She denied pain. Neuro checks were within normal limits. His/Her vitals were temperature 97.5, pulse 72, respirations 16, blood pressure 110/68. At 10:04 A.M., the resident was seated on the floor in his/her room. He/She said he/she was seeing dogs and cats. He/She was assisted to stand and sit in chair. He/She demanded to use the bathroom. Two staff assisted the resident to the toilet. He/She was weak and confused/delusional due to falls. Both eyes were swollen shut. He/She needed assistance of two staff to stand up. The resident's physician and family were notified. At 12:55 P.M., the resident was assessed after morning meeting for facial swelling. He/She was on the floor in his/her room. He/She said he/she was tripped by the dogs or cats running around in his/her room. CNAs assisted the resident off the floor. He/She fell two more times within ten minutes. His/Her facial and leg swelling were noticeable. He/She often sat on the toilet with his/her head between his/her legs. Staff called 911. Review of the resident's EMS report, dated 12/10/24 at 10:12 A.M., showed: On arrival, staff said the resident had multiple falls over the last week. He/She had increased weakness the last few days. The resident was usually up walking around. He/She was not able to walk the last four to five days. Staff noticed his/her eyes swollen shut this morning. The resident complained of pain in his/her face, neck, genitals, and leg. He/She was transported to the hospital. EMS personnel observed the resident on the toilet in his/her room. He/She complained of pain all over. He/She said he/she had fallen and hit his/her head multiple times. He/She was weak the last three days. EMS personnel observed major facial swelling and bruising in multiple stages on his/her face. His/Her eyes were swollen shut. The resident said he/she had been unable to see for two days. A mass the size of a golf ball protruded from his/her abdomen. His penis and testicles were extremely swollen and infected. He/She had pitted edema in his/her lower extremities. The resident was transported to the hospital. Review of the resident's hospital records, showed: -admitted on [DATE] at 10:44 A.M.; -Scalp swelling/hematoma. No facial fractures. The resident was unkept. Penis and testicle swelling due to cirrhosis. No traumatic injuries found. Review of the facility's investigation, dated 12/10/24, showed: -LPN G's written statement, undated: The resident refused vitals. He/She was sitting on the toilet. LPN G informed the night shift to monitor the resident's knee. He/She had a skin tear. The nurse said it looked red and swollen. The resident denied pain. LPN G said I believed (his/her) word although not completely sure. I believe I spoke to family. The second day the resident said he/she was fine. He/She was up in the hallway talking to himself. Staff assisted the resident with a shower. He/She should have documented these things; -CNA H's written statement: On 12/6/24 he/she was assigned to the resident. He/She checked on the resident several times during his/her shift. The resident sat on the toilet the entire shift. He did not eat his meals. He declined assistance. He/She checked on the resident prior to end of shift at 6:30 P.M. and he was still on the toilet. On 12/8/24, when CNA H entered the resident's room, he was sitting on the toilet. The resident was very confused. He thought he was at the hospital; -No documented conclusion. During an interview on 1/9/25 at 2:28 P.M., LPN B said he/she worked with the resident on 12/9/24 and 12/10/24. The resident fell often. He had a fall the weekend before 12/10/24 and sustained two black eyes. He/She did not know if the fall was witnessed. On 12/9/24, the resident had a fall around 9:00 A.M. He/She entered the resident's room to obtain vitals. The resident's eyes were black and blue. He was on the toilet. He refused to let LPN B change his clothes. LPN B and two other staff assisted the resident from the toilet to bed. The resident stayed in bed for 45 minutes, then sat back on the toilet. He was on the toilet the entire shift. On 12/10/24 at approximately 9:00 A.M., he/she entered the resident's room to obtain vitals. He was weak, and his eyes were swollen shut. LPN B notified the DON. When LPN B returned to the resident's room, he was on the floor, by the recliner. The resident said the cats and dogs made him fall. He could not stand up without assistance. Two CNAs assisted him off the floor. The resident requested to use the bathroom. The CNAs cleaned the resident up and he/she was sent to the hospital. The resident had rectal cancer and would sit on the toilet with his head between his legs. Sometimes, the resident sat on the toilet for an entire 12-hour shift. Prior to 12/10/24, the resident was mobile and walked around the facility. The resident often refused care and medication. The physician was aware the resident refused care, had falls and was sitting on the toilet for hours every day. During an interview on 1/13/25 at 11:21 A.M., CNA E said the resident was very weak and confused on 12/9/24. His eyes were black and swollen. He could not see. CNA E told him, he/she had to assist him because he could not see. The resident kept getting up and trying to go to the bathroom. He would not let staff help him. The resident was not combative. He was delusional. The resident would not let staff clean him up. CNA E removed the resident's dirty clothes and he put them back on. The resident has cancer and is embarrassed about it. Staff tried to get the resident to use briefs and he refused. He is not sure if the resident's doctor was notified of his change in condition. During an interview on 1/14/25 at 11:20 A.M., CMT D said he/she usually passed meds and provided care sometimes. The resident received his/her stool medication at 12:00 P.M. On 12/7/24, CMT D noticed the resident's face was red. On 12/8/24, the resident was confused and did not want to lay down. His eyes were black and blue. CMT D told LPN G the resident's face was getting worse. LPN G said the resident fell earlier in the morning. LPN G did not assess the resident or notify the physician. On 12/9/24, the resident's eyes were swollen shut. CMT D notified LPN B. LPN B assessed the resident. The resident was sitting on the toilet with his head between his legs. The resident was weak and could not open his eyes. CMT D, LPN B and a CNA helped the resident from the toilet to the bed. The resident stayed in bed for 45 minutes then returned to the toilet. The resident was alert and oriented times three (to person, place and time) at baseline. He could ambulate and transfer without assistance. During an interview on 1/13/25 at 9:23 A.M., the physician's social worker said according to the physician's notes, he/she saw the resident on 11/12/24. The physician went to see the resident on 12/11/24 and he was not at the facility. The physician received a voicemail on 12/6/24 at 7:46 A.M., from LPN A. LPN A said the resident fell, hit his head, and had a skin tear on his knee. On 12/10/24 at 12:05 P.M., LPN B informed the physician the resident was being sent out to the hospital. The physician was not notified of falls on 12/8/24 and 12/9/24. The physician was not aware the resident refused care and sat on the toilet for hours. During an interview on 1/13/25 at 1:10 P.M., the Administrator and ADON said when a resident falls and hits their head, the physician is notified, and neuro checks are completed for 72 hours. The nurses complete the neuro checks. She does not know when Resident #17's swelling started. They were aware of the falls on 12/10/24 but were not informed of the other falls. 3. During an interview on 1/13/25 at 1:10 P.M. and 1/14/25 at 7:00 P.M., the Administrator said nursing staff are responsible for updating the care plans. Resident #18's care plan should have been updated. If Resident #17's eyes were swollen, the physician should have been notified and he/she should have been sent out. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the deficiency was lowered to the G level. This statement does not denote the facility has complied with state law (section 198.026.1 RSMO) requiring that prompt remedial action to be taken to address Class I violation(s). MO00246395 MO00246450 MO00246460 MO00246790 MO00246791 MO00246793 MO00246843

Based on interview and record review, the facility failed to ensure one resident (Resident #104) with a diagnosis of dysphagia (difficulty swallowing) was served food in the proper consistency to prevent choking. Staff reported the resident was routinely served a whole, hardboiled egg for breakfast. On 12/17/23, the resident was found unresponsive in the first-floor dining room. Cardio Pulmonary Resuscitation (CPR, a lifesaving technique used when breathing or heartbeat has stopped) was started and a piece of hard boiled egg, approximately 2 inches in diameter, was removed from the resident's mouth. The resident expired at the facility. The census was 97. The Administrator was notified on 12/21/23 at 4:00 P. M., of an Immediate Jeopardy (IJ) past noncompliance which began on 12/17/23. The facility implemented a process and inserviced staff on ensuring food is served from the kitchen matching the food tickets, the requirement that eggs must be cut up, setting up resident trays, and cutting food for the residents. Nursing is to read the ticket when passing trays and ensure the food is the correct consistency before serving. The IJ was corrected on 12/17/23. Review of Resident #104's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 9/8/23, showed: -Brief Interview for mental status (BIMS, a screen for cognitive impairment) score: 12 out of a possible 15. A BIMS score of 8-12, showed the resident had moderately impaired cognition; -Eating: required partial/moderate assistance. Helper does less than half of the effort; -Swallowing disorders: none checked; -Diagnoses included: non-traumatic brain dysfunction (injuries to the brain that was not caused by an external physical force to the head), stroke, seizure disorder, traumatic brain injury (TBI, is an injury that affects how the brain works), and lung disease. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: Resident was at risk of impaired nutritional status related to dysphagia with texturized diet order and history of significant weight loss with malnutrition diagnosis; -Goal: Resident will maintain nutritional sufficiency by eating greater than 50% of meals with no swallowing difficulties through next review date; -Interventions: provide diet/supplements as ordered; observe resident during mealtimes for chewing and or swallowing difficulties. Review of the physician order sheet, in use at the time of survey, showed: -Regular diet, mechanical soft texture (a type of texture-modified diet for people who have difficulty chewing and swallowing. Foods may be pureed, ground, finely chopped, or blended to make eating safer) regular consistency. Review of the nutrition/dietary progress note dated 12/8/23, showed regular diet, mechanical soft; no citrus (orange juice, oranges, limes, lemons, grapefruit, or blueberries), dislikes pork. Review of the resident's progress notes, showed: -On 12/17/23 at 2:05 P.M., late entry for 12/17/2023 at 8:25 A.M., Certified Nurse Aide (CNA) was in the hallway outside the dining area waving his/her arms. The nurse went to dining room to assess why the CNA was obtaining the nurse's attention, noted resident bluish in color and without a pulse. The resident was taken to his/her room quickly while code blue and 911 was called. Resident was transferred to floor via two staff members. CPR was started until a faint pulse noted. Emergency Medical Service (EMS) arrived at facility while resident had faint thready pulse. EMS took and controlled the scene upon their arrival; -On 12/17/23 at 2:40 P.M., resident was found unresponsive. Code was called over head by Certified Medication Technician (CMT). The nurse and other nursing staffed ran to assist with the code. CPR was started by nursing staff. EMS arrived 10 minutes after the call was made. EMS began life saving measures. Time of death was called at 9:01 A.M. Review of the handwritten statement, written by [NAME] A, dated 12/17/23, showed the resident was served toast, hot cereal, and boiled eggs. Yesterday, the resident asked [NAME] A if he/she could get boiled eggs again. That is what he/she was served, as the resident requested it. Review of a handwritten statement, written by CNA B, dated 12/17/23, showed CNA D asked CNA B to get the nurse, so CNA B waved his/her hands at the nurse. The nurse asked if it was Resident #104. CNA B and CNA D took the resident to his/her room. The nurse cleaned food out of the resident's mouth after he/she was in bed. Then, the resident was moved to the floor. Staff started CPR and checked his/her code status, did the code page, and called an ambulance for the resident. During an interview on 12/21/23 at 10:20 A.M., CNA B said on 12/17/23 he/she took the resident's tray into the dining room and there were two hard boiled eggs on his/her tray. CNA B said he/she did not cut up the eggs. The resident always had hard boiled eggs and he/she normally picked up the eggs and ate them him/herself. Review of a handwritten statement, written by CNA D, dated 12/17/23, showed CNA D passed the trays in the dining room, and he/she saw the resident feeding him/herself. He/she noticed the resident was leaned over to the left side of the wheelchair. CNA D called the resident's name a few times and the resident did not respond. CNA D checked and the resident's pulse was faint. CNA D looked out the dining room door and saw CNA B in the hall and told him/her to get the nurse. CNA D pushed the resident back in his/her wheelchair so it would be easier to run/push him/her to his/her room. As CNA D pushed/ran down the hall to the resident's room, the nurse told the Certified Medication Technician (CMT) to call a code and 911. CNA D helped the day and night nurse get the resident into bed, by that time nurses from all the floors were coming in to assist. During an interview on 12/21/23 at 9:26 A.M., CNA D said the resident was on a mechanical soft diet. He/She would ask for and get hard boiled eggs. The resident usually picked up the whole egg and ate it. When CNA D went around to collect the trays, he/she noted the resident leaned to the left side. His/Her color was pale and he/she had a faint pulse. CNA D went to the doorway and called CNA B to get the nurse. Review of the handwritten statement, written by CMT E, dated 12/17/23, showed CMT E was at the nurse's station around 8:20 A.M., listening to report about the residents. CNA B was at the end of the hallway by the dining room, waving his/her hands. Licensed Practical Nurse (LPN) C went down the hallway asking, what's wrong? Is it Resident #104?. CNA B replied yes. LPN C yelled down the hall to check the code status. CMT replied he/she was a full code. LPN C told CMT E to call a code and 911. LPN C and other staff performed CPR until EMS arrived. During an interview on 12/21/23 at 9:00 A.M., CMT E said the meal trays arrive to the floor on a cart. Nursing passes the trays out to the residents. If a resident was on a mechanical soft diet, the food will come on a divided plate or a regular plate, it depends on the resident's preference. The meal ticket will say mechanical soft diet. Resident #104 was on a mechanical soft diet. Review of a typed statement by LPN C dated 12/17/23, showed LPN C arrived on the floor at 8:15 A.M., while receiving report, CNA B was at the end of the hall near the dining room, waving his/her hands. LPN C stood up and started to go towards CNA B. LPN C asked what was wrong, then asked if it was Resident #104. CNA B replied yes. LPN C started to run towards the CNA and resident. Another nurse was behind LPN C with the crash cart. The resident appeared blue and unresponsive. LPN C turned to CMT and said, call a code and 911. Staff took the resident into his/her room. LPN C swept the resident's mouth and removed all visible food. Staff transferred the resident to bed then to the floor. Other nurses, supervisor, and staff started to arrive and assist with code. CPR was started immediately and continued until EMS arrived. EMS and police arrived in 10 minutes. During an interview on 12/21/23 at 10:38 A.M., LPN C said he/she did not know if the resident ate breakfast or not. He/She did have food on his/her face and clothing. He/She checked the resident's mouth and there was no food or particles. He/She was in the hall when staff were bringing the resident into his/her room from the dining room. Staff placed the resident into bed. LPN C went to the resident's room and he/she had a pulse at that time. Staff then moved the resident from bed to the floor to start CPR when, shortly thereafter, a pulse was no longer noted. Review of the handwritten statement, written by LPN G, dated 12/17/23, showed at 8:20 A.M. LPN G was giving report to the oncoming nurse, LPN C. While giving report, CNA B waved his/her hands in the air to get our attention. The oncoming nurse yelled, is it Resident #104? The aides wheeled the resident down the hall, as LPN G and the other nurse ran to the resident. LPN G stopped immediately and grabbed the crash cart, while CMT E called the code and called 911. When staff got to the room, LPN G, LPN C and CNA B moved the resident to the bed and then immediately to the floor. Staff began CPR and ambu bagged (disposable mask used for resuscitation) the resident. While performing CPR, LPN G observed what looked like a piece of egg come out of the resident's mouth. Staff continued CPR until the EMS arrived and took over. Review of the written statement, written by LPN F, dated 12/17/23, showed the Manager on Duty (MOD) and a CNA walked onto the unit and asked for the crash cart. LPN F asked what was going on. MOD stated that a code blue was called. LPN F and MOD immediately left the unit with the crash cart. Once they arrived on the unit where the code was called, the nurse said they had begun CPR. Upon entering the room, LPN F observed the resident on the floor, pale and the chest was not rising and falling. LPN F asked staff who was performing CPR what happened. They said they did not know. LPN F asked if the resident was eating and if he/she aspirated. Nurses performing CPR stated he/she was eating breakfast. One of the nurses was relieved of CPR by LPN F. After 30 compressions, instructed the other nurse to give two breathes. Performed second set of compressions, asked for two breathes to be given and noticed the chest did not expand. The other nurse stated that they had checked the resident's mouth and there was nothing. Another nurse at this point relieved LPN F from chest compressions, and during the nurses second set of compressions, LPN F noticed something white in the ambu mask and a piece of egg flew out. The mask was removed from resident's mouth and there was a boiled egg that was broken in half in the resident's mouth. Another nurse swept egg out of the resident's mouth and they re-started CPR. EMS arrived and took over the code. The resident expired at 9:00 A.M. During an interview on 12/21/23 at 12:06 P.M., LPN F said at first nothing was in the resident's mouth, after the third set of compressions, something white was noted in the mask. It had half of a hard-boiled egg and egg yolk. The resident was on a mechanical soft diet. During an interview on 12/21/23 at 2:17 P.M., Registered Nurse (RN) N said, he/she heard the code called and ran towards the elevator to go to the other unit. When he/she got to the room, there were two people in the room, they were in the process of putting the resident on the floor. Once the resident was on the floor, staff started CPR. When staff pressed down to give compressions, the resident had egg in his/her mouth. This happened about three times. The first time, there was a large amount, the second and third time it was a small amount; two to three small fragments, it looked like chewed deviled eggs. The resident did not vomit the eggs up, there was no salvia, the egg was just there. RN N removed the egg from the resident's mouth, and they continued with CPR. During an interview on 12/21/23 at 2:40 P.M., RN O said he/she heard the code called and ran towards the elevator to go to the other unit. When he/she got to the room, the resident was on the floor. The resident's color was grayish. RN N started compressions. When they switched and RN O started compressions; big hunks of egg came out of the resident's mouth. One piece of white was whole and was approximately two inches in diameter. Staff wiped the resident's mouth to get the egg out. RN O felt the resident was choking on egg. The resident may have vomited some of the egg up, but RN O said his/her impression was the egg may have been in the resident's trachea and with the compressions and bagging, it may have just come out. At one point there was a pulse on the pulse ox. When EMT got there they said they had a pulse, and they took over. Review of the ambulance run report, showed: -The unit was notified on 12/17/23 at 8:30 A.M.; -The unit was dispatched to the facility, for a resident with a chief complaint of cardiac arrest. When EMS arrived on the scene and entered the facility, were directed to the patient's room. When we entered the room, observed the patient lying supine (on back) on the floor while staff was performing chest compression as well as ventilations via Bag Valve Mask (BVM, disposable mask used for resuscitation). The patient's skin color was extremely pale, and his/her overall appearance was extremely poor. We were informed the arrest was witnessed but staff could not give a specific account of events leading to the arrest. Separate staff members stated different times regarding how long the patient had been in cardiac arrest, but it was ultimately determined that he/she had been in this state for approximately 15 minutes. Another staff member stated they believed the patient had choked on food causing him/her to asphyxiate (choke) which led to his/her cardiac arrest. Staff had little additional information regarding the patient. We then relieved staff of their CPR efforts. CPR was reinstated and the cardiac fast patches were placed onto his/her torso. The initial cardiac rhythm observed by EMS was asystole (flat line, when the heart's electrical system fails, causing the heart to stop pumping) Cardiac resuscitation efforts were initiated per protocol. Multiple attempts at securing an advanced airway were unsuccessful due to the amount of food lodged in the patient's airway. The food appeared to be a hard boiled egg. Suctioning was performed multiple times and a significant amount of food was removed from the airway. Ultimately, it was determined to secure the patient's airway using an I-Gel 4 (airway). At no point during our resuscitative efforts did the patient present with a cardiac rhythm other than asystole. When we approached the 20-minute mark of resuscitation efforts, medical control at the hospital was contacted and informed of our current code status. After that was determined, resuscitation effort was discontinued, and the time of death was called at 9:00 A.M. During an interview on 12/21/23 at 10:00 A.M., the Director of Dietary Services said dietary is made aware of the resident's diet by the diet communication form. The nursing staff will complete the form and give it to dietary. Sometimes staff or a resident will stop her in the hall or call dietary if the resident is on a special diet or has a request. Dietary is responsible for assembling the food on the trays and checking the meal tickets. The trays are placed on the cart and delivered to the units. Nursing staff deliver the trays to the residents, and they should check the meal ticket with the plate being served. They are the second set of eyes. If nursing serves a tray without reading the ticket, and there was a problem, it will fall on nursing. If a resident was on a mechanical soft diet, dietary would smash hard boiled eggs, or split the egg and nursing would set it up from there. During an interview on 12/21/23 at 3:20 P.M., the Administrator said hard boiled eggs should be served cut up or chopped for a mechanical soft diet. MO00229010