**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on interview and record review; the facility failed to implement interventions to protect Resident 153 from aspiration (breathing foreign material into the lungs) and/or choking as a puree diet was not provided in accordance with physician's orders. In addition, the facility failed to determine causal factors, to develop and/or revise interventions and failed to implement assessed fall prevention interventions for Residents 79 and 88. The sample size was 10 and the facility census was 101. Findings are: A. Review of Resident 153's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/27/22 revealed diagnoses of previous stroke, Alzheimer's disease, epilepsy, depression, high blood pressure and dysphagia (difficulty swallowing). The following was assessed regarding Resident 153: -cognition was moderately impaired; -no behaviors identified; -required supervision and set-up assistance with eating; -weight loss of 5 percent (%) or more in the last month or 10% or more in the last 6 months without a physician prescribed weight loss regimen; and -mechanically altered, therapeutic diet. Review of the resident's Nursing Progress Notes revealed the following: -4/9/22 at 3:58 PM the resident's teeth were hanging partially out of mouth and mouth noted to be full of food. The resident was unable to speak and pointed at mouth while moaning. A Speech Therapy consult was requested; -4/10/22 at 9:59 PM when the evening meal was delivered to the resident, the resident was chewing on peaches which had been served at the previous meal. After completion of the evening meal, the resident's mouth was full of food with drool running down from the side of the resident's mouth. Staff manually removed food from the resident's mouth; -5/23/22 at 6:31 PM staff were called to the resident's room by dietary as the resident was coughing. The resident spit out a small piece of bread with phlegm. A request was sent to Speech Therapy for another evaluation of the resident's diet; -6/7/22 at 2:35 PM the resident was brought to the Charge Nurse as the resident was choking. The resident had unchewed grapes and hamburger in the resident's mouth; -6/7/22 at 4:10 PM the resident continued to work with Speech Therapy once a week and remained on a regular diet with thin liquids; -6/7/22 at 6:00 PM the resident was in the dining room, head was hyperextended backwards, face was turning blue and was unable to speak. After several abdominal thrusts the resident was able to spit out unchewed hamburger meat and began coughing. Staff manually removed the rest of the unchewed hamburger from the resident's mouth; -6/9/22 at 1:00 PM the physician ordered a mechanical soft diet (foods are mashed, chopped, ground or pureed to assist with chewing and swallowing) and ground meats; -8/15/22 at 5:00 AM the resident had a bulge to the left cheek and staff removed 5 chunks of pineapple from the resident's mouth; -9/13/22 at 2:06 PM the resident continued to work with Speech Therapy twice a week, but therapy was to be reduced to once a week. Diet order remained for mechanical soft with thin liquids; -9/13/22 at 9:45 PM the resident was in room and observed choking on pocketed food. Stridor (high pitched respiratory sound caused by an obstruction in an upper airway) noted to bilateral lung fields. The resident was then able to cough and clear breathing; -9/13/22 at 10:41 PM the resident's physician was notified of the resident's aspiration and of coarse lung sounds. Staff were to monitor the resident; -9/14/22 at 11:22 AM new order received for a puree diet; -9/20/22 at 1:57 PM resident continued to work with Speech Therapy with a plan to reduce to 1 time per week. Therapy note indicated the resident was on a mechanical soft diet and not a puree diet as ordered on 9/13/22; -9/30/22 at 11:32 PM the resident had a large emesis in the resident's bed. Emesis consisted mostly of undigested food; -11/20/22 at 6:00 PM the resident was being fed by Nursing Assistant (NA)-II. After the resident was given 3 bites of puree meat, the resident started to cough, and carrots were visualized in the resident's mouth. The resident did not respond to verbal or tactile stimulation. A padded tongue blade was inserted between the resident's teeth by Registered Nurse (RN)-FF and the RN manually removed partially ground steamed carrots from the resident's mouth. Staff attempted to suction with only a few particles of carrots returning. The resident's oxygen saturation (amount of oxygen in the blood stream) level was 63% (normal oxygen saturation level is 95-100 %). The resident was started on 4 liters of oxygen, but oxygen saturation level remained at 58-60%; -11/20/22 at 6:20 PM the resident was transferred to the emergency room per ambulance; and -11/20/22 at 9:30 PM the resident was admitted to the hospital. The resident's family indicated the resident was not doing well and the family had been told the resident had choked on some carrots. Review of a History and Physical from the hospital dated 11/21/22 at 9:23 AM revealed the resident presented to the emergency room for a choking episode. The note indicated the resident had an order for a pureed diet however, it appeared the resident was fed solid food shortly before arriving at the hospital. The resident had multiple large carrot particles extracted from the left upper lobe of lungs. During an interview on 7/20/23 at 3:33 PM the Administrator and the Director of Nursing (DON) confirmed the following regarding Resident 153: -multiple incidents over the past few months of choking. The resident had been working with the Speech Therapist but continued to pocket food and had difficulty swallowing at times; -at high risk for choking/aspiration and had an order for a puree diet; -received total assist from staff with eating and drinking; -ate all meals in the resident's room and not in the dining room; and -11/20/22 during the evening meal, the resident began to cough, and the resident's oxygen saturation level dropped. The facility staff documented partially ground carrots were removed from the resident's mouth and the resident was unresponsive. The resident was sent to the hospital and a hospital report indicated particles of carrots were removed from the resident's lungs indicating the resident did not receive a puree diet as ordered by the physician. B. Review of the facility Fall Prevention/Management Standard policy with a revision date of 2/2019 revealed each resident was to receive adequate supervision and assistance to prevent accidents. The following guidelines were to be followed for fall management and prevention: -identify risk factors for falls based on review of the Fall Assessment results; -implement fall prevention interventions based on individual risk; -if a fall occurs, staff to complete an investigation; -factual evidence to be collected related to the fall event; and -use the Root Cause Analysis process to find out what happened, why it happened and to determine what can be done to prevent it from happening again. C. Review of Resident 88's MDS revealed the resident was admitted [DATE] with diagnoses of depression, heart disease, dementia, anemia, Alzheimer's disease, previous hip fracture and depression. The resident's cognition was severely impaired, the resident required extensive staff assistance with bed mobility, transfers, dressing and toilet use and the resident was frequently incontinent of urine. Review of the resident's current Care Plan with a date of 12/12/22 revealed the resident was at risk for falls related to a right hip fracture, acute respiratory failure and Alzheimer's dementia. The following interventions were indicated: -pressure alarm to bed and to chair. Staff to monitor function of alarm twice a day; -not to leave unattended in the bathroom; -anticipate and meet resident's needs; -call light within reach and encourage use; and -proper fitting, non-skid footwear. Review of an Incident Report dated 1/31/23 at 5:45 PM revealed the resident was found lying on the floor of the resident's room. The resident did not know what had happened and failed to use the call light as the resident was too impatient. Review of the root cause analysis revealed causal factors were not identified, no new interventions were developed and/or current interventions revised to prevent further falls for Resident 88. D. Review of Resident 79's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of skin cancer, chronic obstructive pulmonary disease, previous stroke, anxiety, insomnia and dementia. The resident's cognition was moderately impaired, the resident required extensive staff assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene and the resident was frequently incontinent of bowel and bladder. Review of the resident's current Care Plan dated 5/18/22 revealed the resident was at risk for falls related to impaired balance, psychoactive medication use, incontinence, anxiety, pain, depression and tremors. The following fall prevention interventions were identified: -gripper socks, slippers or shoes to be worn when up; -silent alarm on always; -non-slip pad to seat of wheelchair; -staff to remain with resident in the bathroom; -after meals if resident seems anxious follow back to room and assist with positioning in recliner; and -review information on past falls and attempt to determine cause of falls. Review of an Incident Report dated 1/4/23 at 12:45 PM revealed the staff had been assisting the resident to the bathroom, the resident's legs buckled, and the resident was lowered to the floor. Review of the Root Cause Analysis for the resident's fall revealed a new intervention for 2 staff to assist the resident with standing and for pivot transfers. Review of an Incident Report dated 1/27/23 at 9:56 AM revealed the Activity staff had attempted to transfer the resident to the wheelchair from the recliner. The resident started to sit too early and was lowered to the floor. Review of the Root Cause Analysis revealed staff failed to implement the intervention developed on 1/4/23 for 2 staff to be used for all transfers with the resident. Physical Therapy evaluated the resident for safe transfers and confirmed 2 staff were to be used for all transfers. No new interventions were identified regarding the residents fall. Review of an Incident Report dated 3/7/23 at 9:10 PM revealed staff attempted to stand the resident from the recliner, the resident's legs became weak, and the resident was lowered to the floor. Review of the Root Cause Analysis revealed staff had again attempted to transfer the resident with only 1 person instead of 2 as indicated after the residents falls on 1/4/23 at 12:45 PM and on 1/27/23 at 9:56 AM. Further review of the report revealed no additional interventions were developed and/or current interventions revised for fall prevention. Review of an Incident Report dated 5/11/23 at 4:05 PM revealed staff were in the middle of transferring the resident, the resident lost strength and was lowered to the floor. Review of the Root Cause Analysis revealed staff had tried to transfer the resident alone instead of using the 2 assists as indicated after the residents falls on 1/4/23 at 12:45 PM, on 1/27/23 at 9:56 AM and on 3/7/23 at 9:10 PM. In addition, no new interventions were developed and/or current interventions revised for fall prevention. E. During an interview with the DON on 7/25/23 at 6:48 AM the following was confirmed regarding falls for Residents 88 and 79: -2 staff were to be used for all transfers for Resident 79; -Residents 88 and 79 had repeated falls and remained at risk for continued falls; -nursing staff were to complete a Root Cause Analysis after each fall to determine causal factors for falls; and -causal factors were to be used to develop new interventions or to revise current interventions to prevent further falls.