**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and review of the facility reported incident investigation, the facility failed to ensure food served accommodated resident allergies for 1 of 1 resident (Resident #1) who was hospitalized for an allergic reaction. Failure to ensure resident allergies are noted and followed while serving meals resulted in hospitalization and treatment for an anaphylactic reaction. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: This surveyor determined a deficient practice existed on 04/19/24. The facility implemented corrective action and completed all staff education on 04/22/24. Review of Resident #1's medical record occurred on 05/02/24 and included diagnoses of dementia and an allergy to fish on admission. The resident's current care plan stated, Resident has known allergy to: Fish . Resident will not receive (med, food, substance) to which he has a known allergy. Be alert to food allergies. Resident's diet card noted Fish/Seafood allergy. Review of Resident #1's progress notes identified the following: * 04/19/24 2:12 p.m. nurse entered dining room @ [at] 1250 [12:50 p.m.] to see resident with eyes closed . noted resident to be slow to respond . pale/grey in color. Resident taken back to . room . BP [blood pressure] 76/47, T [temperature] 96.9, P [pulse] 92, R [respirations] 16, 02 [oxygen saturation] 92% on RA [room air]. 10 mins [minutes] and resident was slumped to L) [left] side, color was more pale/grey, and was again slow to respond. BP taken 57/37, notified resident coordinator who came to room and assessed. Physician notified of status and wanted resident seen in ER [emergency room], Son [name] notified and consented to have resident transferred . Resident did loose [sic] consciousness x [times] 2 for seconds at a time . manual BP's taken unable to read/hear, could not get 02 readings, oxygen started 2L/NC [2 liters per nasal canula] for comfort, noted . [resident] to be red in color. Resident transferred to ER by ambulance, left facility @ 2pm. * 04/19/24 3:59 p.m. [provider name from hospital] called and stated that resident will be admitted to hospital for alergic [sic] reaction . Son [name] contacted and is aware, hospital has updated him on status. * 04/22/24 1:00 p.m. Resident returned from hospital approximately 10:15 this morning. hospitalized on 4-19 . for . anaphylactic reaction. The facility's investigation report, dated 04/19/24, stated, . [kitchen staff] in charge of reading the cards that lists the resident's diet, allergies, and likes/dislikes. [kitchen staff] read [Resident #1's] name and did not say anything else on the card . [Resident] was treated at the hospital for anaphylactic shock . Based on the following information, non-compliance at F806 is considered past non-compliance. The facility implemented corrective actions to ensure the deficient practice does not recur by: * The facility completed an investigation with interviews of staff that determined the cause of the incident. Kitchen staff failed to read and follow allergy (fish) noted on diet card. Resident #1 was served fish during lunch on 04/19/24. * Provided immediate dietary staff education regarding importance of reading diet cards every time. You must be reviewing these for every meal. When serving, the person reading cards must announce the resident, the diet, and any allergies or dislike pertaining to that day's meal. Additional dietary staff education completed the same day before dietary staff left regarding changing the format of the diet cards and placing the allergies in red lettering. * On 04/22/24 implemented the use of newly formatted resident diet cards with allergies noted in red lettering. * On 04/22/24 provided education via written information e-mailed to all staff regarding newly formatted resident diet cards with allergies noted in red lettering. The education included the process for breakfast, lunch, supper, and room tray delivery. * On 04/22/24 dietary staff educated and received hard copy of newly formatted resident diet card and process for serving food. * Random audits completed by dietary supervisor to ensure the new process is followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of professional reference, review of facility policy, and staff interview the facility failed to provide care and services for 1 of 1 closed record (Resident #43) reviewed with a change in health status and transfer to the emergency room (ER). Failure to assess and monitor the resident's changing condition resulted in a worsening of symptoms and delay in emergency care. Findings include: Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 189, stated, . the nurse is still responsible for identifying and responding to data that indicate real or potential medical problems. and preventing development of the potential complication. Review of the facility policy titled Notification of Changes occurred on 03/13/24. This policy, dated November 2023, stated, Policy: The purpose of this policy is to assure the resident, provider and or family member . is immediately informed . when there is a change requiring notification. 2. Significant change in the resident's physical, mental, and psychosocial condition such as a deterioration in health . This may include: clinical complications. Review of Resident #43's medical record occurred on all days of survey. Diagnoses included dementia with other behavioral disturbances and adult failure to thrive. An admission Minimum Data Set (MDS), dated [DATE], identified substantial/maximal assist with activities of daily living (ADLs) such as eating, oral cares, hygiene, bathing, and dressing. Review of Resident #43's Emergency department (ED) physician's report, dated 02/28/24, stated, HPI [history of present illness]: . CNA [certified nurse aide] told nursing staff the [sic] when she checked the blood pressure it was 60s/40s [60s systolic over 40s diastolic] and pulse was 111 [beats per minute] . When seen in the ER there was . food particulate in the mouth . there was also a potassium pill in his mouth . Physical exam . Neurologic: No purposeful movement, Heart sounds: irregular, but appropriate, Lungs: clear sounds, Oropharynx: full of food particulate and pills. After it was cleaned out the mucosa was dry. Assessment and Plan: Dehydration, Acute renal failure, and altered mental status . Plan: admit to inpatient. Resident #43's nursing notes showed the following: * 02/26/23 8:25 p.m. BP [blood pressure] 75/55 . noted to have difficult time with holding up his head . took medication with much attempts . writer did hold head up to take medication then resident would allow his head to drop down in front of him . * 02/26/23 8:40 p.m. BP 67/49 . lethargic . call to residents [sic] family . will call for ambulance . Review of the facility's investigation and video evidence showed the nurse (#3) entered Resident $43's room at 6:44 p.m. with medication then stepped out to crush medications and re-entered at 6:49 p.m. At 7:45 p.m., the nurse (#3) entered the resident's room for the last time. At 9:12 p.m., video evidence showed the ambulance crew tranported the resident out of the facility. Review of facility investigation, dated 02/24/24, identified the following: * Family Nurse Practitioner (FNP) (#6) called administrative staff member (#1) with . grave concerns about [nurse #3 name] and her lack of assessment . he is upset that not only did she [nurse #3] not do a manual blood pressure before calling him, but that she [nurse #3] didn't even do the basic ABC's [airway, breathing, circulation] of assessments because his [Resident #43] airway was likely partially obstructed by all of the food that was pocketed in his mouth. * CNA (#4) stated, . [nurse #3] told me to go ahead and lay him [Resident #43] down in bed as she [sic] was just hanging his head and not eating. while in the lift . he went unresponsive . [nurse #3] said she [CNA #4] should lay [Resident #43] down and get his vitals . vitals were reported to name [nurse #3] . she [CNA #4] was not feeling comfortable with the situation and urged [nurse #3] 1 or 2 times to get him out of here . she felt the ambulance needed to be called as he did not look good. * Administrative staff member (#1) stated, . [nurse #3] did not complete an assessment and relied completely on the reported vital signs from the CNAs. The facility's nursing staff failed to monitor Resident #43's declining condition to prevent the development of additional complications. During an interview on 03/13/24 at 12:54 p.m., an administrative staff member (#1) stated, She expected nursing staff to complete a full assessment and verify the vital signs themselves.