**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A past noncompliance Immediate Jeopardy (IJ) was determined to exist effective 11/13/24 related to the facility's failure to ensure a resident was free from accident hazards. The facility failed to safely secure Resident #1 in their wheelchair during transport which resulted in serious injury/harm. On 11/18/24 at 2:48 p.m., the Oklahoma State Department of Health verified the existence of the past noncompliance related to the facility's failure to safely secure a resident in a wheelchair during transport. The past noncompliance IJ was removed effective 11/14/24 after the facility put measures in place to prevent recurrence. On 11/14/24 the facility maintenance supervisor inspected the facility transport van to ensure all safety straps and harnesses were in working order and implemented monthly inspections to ensure proper working order, all drivers were inserviced on proper uses and placement of safety straps in the facility transport van and they will be inserviced quarterly, a QAPI improvement plan was initiated, and CNA #1 was suspended on 11/13/24 and then terminated on 11/14/24. On 11/18/24 at 11:55 a.m., the facilty's transport van was inspected. All harnesses and safety straps were observed to be in good repair with no issues. An IJ was identified from 11/13/24 through 11/14/24. Based on observation, record review, and interview, the facility failed to safely secure a resident in a wheelchair during transport for one (#1) of three sampled residents reviewed for safe transportation. Findings: An undated facility policy/job description titled Transportation Aide, read in part, Has completed a facility orientation on functioning facility transport vehicle and proper placement of straps for resident transport. The policy also read, At any point that it is discovered that any safety mechanism is not functioning properly that the maintenance/ administrator be notified immediately and transportation will be suspended until repairs are made. Resident #1 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease, hypertensive heart disease, and dependence on renal dialysis. Resident #1's admission assessment, dated 10/15/24, documented Resident #1 was not cognitively impaired, ambulated with the assist of a wheelchair and required extensive assistance with ADLs. A facility Incident/Accident Report, dated 11/13/24 at 3:40 p.m., read in part, Reported to me by [CNA#1] that resident fell out of wheel chair in van during transport. Knot to back of head and upper back pain noted. Resident sent to ER. A Nurse's Note, dated 11/13/24 at 4:40 p.m., read in part, [CNA#1] transport called this nurse and stated that [they] had left the hospital with resident and was turning the corner when resident fell out of wheel chair. The document also read, [they] stated [Resident #1] had a knot on [their] head and c/o of upper back pain. The document also read, [name withheld] explained that [they] couldn't latch [them]. An Investigative Witness Statement, dated and signed by CNA #1 on 11/13/24, read in part, I didn't have the residents wheelchair secured, the back of the wheel chair was locked and [their] tires. I didn't lock the front because I thought I did lock them. When I went to step on the gas [they] went flying backwards and [they] hit the metal ramp. An intital Incident Report Form, dated 11/13/24 at 9:59 p.m., documented Resident #1 was being transported back to the facility from the hospital when the driver turned a corner, the resident fell out of their wheelchair. It documented the resident was transported to the ER then transported to [name of hospital withheld] for further evaluation. Resident #1's Emergency Department Note, dated 11/13/24 at 4:39 p.m., read in part, was in a transport van that apparently accelerated too quickly when [their] wheel chair tipped over backwards c/o head neck and upper spine pain. The note also read, there is a nondisplaced vertical linear fracture through the mid C6 vertebrae. The note documented Resident #1 was placed in a neck brace, given Tylenol and morphine for pain, and transferred to an acute care hospital. Resident #1's After Visit Summary, dated 11/13/24, documented Resident #1 was diagnosed with a closed nondisplaced fracture of the sixth cervical vertebrae and a closed head injury from a ground level fall. On 11/18/24 at 3:30 p.m., Resident #1 stated CNA #1 did not buckle their wheelchair in the front in the transport van correctly. They stated when CNA #1 accelerated from the traffic light they fell backwards hitting their head and neck on the ramp in the transport van. Resident #1 stated their family was called and told CNA #1 to take them to the ER. Resident #1 was observed wearing a cervical neck collar and stated they had pain in their neck and shoulders as a result of the accident. On 11/18/24 at 4:25 p.m., the ADON stated CNA #1 reported to the hospital they did not secure the resident in the van, but then they changed their story. The ADON stated CNA #1 reported a passerby and unidentified police helped sit the resident back into the chair and CNA #1 contacted the family which directed them to take the resident to the ER. On 11/18/24 at 4:30 pm., the administrator stated CNA #1 changed their story frequently. They stated the CNA admitted to not securing the residents wheelchair in the transport van correctly and should not have picked up the resident after the incident. The administrator stated CNA #1 was suspended immediately then terminated for the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 10/19/22, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide a physician-ordered therapeutic diet for Resident #2, which resulted in the resident choking and requiring emergency services. The facility failed to provide a mechanical soft diet, causing resident #2 to choke, become unresponsive, and require hospitalization. The resident had a physician's order for a mechanical soft/chopped diet. On 08/26/22, the resident was served coleslaw which had not been properly prepared per the physician order. The facility failed to provide a mechanical diet for texture according to the facility policy for therapeutic diets. The resident choked for approximately five minutes prior to becoming unresponsive and emergency medical services (EMS) documented suffocation/asphyxia. The resident was hospitalized for six days. The hospital discharge summary record documented a diagnosis of acute encephalopathy (damage that affects the brain) present upon arrival to the hospital, likely secondary to suspected aspiration pneumonia versus dysphagia with choking. An Elite Comprehensive Report for resident #2, from emergency medical services and dated 08/26/22 at 1:20 p.m., documented in parts .Complaint Unresponsive . 08/26/22 1:25 p.m., . Patient Care Report .Staff met us at the rear entrance. The female staff member stated that the pt had choked on fish while eating lunch approximately 20 minutes prior to our arrival. She stated that they removed the obstruction from the pt's airway and he was breathing on his own: but has remained unresponsive to verbal stimulus since the event. They stated that the choking event lasted approximately 5 minutes total . As we approached the patient he was sitting upright in his wheelchair. His head was slumped down and snoring respirations were noted . The patient's airway was manually opened via head tilt chin lift. The airway remained open with manual stabilization. The snoring respiration subsided at this point.The patient was unresponsive and unable to follow commands. The PT's pupils were bilaterally pin point and unresponsive to light.His airway was patent and manually maintained throughout transport. Intermittently the patient would cough up small amounts of food with saliva and I would suction the foreign body from the PT's mouth.Clinical impression . Possible anoxic brain injury.No interventions improved patient's unresponsiveness . The patient was determined to be a priority 2 transport to {name deleted} hospital. The pt however never became alert or oriented. On 10/19/22 at 4:04 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 10/19/22 at 4:50 p.m., the Administrator and the corporate RN were notified of the IJ situation. On 10/20/22 at 4:17 p.m., an acceptable Plan of Removal was provided by the corporate RN and Administrator. It documented the following: Corrective Action: Plan of removal On, 10/19/2022, All staff In-serviced on Facility Policy and Procedure Choking, Heimlich Maneuver, Preventing Choking, and completion of Incident reports. 1. All new hires will be educated on choking, Heimlich maneuver, and preventing choking. 2. Admin/designee will review new hire packets to ensure all training is completed. 3. Admin/designee will report any negative findings quarterly to Qapi On 10/19/2022, all licensed RN/LPN In-serviced on Facility Policy and Procedure Documentation, Physician Notification. Completed by 8 p.m. 10/19/22 1. All licensed new hires will be educated on Facility Policy and Procedure Documentation and Physician notification. 2. Don/designee will review all new hire packets to ensure all training is completed. 3. Don/designee will report any negative findings quarterly to Qapi On 10/19/22 Inservice provide to all dietary/nursing staff on Facility Policy and Procedure Therapeutic Diet. To be completed 6 p.m. 10/19/22. 1. All new hires will be educated on the Facility Policy and Procedure Therapeutic Diet. 2. Dietary manager will review all new hire packets to ensure all training is completed. 3. Dietary manager will report any negative findings quarterly to Qapi 4. Observation of meal service will be conducted by dietary/nursing staff to ensure proper diets are being served per physician orders. On 10/19/22 Chart review of all 67 resident's dietary orders were reviewed and cross referenced with dietary cards to ensure physician ordered diets are followed. Completed by 10 a.m. 10/20/22 1. Dietary manager/designee will observe meal service to ensure physician ordered diet is served daily X 3 weeks or until substantial compliance is achieved. 2. Dietary manager/designee will report any negative findings to DON at time of occurrence. 3 Dietary Manager/designee will report any negative findings quarterly to Qapi. On 10/20/22, interviews were conducted with facility staff regarding education and in-service training pertaining to the immediate jeopardy plan of removal. Staff reported they had been in-serviced and were able to verbalize understanding of the information and training provided. The immediacy was lifted, effective 10/20/22 at 10:00 a.m., when all elements of the plan of removal had been implemented. The deficient practice remained at an isolated level with potential for harm to the resident. Based on record review, observation, and interview, it was determined the facility failed to ensure the therapeutic diet policy was implemented, and the emergency procedure for choking was followed, for one (#2) of five residents reviewed for therapeutic diets. The facility reported 13 residents with mechanical soft/ground diet orders (not including pureed). Findings: The facility Therapeutic Diets policy, dated October 2017, read in parts, .Therapeutic diets are prescribed by the Attending Physician to support the resident's treatment and plan of care in accordance with his or her goals and preferences.A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet . The facility's Emergency Procedure - Choking policy, dated August 2018, read in parts, .Conscious Resident -- Standing or Sitting 1. Ask the resident if he or she is choking . 2. Ask the resident to cough or speak if at all possible . 6. If the resident cannot cough, only then should abdominal thrusts be performed . .Unconscious Resident . 1. Ease the resident .to the floor. 4. Perform abdominal thrusts . 5. Perform the finger sweep maneuver to check for a foreign body . a. Keep the resident's face up . Documentation The person performing this procedure should record the following information in the resident's medical record: 1. The date and time the procedure was performed. 2. The name and title of the individuals who performed the procedure. 3. The exact time the choking began. 4. The exact time of any unconsciousness. 5. All assessment data obtained during the procedure. 6. The time the procedure was started and stopped. 7. The resident's response to the procedure. 8. The signature and title of the person recording the data. .Reporting 1. Report results promptly to the supervisor and the attending physician. 2. Notify the resident's personal physician of all assessment data, observations and results. 3. Report other information in accordance with facility policy and professional standard of practice. Resident #2 had diagnoses which included right-sided CVA hemiplegia, aphasia, hypertension and depression. The resident's Care Plan, dated 04/21/20 and revised on 07/15/22, read in parts .I have potential for nutritional problems because I have no teeth, .and communication problems. Intervention, I eat a soft mechanical chopped diet double portion with regular liquids.Nursing staff will monitor me while eating to ensure that I am having no difficulty chewing or swallowing my food . A plan of care for code status was revised on 11/21/21, read in parts .I have chosen to be full code status. Intervention, If I choke perform the Heimlich Maneuver and proceed with CPR as needed. The resident's monthly Physician's Order, dated 08/01/22 to 08/31/22, documented Soft mechanical chopped diet double portions regular liquids. A weekly menu, dated 08/26/22, in the lunch column documented: Fried Fish, French Fries, Creamy Coleslaw, Hushpuppies, Tarter Sauce, Lemon Pie. A nurse note for resident #2, dated 08/26/22 at 12:30 p.m., documented Resident in dinner [sic] room @ lunch eating choked on coleslaw and stopped breathing normal after choking sent out via ambulance -- [Name deleted] LPN. A Diet Sheet for resident #2, dated 08/26/22, documented the resident consumed 100% of his lunch meal. Resident #2's Treatment Record had no vital signs documented on 08/26/22 related to the choking incident. An emergency room Report for resident #2, dated 08/26/22 at 6:05 p.m., documented in parts .nursing home resident who presented with complaint of unresponsiveness. Reportedly patient choked on a fish for almost 5 minutes around 1 PM.since then he has become less responsive. Hospital records documented resident #2 remained in the hospital from [DATE] through 08/31/22. The Hospital Discharge Summary, dated 08/31/22 at 10:49 a.m., documented Discharge DX: Acute encephalopathy, present on admission (POA) likely secondary to suspected aspiration pneumonia versus dysphagia with choking. On 10/19/22 at 10:20 a.m., the dietary manager reported the resident's coleslaw had not been ground up per the therapeutic diet order. The dietary manager reported, we fixed it right then and made sure even if the food was chopped up it would still need to be ground up in the blender. The dietary manager reported a staff member had swept their finger through the resident's mouth but she couldn't remember if anyone had attempted a Heimlich maneuver on the resident. She reported the resident did become unresponsive. On 10/19/22 at 10:52 a.m., the corporate nurse reported they did not do an incident report and no one had attempted a Heimlich maneuver on the resident. On 10/19/22 at 11:30 a.m., the DON reported LPN #2 noticed the resident choking and reported it to the DON. The DON reported she went to the resident and attempted a finger sweep of the resident's mouth. The DON reported she continued this procedure the whole time. The DON stated she removed a hand-full of fish from the resident's mouth and stated, I couldn't believe how much fish I got out of him. The DON reported she did not think to attempt the Heimlich maneuver. The DON reviewed the choking policy and stated she did not follow the facility policy or the resident's care plan. On 10/19/22 at 12:45 p.m., the resident was observed in the dining room feeding himself. His food was observed to be mechanical soft ground. Staff members were observed in the dining room supervising residents while eating. On 10/20/22 at 10:10 a.m. LPN #2 reported she was supervising lunch in the dining room on 8/26/22. She stated resident #2 was eating fish and coleslaw. The LPN stated she noticed the resident was choking on the coleslaw, went to check on him, and gave him a thrust to the back. The LPN stated some of the coleslaw came out, she removed the remainder of coleslaw from the resident's plate, a few minutes later the resident was coughing and choking on the fish. The LPN reported the coleslaw was regular slaw, not ground. The LPN stated the fish was fried and the crust was hard. The LPN reported the DON was coming around the corner so she got her attention. The LPN stated the resident was slumping down so she straightened him back up but he kept slumping over. The LPN stated the DON started doing a finger sweep and continued this procedure. The LPN stated she told the DON the resident should be sent out to the emergency room and the DON left to call for emergency services. The LPN stated she thought the resident aspirated on the coleslaw before he continued to eat the fish. On 10/20/22 at 4:00 p.m., the DON was interviewed and stated the resident's care plan for a therapeutic diet, as well as the choking policy, should have been followed.