Failure to Follow Dietary Recommendations Results in Choking Incident
Summary
The facility failed to ensure that a resident with specific dietary needs received adequate supervision and assistance to prevent accidents, resulting in a choking incident. The resident had a history of unspecified protein-calorie malnutrition, dehydration, and generalized muscle weakness, and was on a mechanical soft diet with thin consistency. Speech therapy recommendations specified that the resident's food should be cut into bite-size pieces and that small bites or sips should be facilitated during meals. However, these recommendations were not communicated on the resident's meal tray ticket, nor were they consistently followed by staff. On the day of the incident, an occupational therapist handed the resident half of a beef enchilada, approximately 2.5 inches in size, which was not cut into bite-size pieces as required. Despite verbal and visual cues to take small bites, the resident placed the entire portion in his mouth, leading to choking and labored breathing. Staff present attempted to assist the resident, but the food size and lack of adherence to the recommended feeding techniques contributed to the choking event. The speech therapist later confirmed that staff should have cut the food into smaller portions and that such instructions should have been clearly communicated and followed. Further review revealed that other residents with similar dietary needs had varying instructions on their meal tray tickets, such as "cut up meats" or "cut food into bite size pieces," but the process for ensuring these directions were consistently applied was lacking. The nursing home administrator acknowledged that speech therapy recommendations should be properly communicated and documented on meal tray tickets, and that staff should follow these recommendations. The failure to communicate and implement individualized dietary precautions resulted in a choking incident and subsequent death, placing additional residents at high risk for similar events.
Plan Of Correction
We were unable to correct deficiency F0689 related to Resident 1 as resident expired in the facility. Residents 6-14 were screened by Speech Therapy for appropriate diet and checked to see if at risk for choking or require any new safety measures. Director of Rehab audited all current residents that have had a speech therapy diet recommendation to ensure their current diet order reflects speech therapy recommendations. Director of Rehab educated all therapy staff on the new procedure of diet recommendations to be written on the speech therapy recommendation form and physician order as well as provided to nursing. Speech Therapy was also educated to give the speech therapy recommendation form to Dietary. Speech Therapists were instructed if trialing any changes to the diet, the therapist must stay with the resident until the trial item is completed. The Director of Rehab is conducting an ongoing audit for any new speech therapy recommendations to ensure they match the diet order. All nursing staff was educated prior to the start of their shift on the new choking policy and signs and symptoms to look for with a choking resident. Education was given to all nursing staff prior to the start of their shift on diet and diet textures. Dietary Manager educated all dietary staff prior to the start of their shift on diet and diet textures and cutting up food as indicated on the meal ticket. Dysphagia/Choking Procedure in-service was provided to the staff by Anthony Clark, Director of Nursing, and Talayne Gates, SLP, on Tuesday, October 14th at 7am, 1pm, and 3pm, and will be provided on Thursday, October 16th at 7am, 1pm, and 3pm to licensed staff and nursing assistants. The Director of Nursing and Assistant Dietary Manager are conducting audits of all new dietary orders or changes and recommendations for meal ticket accuracy through October 31, 2025. The Dietary Manager audited all meals during tray line service to ensure meal ticket matches diet order and visually observe meal served is accurate through 10/10/25. Beginning 10/13/25, the Dietary Manager will audit 3 meals per week during tray line to ensure meal ticket matches diet order and visually observe meal served is accurate through October 31, 2025. Direct in-service training on F0689, Accidents and Incidents, for all licensed staff and nursing assistants will be provided by Sophie Campbell, MSN, RN, CRRN, RAC-CT, CNDLTC. Sophie Campbell is the Executive Director of the Pennsylvania Association of Directors of Nursing Administration and is an approved directed in-service provider on the list from the Department of Health. The in-service will be held on Wednesday, October 29th at 7am, 1pm, and 3pm. This in-service will be recorded for staff that is unable to attend. Licensed staff unable to attend the in-service will be required to watch the recorded in-service prior to the start of their next shift. All ongoing audits will be reviewed at the monthly QAPI to determine if further auditing is needed. <End of formatted text>
Removal Plan
- Choking policy was reviewed and updated to American Heart Association Standards.
- All nursing staff currently working in the building will be educated by Employee 6 (Assistant DON) on the revised choking policy.
- All other nursing staff will be educated by the Registered Nurse (RN) Supervisor prior to the start of their shift. This will include all full time, part-time and nursing staff.
- Employee 6 will educate all nursing staff currently working on the signs to look for when someone is choking.
- All other nursing staff will be educated by the RN Supervisor prior to the start of their shift. This will include all full time, part-time and nursing staff.
- Employee 7 audited all residents on current caseload to ensure current speech therapy diet recommendations were being followed.
- Employee 7 will audit all residents who have had current speech therapy diet recommendations to ensure their current diet order reflects speech therapy recommendations.
- Employee 7 will educate speech therapists on new procedure to write recommendations on speech therapy recommendation form and physician orders.
- Employee 7 will educate Employee 1 on following dietary orders.
- Employee 12 (Dietary Manager) will educate dietary staff currently working on diet and diet textures.
- All other dietary staff members will be educated by Employee 12 prior to the start of their shift. This will include all full time, part-time, and as needed staff.
- All nursing staff currently working in the building will be educated by Employee 6 on diets and diet textures and to read and follow meal tickets.
- RN Supervisor will educate all nursing staff currently working on diets and diet textures and to read and follow meal ticket directions.
- Employee 12 (Dietary Manager) audited evening meal service tray line to ensure meal tickets matched diet order and visually observed meal service was accurate.
- All meals will be audited during tray line to ensure meal ticket matches diet order and visually observe meal served is accurate.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Follow Fall Interventions: A resident with dementia, ESRD on dialysis, impaired mobility, and a history of falls was observed ambulating and self-transferring in her room and bathroom without staff assistance, despite orders and a care plan requiring one-person assist with a walker, call light use, frequent safety checks, and skid strips by the bed. Staff interviews confirmed the resident was transferring independently and that the skid strips were not in place as documented.
A resident assessed as high risk for falls did not receive the physician-ordered fall mat on the right side of the bed. Surveyors observed no mat during multiple checks, and the TAR did not reflect the intervention. The resident said the mat had been removed after a new bed was placed, while an RN and the DON acknowledged the order remained in place even though the mat was no longer being used.
Smoking safety interventions were not consistently implemented for four residents who smoked. Two residents were observed smoking with staff supervision but without the smoking aprons listed in their assessments and care plans, and two other residents were also observed smoking in wheelchairs without aprons despite care plan interventions requiring them. The DON confirmed the apron requirement for two of the residents, while the ADON stated residents sometimes complained about the aprons and that he did not know when smoking assessments were completed.
A resident with cerebral palsy, severe cognitive impairment, wheelchair use, and a care plan requiring a mechanical lift for all transfers was manually transferred by a CNA instead of using the lift. During observation, the CNA lifted the resident by the upper back and moved him between the wheelchair and bed without mechanical assistance, despite having completed lift competency training and despite the DON confirming the resident required a mechanical lift for all transfers.
Failure to supervise a resident at risk for elopement led to repeated exit-seeking and wandering events, including being found off the unit and near exterior areas. The resident had dementia with cognitive impairment, hemiplegia, and diabetes, and staff notes described missing documentation of several wandering episodes, an incomplete care plan intervention, and incidents involving a broken alarmed door, a Wanderguard, and an unknown visitor letting the resident off the unit.
A resident with severe cognitive impairment fell during a lift transfer when a sling strap came loose and the chest strap clip broke, and two other residents were observed being transferred with total body lifts using slings that were not verified against their care plans or mobility assessments. Staff interviews showed some CNAs relied on the sling already in the room or on how it fit, rather than consistently checking the care plan or Kardex for the correct sling size and transfer method.
Failure to Follow Fall Interventions
Penalty
Summary
The facility failed to ensure that a resident's fall interventions were in place for one resident reviewed for falls. The resident had diagnoses of dementia and end-stage renal disease requiring dialysis, was documented as having intact cognition but needing supervision with ADLs, transfers, and walker use, and was identified as a fall risk due to ESRD, impulsive behavior, and impaired mobility. The resident's nursing and provider orders directed staff to assist with ambulation, remind the resident to use the call light and wait for staff, and complete frequent safety checks each shift. The resident had a documented fall in which she was found sitting on the floor between her drawer and walker with bleeding from a forehead injury and a skin tear to her jaw, and she was transferred to the hospital where she received stitches. The incident report stated the resident lost her balance when she walked to her drawer to close it. The resident's care plan later identified a self-care performance deficit related to actual falls, weakness, and impaired mobility, and included interventions such as assistance from one staff member with a walker and gait belt, assistance with transfers and toileting, use of assistive devices, skid strips next to the bed, and frequent monitoring for safety. During observations, the resident was seen ambulating and self-transferring in her room and bathroom without staff assistance and at times without using her walker or call light. Staff observed the resident walking independently in her room, and an unidentified staff member passed by without entering the room. The resident stated that she walked and used the bathroom by herself and did not need to follow instructions. Staff interviews confirmed that the resident transferred independently and ambulated without a walker or staff assistance, while another nurse stated the resident was not supposed to self-transfer and that skid strips were not present despite being listed in the care plan. The DON stated that staff were expected to follow resident orders and care plans for safety.
Missing Ordered Fall Mat for High-Fall-Risk Resident
Penalty
Summary
The facility failed to ensure a resident assessed as high risk for falls received the physician-ordered fall prevention intervention of a fall mat positioned on the right side of the bed. Resident #50 was admitted with diagnoses including orthostatic hypotension, lack of coordination, reduced mobility, and communication deficit. The resident’s fall risk assessment showed a score of 50, indicating high risk for falling, and the care plan identified the resident as at risk for falls and fall-related injury due to a history of falls with fracture, cognitive impairment, and decreased safety awareness. During multiple observations, the resident was seen at the bedside and no fall mat was present on the right side of the bed or located in the room. The physician order dated 6/7/2026 specified a mat on the right side of the bed, but the MAR and TAR did not reflect the fall mat as an implemented intervention. The resident stated the fall mat had been removed after a new bed was placed and had been gone for a long time. An RN stated the resident was a fall risk and that the order for the fall mat should be followed or cancelled if no longer needed. The DON stated the bed had been changed out and the mat would get in the way, and the order should have been cancelled.
Smoking Safety Interventions Not Followed
Penalty
Summary
The facility failed to ensure adequate assessment and implementation of smoking safety interventions for four sampled residents who smoked. Residents #12 and #85 were observed smoking in the designated smoking area with staff supervision on multiple occasions, but neither was observed wearing a smoking apron even though the smoking binder and care plan indicated they needed one. During an interview, the ADON confirmed both residents were listed as needing aprons and stated the residents sometimes complained about the apron, but they should not smoke unless they put it on. The ADON also stated he does not go out with smokers often and does not know when assessments are completed. Resident #12 had diagnoses including COPD, muscle weakness, and epilepsy, and smoking evaluations noted tobacco use and balance problems while sitting or standing; smoking was added to the care plan with a clothing protector intervention. Resident #85 had diagnoses including hemiplegia and right-hand contracture, and although initial smoking evaluations indicated tobacco use with no impairments, smoking was later added to the care plan with a clothing protection requirement. Resident #52, who had CVA with right-sided weakness and paralysis, diabetes, mood disorder, major depressive disorder, and right hand and upper arm contracture, was observed smoking in a wheelchair without a smoking apron despite a care plan intervention requiring one. Resident #11, who had TBI, schizoaffective disorder, major depressive disorder, paraplegia, and upper extremity contractures, was also observed in the smoking area in a wheelchair without a smoking apron, and no attempt was made by the smoking monitor to get the apron on. The DON confirmed that Residents #52 and #11 were supposed to wear smoking aprons when smoking, and the facility smoking policy required residents to be educated and evaluated for smoking upon admission, re-admission, and quarterly.
Failure to Use Required Mechanical Lift for Resident Transfer
Penalty
Summary
The facility failed to ensure Resident #5 was transferred with a mechanical lift as required. Resident #5 was admitted with diagnoses including cerebral palsy, BPH, and hypertension, and a quarterly MDS showed severe impairment in thinking with a BIMS score of 4. He required substantial to maximal assistance with toileting hygiene, used a wheelchair for mobility, and his care plan documented a history of falls with interventions initiated for a mechanical lift for all transfers to wheelchairs. A POC task also indicated he required a mechanical lift for transfers every shift, and he was listed among residents requiring a sling/mechanical lift. During observation, CNA C provided incontinent care and transferred Resident #5 from his specialized wheelchair to the bed and back without using a mechanical lift. Instead, she manually lifted him by placing her arms around his upper back and interlocking her fingers. In interview, CNA C stated she had been employed for a month, had completed lift competency during orientation, but did not use the lift because she felt comfortable transferring him without assistance and had never used the mechanical lift on him, although other staff did. The DON stated Resident #5 required a mechanical lift for all transfers and that staff could see this in the POC. The facility policy stated mechanical lifting devices shall be used for lifting and moving residents when necessary.
Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident elopement for a resident who was identified as at risk for elopement and did not reside on a secured unit. The resident had diagnoses including hemiplegia, diabetes, and dementia, and the MDS indicated cognitive impairment. The record showed multiple elopement evaluations with changing results, including several assessments that identified the resident as at risk for elopement in July 2026, while earlier assessments had indicated not at risk or were incomplete. The care plan identified the resident as an elopement risk/wanderer related to impaired safety awareness, but the record contained only one incomplete intervention related to wandering, and no resident preferences were included. Behavior monitoring documented exit-seeking and wandering behaviors on multiple occasions in May, June, and July 2026, but progress notes did not document the behaviors noted on 5/21/26, 6/21/26, and 7/14/26. A physician order for a Wanderguard was created after the resident was found wandering outside on the curb, and staff notes described discussions with family and assessments after the resident was returned to the unit. The resident was later involved in additional elopement-related events. Staff statements and progress notes described the resident being found near a door, in the front hall, in the assisted living area, and off the unit near common areas, with staff searching for her after she was reported missing. One note stated the resident could escape through a security door because the alarm was broken and had not been fixed yet. Another investigation note stated the resident was found off the unit in a common area adjacent to the unit after being let off by an unknown visitor. The facility determined that the resident was cognitively unable to recognize the door requiring a code and would be physically unable to open it without assistance. The report states the facility was out of compliance with resident safety and supervision since 4/12/26.
Failure to verify correct sling size and safe lift use during resident transfers
Penalty
Summary
The facility failed to ensure staff followed accident prevention interventions and safe device use for three sampled residents who required total body lift transfers. The report states that four certified nursing assistants did not verify the correct sling size before transferring residents, despite care plans and the lift’s sling-size identification system directing staff to use specific sling sizes based on resident weight and transfer needs. Resident 39 had severe cognitive impairment, Alzheimer’s disease, dementia with behavioral disturbance, anxiety disorder, and muscle weakness. Her care plan and mobility assessments showed a progression from sit-to-stand lift use to total body lift use with two staff members and a medium sling. On 5/1/26, she was transferred from her wheelchair to her bed by a CNA using a sit-to-stand lift when the sling strap came loose from the hook on the lift and the chest strap clip broke, causing her to fall backward onto the floor. She sustained a skin tear on her right forearm, bruising to the right side of her face, redness to the right side of her body, and a bruise on her right frontal scalp. She was sent to the ER, where X-rays showed no acute findings or fractures. Observations later showed resident 39 being transferred with a total body lift using a large sling, and resident 8 and resident 25 were also observed with large total body lift slings on. Resident 8 had paraplegia, moderate cognitive impairment, and a care plan directing total body lift transfers with a medium and extra-large sling, while his mobility assessment indicated an extra-large sling and two staff members. Resident 25 had vascular dementia and muscle weakness; her care plan directed total body lift transfers with two staff members, and her mobility assessment indicated a large sling. Interviews with CNAs showed that staff sometimes relied on the sling already in the room or judged sling size by how it fit, rather than consistently referring to the care plan or Kardex. The DON and MDS coordinator stated that staff were expected to use the resident’s care plan or Kardex to determine sling size for safe transfers.
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