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Due to the manner and degree of the deficient practice, the facility failed to meet the Condition of Participation for Special Requirements for CAH Providers Long-Term Care.

Based on observation, interview, and record review, the facility failed to:

- protect a patient with a history of suspected familial financial exploitation and physical abuse from continued abuse (See C1612).

- thoroughly investigate all allegations of suspected abuse (See C1612).

- report to the State Agency the alleged allegations and findings of the investigation (See C1612).

- screen prospective employees for a criminal background prior to providing patient care (See C1612).

- train new and existing employees on the prohibition and prevention of patient abuse (See C1612).

- treat a patient with respect and dignity by providing fluids through a baby bottle (See C1626).

- obtain a clarification order for the correct consistency of a "thickened liquids" order which resulted in inaccurate and inconsistent provision of thickened liquids (See C1626).

- ensure a nutritional assessment by a registered dietitian and/or a speech therapy evaluation after a significant change in condition occurred resulting in difficulty swallowing and food and fluid aspiration (See C1626).

- ensure a patient was provided a consistent and appropriate therapeutic diet and fluid consistency while utilizing the appropriate adapted eating/drinking utensils to maintain the patient's highest practical well-being and dignity (See C1626).

- ensure the appropriate emergency supplies were readily available for a patient with observed food and fluid aspiration and coughing (See C1626).

The accumulated effect of these deficient practices contributed to the continuation of physical abuse as evidenced by continued positive drug screens for THC and methamphetamines and psychosocial harm as evidenced by negative behavioral symptoms of aggression and catastrophic emotional reactions of outbursts and yelling out by 1 (#1) patient; and contributed to food and fluid aspiration which resulted in the suctioning of the patient and continued food and fluid aspiration and coughing which had the potential to cause aspiration pneumonia and/or aspiration death for 1 (#1) of 3 sampled patients.

IMMEDIATE JEOPARDY

On 3/29/22 at 3:00 p.m., the facility Administrator, Director of Nursing, Chief Medical Officer, and Quality Assurance Officer were notified that an Immediate Jeopardy existed in the area of §485.645 Condition of Participation: Special Requirements for CAH Providers of Long-Term Care Services, which was related to C1612 and C1626.

PLAN TO REMOVE IMMEDIACY:

An acceptable plan to remove the Immediate Jeopardy was received on 3/30/22 at 3:48 p.m.

Plan for Removal of Immediacy for:

§485.645: COP Swing Bed for (C1612) Abuse.

The outlined items below are being presented to help make a sustainable plan to improve the care of our Swing Bed patient in the Logan Health Cut Bank facility.

l. The physician will order a urine drug screen on the patient to get a baseline for the patient on 03.29.2022. If a positive result occurs at any time, the Lab Supervisor will follow the protocol provided by Mayo Clinic to get a drug screen for metabolites with a physician order.
a. Patient will be made aware of ongoing plan of care, protection and will be provided an opportunity to provide input to care plan.
b. Frequency of testing will occur when cognitive physical and behavioral concerns additional drug screenings will occur.

Protect

l. All staff has been notified of zero visitors for patient until guidance from the patient on allowed visitors can be obtained. Supervised visitation will be allowed between the hours of 15:00-17:00 Monday through Friday. Weekend hours will be determined by staffing availability.
2. Patient will provide a list of approved visitors 03.30.2022.
a. Individuals on the approved list will verify their identity by providing a picture ID that has been issued by a State or Federal government.
i. Screening staff will note on a log the time and date an individual was visiting.
b. Staff will accompany all visitors for the entire time they are in the building.
i. Screening staff will hand off to staff that are supervising the visit.
ii. The supervising staff will escort the visitor from the room to out of the building and note the time to screening staff as to when the individual was out of the building.
c. The Risk Manager and Chief Nursing Officer will educate the new protocols around visitation for patient.
3. Scripting will be provided to staff to help in directing patient's visitors of what is put into place to protect the patient.

Investigate and Report

4. The Human Resources and Quality team will conduct a full investigation of all staff and visitors that were known to be in and around the patient during time periods of concern. The investigation will be conducted starting immediately on 03.30.2022
a. To include but not be limited to Logan Health staff and providers and to include Nursing home staff and patient's family.
b. A copy of the report of the investigation will be provided to the surveyor.
c. All results will be shared with the Logan Health attorney to assist in developing a report to the State Survey and Certification Agency.
d. It will be signed and sent by the Vice President, Cherie Taylor, on by 04.05.2022.
5. Upon notice from State Surveyor concerns at 15:00 a team was disseminated to begin formally investigating the concerns.
a. A list of employees who have had contact with the patient has been compiled at 12:00
b. Authorization was received from Teamster Union contact to be able to interview staff at 13:40,
c. Authorization was received from Montana Nursing Association Union to proceed with interviewing staff at 14:00
d. Risk Manager was in contact with Risk Department at Logan Health Kalispell to assist with investigation of family and outside entities.

Training

6. Education created to outline information in our policy; Suspected of Identified Abuse, Neglect, and Exploitation (Admin.0096) and will be disseminated to all employees through multiple education sessions and venues.
7. We will provide training to staff to ensure they are entering the room accompanied by an additional staff member, to ensure there are always two employees attending the patient.
8. All on-site staff will attend education starting on 3.30.2022 at 15:00 and on 3.31.2022 at several sessions throughout the day on policy on abuse (Admln.0096).
a. Employees will attest to understanding the policy and any updates
b. Quiz will be provided to every employee to ensure the understanding and comprehension of education provided.
c. Education will be provided via HealthStreams at a minimum of twice annually for the next year and then in accordance with policy Admln.0096.
d. Any staff off site will be required to participate in the education, attestation, and quiz prior to or at the beginning of their next shift on-site.
e. For newly hired staff this training will be made available via Healthstreams and at the new hire orientation.
9. To ensure all staff receive training the following will be completed:
a. Staff will sign an attestation
b. Quiz will be administered to all staff
c. Staff will be tracked via spreadsheet by Quality Manager

The Removal of Immediacy start was March 30, 2022 at 3 pm.

For §485.645: COP Swing Bed for (C1626) Nutrition:

The outlined items below are being presented to help make a sustainable plan to improve the care of our current patients in the Logan Health Cut Bank facility.

1. Update policy Consultant Dietitian (Dietary.0003) on 03.30.2022. Educate all clinical staff on updates at the scheduled Nurse meeting on 03.31.2022 at 16:30.
a. Onsite staff will be educated on updated policy immediately 03.30.2022
2. Educate nursing staff on replacement of suction canister in patient rooms when appropriate.
3. Speech therapy and Occupational therapy have been scheduled to come and assess the patient on 3.30.2022.
a. Copy of assessment will provided to surveyor upon completion.
b. Education to be given immediately to staff on site on the recommendations received from Speech Therapy and Occupational Therapy in regard to the patient's care
c. Remaining nursing staff will be educated on 03.31.2022 at 16:30.
4. Occupational Therapy provided education to all nursing staff on shift on 03.30.2022 at 11:00 on how to properly use and position patient in Broda chair loaned to our facility from Glacier Care Center.
5. Speech Therapy provided their recommendations in regard to Nectar Thickened and when to use with patient. It will only be used at this time during meals until the dietician arrives on 03.31.2022.
a. Education was provided to CNAs on-site at 14:00.
6. Dietician to be on site by 03.31.2022 for an assessment and assign appropriate diet for patient and update patient's meal ticket.
a. Copy of assessment will provided to surveyor upon completion.
b. Documentation on assessment will be done on paper and will be scanned into patient's medical record.
c. Nursing staff is feeding patient and monitoring his intake.

d. Meals provided to patient until assessment is completed will be in accordance to patient's requests and within the doctor's orders.
7. Bottle has been removed and disposed of from the patient's room. Occupational therapy and speech therapy to provide direction on adaptive tools to help assist the patient to be more self sufficient and reduce risk of aspiration. And given any recommendations to be carried out through nursing.
a. Water will be at bedside and readily available to patient with staff supervision.
8. On 03.29.2022 tracking ins and outs was immediately put into place to closely track ins and outs on the patient to monitor hydration.
9. Current lab values will be obtained to allow Dietician to review to properly asses the patient.
10. Current weight was taken on patient 03.29.2022 at 15:25.
a. Weight will be monitored and tracked daily
11. All staff will attend education provided on 3.30.2022 and on 3.31.2022.
12. We will reevaluate in accordance to Speech Therapy and Occupational Therapy recommendations.

The Removal of Immediacy start was March 30, 2022 at 5 pm.

REMOVAL OF IMMEDIACY

The removal of the immediacy was verified onsite by the State Survey Agency on 3/31/22 at 1:00 p.m. Once the immediacy was removed, the deficiency remained at a Condition Level.

Based on observation, interview, and record review, the facility failed to follow their established policy and procedures to provide protection for the health and welfare of their patients from continued abuse and financial exploitation by failing to:

- protect a patient with a history of suspected familial financial exploitation and physical abuse from continued abuse;

- thoroughly investigate all allegations of suspected abuse;

- report to the State Agency the alleged allegations and findings of the investigation;

- screen prospective employees for a criminal background prior to providing patient care;

- train new and existing employees on the prohibition and prevention of patient abuse; and

- treat a patient with respect and dignity by providing fluids through a baby bottle.

The accumulated effect of these deficient practices contributed to the continuation of physical abuse as evidenced by continued positive drug screens for THC and methamphetamines and psychosocial harm as evidenced by negative behavioral symptoms of aggression and catastrophic emotional reactions of outbursts and yelling out by 1 (#1) of 3 sampled patients. Findings include:

IMMEDIATE JEOPARDY

On 3/29/22 at 3:00 p.m., the facility Administrator, Director of Nursing, Chief Medical Officer, and Quality Assurance Officer were notified that an Immediate Jeopardy existed in the area of §485.645 Condition of Participation: Special Requirements for CAH Providers of Long-Term Care Services, which was related to C1612 and C1626.

REMOVAL OF IMMEDIACY

An acceptable plan to remove the Immediate Jeopardy was received on 3/30/22 at 3:48 p.m.

The removal of the immediacy was verified onsite by the State Survey Agency on 3/31/22 at 1:00 p.m. Once the immediacy was removed, the deficiency remained at a Condition Level.

A. Protect

A review of the facility's policy and procedure titled, Policy and Procedure for Suspected or Identified Abuse, Neglect and Exploitation, with a revision date of 7/2020, showed:

- "Purpose:
To establish guidelines for all [Facility] personnel to follow in the provision of treatment and mandatory reporting related to victims of suspected child/elder/vulnerable adult abuse, neglect, exploitation, and rape/sexual molestation...

- 3.2. Physical Abuse:
- 3.2.1. Physical injury that results in substantial harm to the person, or the genuine threat of substantial harm from physical injury to the person, including an injury that is at variance with the history or explanation is given and excluding an accident or reasonable discipline by a parent, guardian or managing possessory conservator that does not expose the person in a substantial risk of harm. Failure to make a reasonable effort to prevent an action by another person that results in physical injury and substantial harm to the person...

- 4.2. Neglectful Supervision: Placing in, or failing to remove, the person from a situation that a reasonable individual would realize required judgment or actions beyond the child's level of maturity, physical condition or mental abilities and that results in bodily injury or substantial risk of immediate harm to the person...

- 5. Exploitation means the deliberate misappropriation of a patient's/resident's property, the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a patient's/resident's belongings or money without the patient's/resident's consent. The illegal or improper act of using the resources of a child, an elderly person, or a vulnerable person for monetary or personal benefit.

- 6. At-Risk Populations:
- 6.1 Elderly- Adults who are 60 years of age or older...
- 6.3 Vulnerable adult -A developmentally disabled person 18 years of age or older or as defined by the Department of Health and Human Services.

- Policy:
- 1. Patients and residents are to be free from abuse, neglect, and exploitation by staff, physicians, the staff of other agencies offering services, family members, legal guardians, visitors or other patients/residents. Alleged, suspected, or observed abuse/neglect/exploitation of a patient/resident and/or his/her belongings will be assessed, reported and appropriate referrals made...

- 4. Staff will observe for abuse, neglect, and exploitation and provide care in a safe environment. The staff member may make a report directly to Adult/Child Protective Services or inform the nursing supervisor, social services designee, or CNO. The CEO will be informed of all alleged episodes of patient abuse and neglect. Objective criteria are used by health care personnel for the assessment of possible victims. High-risk groups for abuse include the elderly, children, and vulnerable adults as defined above...

- 9.5 Development of safety plan, when needed:
- 9.5.1 If visitor or family member displays any abusive behavior, they will be asked to leave, at once, following the facility's/department's security policy.
- 9.5.1.1 Law Enforcement may be asked to assist.
- 9.5.1.2 A report will be made to the appropriate protective service agency.
- 9.5.1.3 Any visitor restrictions necessary to keep the patient/resident free from abuse/neglect and exploitation will be fully explained to the patient/resident and family and are determined with their participation and documented in the chart. Permission to visit inpatients, outpatients, or swing bed patients will only be allowed by written authorization of the attending physician, protective services, and/or the patient/resident. As appropriate, supervised visits will be offered and arranged as patient/resident desires."

During an interview on 3/23/22 at 9:15 a.m., NF1 stated they were concerned regarding patient #1 who was a vulnerable elderly individual with dementia and was bed ridden. NF1 stated they were concerned the facility, which patient #1 currently resided at, was not protecting the individual from continued abuse related to the patient having repeated positive drug screens for methamphetamines and THC since their admission to the facility on 10/13/21.

During an interview on 3/22/22 at 3:30 p.m., NF2 stated they had received a call from staff member B regarding patient #1 testing positive for THC and methamphetamines at different dates, which had coincided with family visitations.

During an interview on 3/23/22 at 1:18 p.m., NF6 stated patient #1 had been living in his home independently, then NF7 moved into the patient's home, and was acting as the patient's caretaker. NF6 said that NF7 was currently on probation for a criminal conviction for forgery, methamphetamine lab and distribution. NF6 stated they felt after NF7 had moved into the patient's home, he began to isolate the patient from the rest of the family through threats of violence and aggressive behavior. In March of 2021, NF7 completely isolated the patient from all family and had the patient complete a quick claim on his house, placing the house in NF7's name. NF6 said NF7 had also "racked up a bunch of credit card debt" under the patient's name. NF6 said the patient had a history of marijuana use, and NF7 had the patient obtain a "green card" so he could "grow pot" under the patient's medical marijuana card. NF6 stated patient #1 had never used methamphetamines in his life and she was upset to find out it was in his system, stating, "if [patient #1] had meth in his system it was because of NF7." NF6 said after they had been notified that the patient had been admitted to the hospital and had wanted to change his POA from NF7 to NF6 and NF8, they contacted their attorney. The attorney visited patient #1 on 10/21/21 and had determined the patient was of sound mind and changed the patient's POA from NF7 to NF6. She said she had visited the patient shortly after he was admitted to the hospital and was astounded at his appearance. She said he was bruised from head to toe and had scabs all over his body. NF6 stated the facility staff had told her the patient had looked "even worse" when he was brought into the emergency room. NF6 was told he had a plate sized bruise on his left side, a subdural hematoma, a major infection, and was severely dehydrated and malnourished. NF6 was also told the patient had tested positive for methamphetamines and THC at the time he was brought into the facility. NF6 said the patient would never have knowingly taken methamphetamines and felt it had occurred because the patient was living with NF7, who had a history of methamphetamine production and distribution. NF6 stated she was then in touch with staff member B regarding the patient since the patient did not have any money and could not get MCD because of the quick claim on his home. She said she had been meeting with staff member B in an attempt to find a place for the patient to go and look into any additional financial grants or programs within the community. NF6 said she and other members of their family had visited the patient on several different dates, and then was "accused" of providing the patient with drugs during those visits. NF6 said she was upset by the allegation that the facility was completing urine drug screens after their visits. NF6 said they had attempted to explain their concerns and thoughts on how the patient may be testing positive for methamphetamines and THC to staff member B but did not feel staff member B had followed up on those concerns. NF6 said the facility had created an approved visitor list, but had continued to allow unapproved visitors, such as NF3, to visit the patient unsupervised. She said she had even asked the facility to provide supervised visitation with the approved visitors but was refused. She stated she eventually quit visiting patient #1 because every time she did, the patient tested positive for drugs, and she felt they were being "blamed" for the continued methamphetamine in the patient's system and had used the patient as "bait" in order to "catch us" giving the patient drugs. NF6 also said she was worried the facility had continued to allow visitation from NF7, causing the patient to become upset and fearful. Stating when the facility had decided to place the patient on comfort care, after the patient had what she believed was stroke, they had removed any visitation restriction for patient #1. NF6 felt strongly that the facility had allowed NF7 to continue visiting the patient even after the patient had asked that he not visit, causing the patient distress and fear. NF6 provided the following timeline for dates of their visitations with the response by the facility as follows:

- 10/13/21: Patient #1 admitted into the facility after being brought to the ER with contusions, subdural hematoma, and a urine drug screen at the time which was positive for methamphetamines and THC.

- 10/21/21: The patient requested the POA to be revoked from NF7 and changed to NF6 and NF8. NF6 also visited the patient in the facility. Stating he "looked horrible."

- 11/11/21: NF6 had an unsupervised visit with the patient, stating, "he [patient #1] looked good and spoke clearly with good word search."

- 12/8/21 or 12/9/21: NF6 alleged NF7 had visited the patient had brought him a CD Player and CDs. She asked staff member B to review the camera to see if NF7 had entered the patient's room but was denied.

- 12/10/21: NF6 met with staff member B to determine payment eligibility for the patient. NF6 had ran into NF3 unsupervised in the patient's room. NF6 said NF3 had explained he was checking on the patient since he was his client prior to being admitted to the hospital. NF6 said she reported NF3's visit to staff member B, who said she did not know why NF3 would visit the patient and that NF3 did not "have privileges" at the facility.

- 12/12/21: The patient received another drug urine screen which was again positive for both methamphetamines and THC.

- 12/13/21: NF6 was notified the patient had tested positive again for drugs. NF6 was told by staff member B the facility was marking the visitor's patient #1 had and noted he had tested positive for drugs after being visited by the family. NF6 said she became very upset with staff member B and asked her why they were only testing after they visited the patient, and why were they not "looking into the other visitors." Also on this date, NF6 said staff member H had visited with the patient and told the patient that they would "throw him" out of the hospital "if he didn't quit using meth." NF6 stated when she spoke with patient #1 later about his encounter with staff member H, she said patient #1 was crying and kept "swearing to me that he didn't know how it [meth] got in his system". NF6 said the patient was very upset by that encounter and was fearful of "being thrown out" of the facility and having to go back to live with NF7.

- 12/22/21: The patient tested positive again for THC but not methamphetamines.

- 12/27/21: NF6 stated NF8 had visited the patient and noted a "no visitors" sign on the patient's door. NF6 stated the facility obtained another drug screen four hours after NF8 visited the patient, which was again positive for THC, but not methamphetamines.

- 1/1/22: NF8 had visited the patient again and the facility completed another drug screen which showed the patient was positive for THC.

- 1/17/22: NF6 spoke with patient #1, stating he "sounded good and could have a good conversation" with the patient.

- 1/18/22: The patient had another urine drug screen which was negative for both methamphetamines and THC.

- 1/18/22 to 1/21/22: NF6 attempted to call and speak with patient #1 everyday several times a day and was told by staff that he was asleep.

- 1/21/22: NF6 called and was able to speak with patient #1 on the phone. NF6 said when the patient answered the phone, she could not understand anything he was saying and he was incoherent slurring his words, and he kept repeating, "help me."

- 1/22/22: NF6 visited patient #1 at the hospital and said the patient looked like he had a stroke. He was drooling and his left side of his face was drooping.

- 1/24/22: NF6 was notified by staff member B that patient #1 had tested positive again for THC. NF6 said staff member B had offered to "lock up any [marijuana] edibles" for the patient. NF6 said she was not giving the patient any drugs or "pot" and told staff member B she was concerned NF7 was having someone put the drugs in the patient's food.

- 1/25/22: NF6 met with staff member H about the patient's change in condition. NF6 said staff member H had yelled and pointed his finger at her and accused her of giving the patient drugs; and, staff member H had "screamed" at her and said the patient's condition was not because of a stroke, it was because of his continued "meth use."

- 2/7/22: NF6 found out the patient had been placed on comfort care by the facility. She was told the reason for placing patient #1 on comfort care was failure to thrive. NF6 was notified they had not figured out how patient #1 was testing positive for methamphetamines or THC but that the facility had lifted all visitation restriction for the patient.

- 2/14/22: NF6 obtained a restraining order against NF7.

- 2/19/22: NF6 and NF8 visited patient #1 at the facility.

- 3/1/22: NF6 spoke with law enforcement because NF7 had sent a violent threat to NF8 and asked for help. They were told law enforcement could not do anything for them because NF7 was on probation.

- On 3/9/22 or 3/11/22: NF6 stated a family member was visiting patient #1 at the facility, when NF7 had entered the patient's room. NF6 stated the family member had reported patient #1 had become visibly upset when NF7 visited. NF6 asked if the facility would complete a drug screen for patient #1 after NF7 had visited and was told they would no longer be testing patient #1 for drugs since he was now on comfort care. NF6 stated the family member who was visiting the patient at that time, said that the patient asked that NF7 not be allowed to visit because he was afraid "[NF7] would hurt the nurses."

During an interview on 3/24/22 at 10:52, NF2 stated he was notified by staff member B at the facility, "close to [patient #1's] admission" to the hospital, of concerns of abuse and financial exploitation from NF7 of patient #1. NF2 said when he visited patient #1 at the facility, staff had "made it sound like" the patient had told them that he had been beaten and financially exploited by NF7. But when NF2 spoke with the patient about the allegations, patient #1 had told him that he had fallen in the hallway at home and had knowingly given his money to NF7. NF2 stated when he then checked back with the "nurses" he said they had then told him that they only suspected NF7 had abused and financial exploited the patient, and the patient had not actually told them of the abuse. NF2 further stated the staff had notified him that patient #1 had methamphetamines and THC in his system when he was admitted into the hospital and continued to test positive for methamphetamines and THC even with a limited visitor list. NF2 stated the facility expressed concerns that it was NF8 who was providing the drugs to the patient. NF2 stated he had spoken with NF6 at a later date and was told by that individual that it would "be completely out of [NF8's] character" to use meth and patient #1 had never used methamphetamines; and, that NF7 had been manufacturing and distributing methamphetamines for years and had even been incarcerated for methamphetamines. NF2 looked up NF7's criminal conviction history on "ConWeb", and stated NF7 had been convicted for, "forgery, operation of clandestine drug laboratory, and criminal possession of dangerous drugs." NF2 stated he did not create a report for this investigation.

During an interview on 3/28/22 at 3:00 p.m., staff members F, G, and J stated patient #1 was on comfort care and there were no current visitation restrictions in place for the patient. They stated they had concerns of certain visitors potentially providing the patient with drugs and had been obtaining urine drug screens on the patient after he had visitors, and he would test positive for methamphetamines and THC. They stated they were not able to provide supervised visitation for those who visited patient #1. Staff member F, G, and J stated patient #1 had told them on several different occasions that NF7 had physical abused him and took his money. They said they reported these concerns to APS and Law Enforcement. Staff member F said NF7 had an unsupervised visit with patient #1 shortly after he was put on comfort care; after which, the patient was visibly upset and had told her that, "he [NF7] was a bad man and was afraid he would hurt the nurses," and did not want him [NF7] to visit anymore. Staff member F said the patient had also told them that NF7 had taken all his money and belongings. Staff members F, G, and J stated the patient had other visitors other than those on the limited visitation and could not say who or when they had visited. They said all visitors check in at the main entrance and were signed in there.

During an observation and interview on 3/28/22 at 3:32 p.m., a sign was posted on patient #1's door which stated no visitors, and to check in at the nurses station. During an interview with patient #1 he stated he had heard that he had tested positive for meth and did not know how it got in his system. He said he was afraid they [facility] would kick him out, and he did not have anywhere to go. He said his girlfriend was mad at him because, "he was in a bad way," and he did not want his son to visit because he was a "bad man."

During an interview on 3/28/22 at 3:58 p.m., staff member G stated the patient had told them that NF7 had abused him at home and took all his money. He also changed his POA from NF7 to NF6 and NF8. Currently he was on comfort care and there were no visitation restrictions for him. She said before he was on comfort care he was on limited visitation list, and approximately 2 hours after those individuals visited, he would start having diarrhea and would exhibit negative behaviors of aggression and yelling. Because of those behaviors they would obtain a urine drug screen, which tested positive for methamphetamines and THC. Staff member G stated he continued to test positive for methamphetamines and THC after most of those visits. She stated the patient did have other unsupervised visitors during those times as well, such as NF3.

During an interview on 3/28/22 at 4:05 p.m., staff member E stated all visitors were screened in at the door for COVID-19 symptoms prior to being admitted. They did not keep a visitors log other than writing the visitors name on the COVID-19 screen in sheet and who they were visiting. She stated she was not aware of any visitation restrictions for patient #1, but would have anyone who did come to visit check in at the nurses' station, where they could sign in.

During an interview on 3/28/22 at 4:15 p.m., staff member B stated patient #1 was currently on comfort care and did not have any visitation restrictions. Staff member B stated when patient #1 was admitted to the facility on 10/13/21, he was under the care of NF7, and when he was brought to the ER he appeared to have been physically abused. He had contusions over his entire body, a subdural hematoma, was malnourished and dehydrated, and had tested positive for methamphetamines and THC. Staff member B stated the patient had requested that his POA be changed from NF7 to NF6 and NF8, which occurred on 10/21/21. She had worked with NF6 on different occasions trying to get payment options and MCD for the patient but was not able to do so because of the quick claim on the patient's home that was completed by NF7. She stated patient #1 was basically indigent and was currently receiving all services free of charge. Staff member B said they created a limited visitors list which included NF6 and NF8 and noted that after those individuals would visit the patient, he would have a sudden change in behavior and become aggressive and yelling at staff. She stated they would then test the patient for the possibility of drugs in his system afterwards and he would be positive for methamphetamines and THC. She stated this occurred on several different occasions. Staff member B said she was aware of other individuals visiting the patient, such as NF3. She said NF3 was not a provider for patient #1, and did not have any privileges at the facility, but believed he may have been the patient's provider prior to the patient being admitted to the hospital. She stated these concerns were reported to NF1 and NF2 but did not feel they helped the patient. She said she even asked NF1 for help with protecting the patient and they refused to help and did not even investigate the allegations they reported.

During an interview on 3/29/22 at 9:25 a.m., staff member L stated all visitors were screened in at the front desk for COVID-19. She stated they did not have a visitors log but would put the name of the individual visiting and who they were visiting on COVID-19 screening sheet. She stated the nurses would let her know if there were any changes in visitation for patients. Staff member L said she had any visitors for patients check in at the nurse's station.

During an interview on 3/29/22 at 9:30 a.m., staff members M and N stated patient #1 did not currently have any visitation restrictions. She stated he previously had a limited visitor list which did not include NF7. She stated after he had certain visitors, his behavior would become aggressive, and he would start yelling. She stated he would be given a urine drug screen which showed he was positive for methamphetamines and THC. Staff member M said the patient would continue to test positive for methamphetamines and THC after such visits. Stating the patient would claim he did not know how he was getting the drugs. She stated they did not restrict those individuals which they believed may have been providing the patient with the drugs but would test the patient after they visited. She stated the patient had other unsupervised visits from individuals not on the limited visitor list. She stated there was one day they were they were very busy and NF7 visited the patient unsupervised. She said after NF7 left, the patient was upset and said that "my [NF7] was not a good man," and did not want him visiting anymore.

During an interview on 3/29/22 at 10:03 a.m., staff member H stated patient #1 was brought into the emergency room by his son. The patient had a brain bleed and had cannabis and meth in his system. Staff member H stated the patient was being provided carefree of charge and everything which had happened to the patient was because of drugs, and alcohol, and nothing else. Staff member H stated the patient had a change in condition and they tested him for a stroke, all free of charge, and the change in his condition was due to nothing other than the patient using drugs. He said after the patient was admitted he would start having "bizarre behavior" and they would test the patient for drugs, and he would be positive for methamphetamines and cannabis. Because of his "bizarre behaviors," he said he had to schedule Haldol and Ativan for him, just to calm him down.

During an interview on 3/30/22 at 12:03 patient #1 stated he was worried about NF7 visiting and did not want him to hurt anyone, and that NF7 had taken everything from him. Patient #1's eyes were watery.

During an interview on 3/30/22 at 12:15 p.m. NF3 stated NF7 had brought patient #1 into their office to establish care. He then started to see the patient in his home for palliative care starting 1/25/20. NF3 said he was aware of NF7's criminal conviction history and drug use. He said he was aware NF7 was the patient's medical and financial POA, and NF7 had told him during one of his visits that while he was incarcerated he had studied the laws regarding the POA in the prison's law library. He said NF7 had made it very clear to him that he was the POA for patient #1 and he would be making his financial and medical decisions. NF3 stated during a home visit in September 2021, patient #1 had told him that he wanted to go to an ALF and wanted NF7 to go be with his family in Kalispell. NF3 stated NF7 was adamant that he was the patient's POA, and he would be making the medical decisions for him, and he had no plans on moving the patient to an ALF. NF3 stated shortly after that visit, there had been an APS investigation but they had not found any evidence of elder abuse or financial exploitation. NF3 stated he could tell that NF7 was becoming increasingly paranoid and had started to refuse allowing anyone other than himself to visit the patient. NF3 said NF7 had refused to allow any other family to visit the patient because he did not trust anyone. NF3 stated he was aware that NF7 was very knowledgeable in the POA laws and that the patient was in a very vulnerable situation to be exploited by NF7, but he did not report these concerns since he did not feel he had seen any evidence of abuse at that time. He said he did finally call the EMS just prior to the patient being admitted to the hospital because he could not get his blood sugars to come up and he had very low blood pressure. NF3 said he had visited the patient at the facility after he was admitted on four different occasions. He stated he visited the patient to see how he was doing and if he would be discharged. NF3 stated he visited the patient unsupervised by staff. He said he had not received an order to visit the patient in the hospital and was just checking on him.

Review of the facility's COVID-19 screening sheets of dates and times of visitors for patient #1, and a review of patient #1's Urine Drug Screenings showed the following dates of visitation and the results from the urine drug screens:

- 10/19/21 at 9:50 p.m., NF8 visited the patient.

- 10/20/21 at 11:30 a.m., NF3 visited the patient.

- 10/25/21 at 4:55 p.m., NF7 came to facility to visit. Was not permitted in and became angry and started pounding on the doors.

- 10/25/21 at 5:15 p.m., law enforcement was called regarding NF7's behavior.

- 10/29/21 at 4:05 p.m., APS visited patient.

Urine Drug Screen, ordered and collected on 12/9/21, showed:
- Amphetamines: Negative
- Benzo: Positive (A)
- Methamphetamine: Negative
- THC: Positive (A)
- "Urine Drug Screen Interpretation: Qualitative results only. A result of "negative" may mean that the drug is present, but below the threshold of the method. A result of "positive" indicates a presence of the drug in the sample. Additional tests are necessary for confirmation." A notation made by staff member B showed the patient had a change in his behavior.

- 12/12/21, unknown time, NF6 and NF9 visited the patient.

Urine Drug Screen, ordered and collected on 12/12/21, showed:
- Amphetamines: Negative
- Benzo: Positive (A)
- Methamphetamine: Positive (A)
- THC: Positive (A)
A notation made by staff member B showed, "after visited by [NF6] and [NF9]."

- 12/13/21 at 5:10 p.m., NF6 and NF8 visited the patient.

- 12/16/21 at 11:12 a.m., NF3 visited the patient.

- 12/22/21 at 9:00 a.m., NF8 visited the patient.

Urine Drug Screen, ordered and collected on 12/22/21 , showed:
- Amphetamines: Negative
- Benzo: Negative
- Methamphetamine: Negative
- THC: Positive (A)
A notation made by staff member B showed, "after [NF8] visited the patient."

- 12/23/22 at 1:15 p.m., NF3 visited the patient.

Urine Drug Screen, ordered and collected on 12/23/21 , showed:
- Amphetamines: Negative
- Benzo: Positive (A)
- Methamphetamine: Negative
- THC: Positive (A)
A notation made by staff member B showed, "after visitor [NF3]."

- 12/27/22 at 11:13 a.m., NF8 visited the patient.

Urine Drug Screen, ordered and collected on 12/27/21, showed:
- Amphetamines: Negative
- Benzo: Positive (A)
- Methamphetamine: Positive (A)
- THC: Positive (A)
A notation made by staff member B showed, "patient had blood nose 2:52 p.m., and [NF8] had visited the patient at 11:13 a.m."

- 1/1/22 at 12:00 p.m., NF8 visited the patient.

Urine Drug Screen, ordered on 1/1/22 and collected on 1/2/22 , showed:
- Amphetamines: Negative
- Benzo: Negative
- Methamphetamine: Positive (A)
- THC: Positive (A)
A notation made by staff member B showed, "visited by [NF8] at 12:00 p.m."

- 1/3/22 at 11:30 p.m., NF8 visited the patient.

- 1/4/22 at 10:31 a.m., NF10 visited the patient.

Urine Drug Screen, ordered on 1/5/22 and collected on 1/6/22 , showed:
- Amphetamines: Negative
- Benzo: Positive (A)
- Methamphetamine: Positive (A)
- THC: Positive (A)
A notation made by staff member B showed, "1/4/22 at 10:31 a.m., patient #1 was visited by [NF10]."

Urine Drug Screen, ordered and collected on 1/7/22, showed:
- Amphetamines: Negative
- Benzo: Positive (A)
- Methamphetamine: Positive (A)
- THC: Positive (A)

Urine Drug Screen, ordered and collected on 1/8/22, showed:
- Amphetamines: Negative
- Benzo: Positive (A)
- Methamphetamine: Negative
- THC: Positive (A)

Urine Drug Screen, ordered and collected on 1/9/22, showed:
- Amphetamines: Negative
- Benzo: Positive (A)
- Methamphetamine: Negative (A)
- THC: Positive (A)

Urine Drug Screen, ordered on 1/9/22 and collected on 1/10/22, showed:
- Amphetamines: Negative
- Benzo: Positive (A)
- Methamphetamine: Negative
- THC: Positive (A)

Urine Drug Screen, ordered and collected on 1/11/22, showed:
- Amphetamines: Negative
- Benzo: Positive (A)
- Methamphetamine: Negative (A)
- THC: Positive (A)

Urine Drug Screen, ordered and collected on 1/12/22, showed:
- Amphetamines: Negative
- Benzo: Positive (A)
- Methamphetamine: Negative
- THC: Positive (A)

Urine Drug Screen, ordered and collected on 1/13/22, showed:
- Amphetamines: Negative
- Benzo: Negative
- Methamphetamine: Negative
- THC: Positive (A)

Urine Drug Screen, ordered and collected on 1/14/22, showed:
- Amphetamines: Negative
- Benzo: Negative
- Methamphetamine: Negative
- THC: Positive (A)

Urine Drug Screen, ordered and collected on 1/15/22, showed:
- Amphetamines: Negative
- Benzo: Negative
- Methamphetamine: Negative
- THC: Positive

- 1/16/22, no time noted, NF7 came to visit, but was not let into the facility.

Urine Drug Screen, ordered and collected on 1/16/22 , showed:
- Amphetamines: Negative
- Benzo: Positive (A)
- Methamphetamine: Negative
- THC: Positive

Urine Drug Screen, ordered and collected on 1/17/22, showed:
- Amphetamines: Negative
- Benzo: Positive (A)
- Methamphetamine: Negative
- THC: Positive

Urine Drug Screen, ordered and collected on 1/18/22 , showed:
- Amphetamines: Negative
- Benzo: Positive (A)
- Methamphetamine: Negative
- THC: Positive (A)

Urine Drug Screen, ordered and collected on 1/19/2

Based on observation, interview, and record review, the facility failed to:

- obtained a clarification order for the correct consistency of a "thickened liquids" order which resulted in inaccurate and inconsistent provision of thickened liquids;

- ensure a nutritional assessment by a registered dietitian and/or a speech therapy evaluation was completed after a significant change in condition occurred in a patient who developed altered swallowing abilities and aspiration of food and fluid;

- provided a consistent and appropriate therapeutic diet and fluid consistency while utilizing the appropriate adapted eating/drinking utensils for a patient with vision loss, limited mobility, and altered swallowing abilities to maintain the patient's highest practical well-being and dignity;

- ensure the appropriate emergency supplies were readily available to provide emergency suction for a patient with observed food and fluid aspiration and coughing.

The accumulation of these deficient practices contributed to oral aspiration which resulted in the suctioning of the patient and continued food and fluid aspiration and coughing which had the potential to cause aspiration pneumonia and/or aspiration death for 1 (#1) of 3 sampled patients. Findings include:

IMMEDIATE JEOPARDY

On 3/29/22 at 3:00 p.m., the facility Administrator, Director of Nursing, Chief Medical Officer, and Quality Assurance Officer were notified that an Immediate Jeopardy existed in the area of §485.645 Condition of Participation: Special Requirements for CAH Providers of Long-Term Care Services, which was related to C1612 and C1626.

REMOVAL OF IMMEDIACY

An acceptable plan to remove the Immediate Jeopardy was received on 3/30/22 at 3:48 p.m.

The removal of the immediacy was verified onsite by the State Survey Agency on 3/31/22 at 1:00 p.m. Once the immediacy was removed, the deficiency remained at a Condition Level.

1. Clarification of Thickened Liquid Order:

During an observation on 3/28/22 at 3:42 p.m., patient #1 was lying flat in his bed, his lips were dry and peeling and his tongue was dry and cracked. On his bedside table was a gray pitcher half full of plain water, two Styrofoam cups each with a bendable straw and filled with plain non-thickened water, a full bottle of a sports drink, not thickened, and a clear baby bottle with a plastic nipple which had the nipple cut to a larger opening that was half full of non-thickened water. The patient requested a drink. He was placed in a sitting position and held the sports drink in his left hand while sucking the drink through a bendable straw. Patient #1 stopped to cough several times while drinking. The patient coughed hard enough while he was drinking the sports drink through the straw that his eyes started to water.

During an interview on 3/28/22 at 4:05 p.m., staff member G stated patient #1 had a significant change in his condition which resulted in him having a difficult time swallowing regular liquids and also decreased his ability to feed himself due to limited upper extremity mobility. She stated he had been being provided thickened liquids, but he did not like the consistency, so they quit thickening his fluids. She said he often coughs during meals and drinking, stating they have had to suction him previously due to aspiration. Staff member G stated his therapeutic diet order was for "thickened liquids" but could not say which consistency.

During an interview on 3/28/22 at 4:15 p.m., staff member I stated patient #1's family member brings him the sports drinks. She stated they did not thicken the sports drinks for him. Staff member I said they would follow the direction on the back of the "Thicket" cannister when thickening his fluids. Stating she did not know which consistency she should actually be thickening his fluids. She stated he had started to refuse any of the thickened liquids, so they had been providing regular consistency fluids for him.

During an interview and record review on 3/28/22 at 5:09 p.m., staff member B stated patient #1 started having difficulty swallowing following a change in his condition. She said the nurses started to thicken his fluids for him to help him swallow without aspirating. Staff member B checked the patient's current and previous diet orders, stating patient #1 was on "regular liquids" starting 12/27/21. Then his diet order was changed to "thick liquids," starting 1/23/22. Staff member B stated there were no clarification orders in the patient's record as to the consistency of the thickened liquids.

During an observation on 3/29/22 at 9:30 a.m., patient #1 was asleep in his bed lying flat on his back. There was a gray pitcher with unthicken water, and two Styrofoam cups both with bendable straws half full of regular consistency water, and a non-thickened sports drink three quarters full, on the patient's bedside table.

During an interview and record review on 3/29/22 at 9:50 a.m., staff member M stated patient #1 had been receiving thickened liquids, and they followed the directions on the back of the "Thicket" canister to thicken his fluids. Staff member M stated she did not know the exact consistency to thicken his fluids. She stated the patient was being provided care out of pocket and it was up to the doctor to order his diet and fluid consistencies. Staff member M "looked up" the patient's diet order from staff member H, dated 1/23/22, stating it was for "thick liquids." Staff member M stated there was not a clarification order for the consistency of the "thick liquids" order, stating it would be necessary to obtain such an order to know which consistency they should have provided for the patient.

Review of patient #1's Physician Orders, dated 1/23/22, showed, "thick liquids." Further review of the patient's record failed to show a clarification order for the thickened liquid consistency.

2. RD and SLP Nutritional Assessments

A review of the facility's policy and procedure titled, Nutritional Assessment, with a an effective date of 7/2008, showed:

- "Purpose: To evaluate the swing bed/geriatric patient's nutritional status and develop a program for his/her nutritional needs. A Nutritional Screening must be initiated for all patients at the time of admission. A nutritional assessment must be completed on all swing beds within 7 days...

- The completed Nutritional Assessment must be signed by the Consultant Dietitian and entered into the patient's medical record. The Consultant Dietitian should discuss any nutritional problems with the nurse in charge and /or the physician as necessary. Nutritional information must be incorporated into the Multi-Disciplinary Resident Care Plan...

- Periodically the Consultant Dietitian must evaluate the nutritional progress of the patient. She/he should give diet counseling and provide discharge diets as ordered by the physician. The consultant dietitian will work with the dietetic technician in providing services. Documentation of such services should be recorded in the resident's medical record."

During an observation on 3/28/22 at 3:42 p.m., patient #1 was lying flat in his bed, his lips were dry and peeling and his tongue was dry and cracked. On his bedside table was a gray pitcher half full of plain water, two Styrofoam cups each with a bendable straw and filled with plain non-thickened water, a full bottle of Kirkland brand sports drink, not thickened, and a clear baby bottle with a plastic nipple which had the nipple cut to a larger opening that was half full of non-thickened water. The patient requested a drink. He was placed in a sitting position and held the sports drink in his left hand while sucking the drink through a bendable straw. Patient #1 stopped to cough several times while drinking. The patient coughed hard enough while he was drinking the sports drink through the straw that his eyes started to water.

During an interview on 3/28/22 at 4:05 p.m., staff member G stated patient #1 had a significant change in his condition approximately three months ago which resulted in him having a difficult time swallowing regular liquids and also decreased his ability to feed himself due to limited upper extremity mobility. She stated he was being provided regular liquids and preferred a mechanical soft diet due to his dentition. The staff member stated they had completed nursing nutrition assessments on the patient but did not order a dietary consult or a speech evaluation after his change in condition because the facility did not have a registered dietitian or a speech therapist.

During an interview on 3/28/22 at 4:15 p.m., staff member I stated they would order a mechanical soft diet for him from the kitchen since he preferred that texture. She stated he would cough and choke at times while eating and drinking.

During an interview and record review on 3/28/22 at 5:09 p.m., staff member B stated patient #1 started having difficulty swallowing following a change in his condition on 1/23/22. She stated it was the expectation for nursing staff to complete regular nursing nutrition assessments on patients and also when they had a change in condition which would affect their ability to swallow. She stated if the assessment completed by the nursing staff scored "7" or higher, they were expected to get an RD assessment. Staff member B stated they have not had an RD at their facility for a while and were aware it was a concern. They stated the facility had been working with their regional administrators to obtain a regular RD. Staff member B stated they do have access to contracted RD and Speech Therapist, if needed. She said they have not obtained either assessment for patient #1. The staff member reviewed patient #1's most recent Nursing Nutrition Assessment, dated 2/7/22, which showed patient #1 had scored a "9," which would indicate a dietary consult. Staff member B said it would be important to obtain an RD and/or a Speech Therapy Evaluation for a patient that had a new onset of difficulty with swallowing, such as patient #1 to prevent aspiration pneumonia or choking.

During an interview and record review on 3/29/22 at 9:50 a.m., staff member M stated patient #1 had a change in his condition which had caused him difficulty with swallowing. She stated regular nursing nutrition assessments have been completed for the patient. She stated she believed they were to order a dietary consult if the patient had scored a "7" or higher on the assessment. Staff member M stated they have not ordered a dietary assessment by an RD or requested a speech evaluation by a speech therapist because the facility did not have either. She stated, however, those assessments would be important for someone with dysphagia, such as patient #1, to prevent aspiration. Staff member M said the patient had been receiving hospital services, free of charge.

During an observation and interview on 3/29/22 at 11:52 a.m., patient #1 was being assisted with his meal by staff member F. The patient would cough intermittently after bites of food and swallowing milk. Staff member F said the patient had eaten pureed meat and potatoes with gravy and she had "smashed" the cauliflower for him. She stated he often coughed when eating his meals.

Review of patient #1's Nursing Nutrition Assessment, dated 2/7/22, showed:

- Oral intake food past 30 days: "(1)26-75%"
- Oral intake of fluid past 30 days: "(1)25-75%"
- Relevant Conditions/Diagnosis: "(1)Anemia, infection, recent CVA, FX, UTI, ETOH abuse..."
- Physical and Mental Function: (3) Bed ridden, total dependence, coughs or aspirates while eating..."
- Lab values: "NA [not applicable]"
- Skin Conditions: (1) Stage I or II pressure ulcers, skin tears not healing, history of pressure ulcers."
- Add all (0)'s, (1)'s, and (3)'s for Total: "9"
- "If total more than 8 points, dietary consult".

Review of patient #1's Medical Record did not show a dietary consult or a speech therapy evaluation was ordered after his change in condition on 1/23/22.

Review of the Accepted Plan to Remove Immediacy, dated 3/30/22 at 3:48 p.m., showed, "Speech therapy and Occupational therapy have been scheduled to come and assess the patient on 3/30/22... Speech Therapy provided their recommendations in regard to Nectar Thickened and when to use with patient. It will only be used at this time during meals until the dietician arrives on 03.31.2022...6. Dietician to be on site by 03.31.2022 for an assessment and assign appropriate diet for patient and update patient's meal ticket..."

Review of patient #1's Adult Speech and Language Evaluation, dated 3/30/22, showed:

- Oral Trial: "...Thin liquids trialed x15 boluses, with coughing observed x3 trials. Watery eyes, gurgling observed which are suggestive of signs and symptoms of aspiration..."

- Summary: "[Patient #1] is fully dependent for all oral intake and is observed with overt signs and symptoms of aspiration and penetration on thin liquids, including coughing, gurgling, and watery eyes when alternating thin water during mealtime oral consumption. He tolerated thin water oral intake for 75 percent of opportunities with no overt signs and symptoms of aspiration or penetration. He tolerated mechanical soft textures well this session."

-Recommendations: "Trial thin liquids between meals... Trial nectar thick liquids at mealtimes to decrease risk of aspiration during oral intake. Current diet recommendations: mechanical soft solids, thin water between meals, trial nectar thick liquids at mealtime..."

Review of patient #1's Registered Dietitian Note, dated 3/31/22, showed:

-Diet Order: "Mechanical soft, Nectar thick liquids at meals, thin liquids between meals..."

3. Therapeutic Diet and Use of Baby Bottle

During an interview on 3/23/22 at 1:18 p.m., NF6 stated she had spoken with patient #1 on the phone 1/17/22 and he had "sounded good and could have a good conversation." When she was able to speak with him on the phone again on 1/21/22, she stated he was incoherent and kept mumbling repeatedly "help me." She stated she had visited patient #1 at the facility on 1/22/22, and he looked "awful" like he had "another stroke." She said his left side of his face was drooping and he was drooling all over himself. She stated when she walked in the staff were feeding him from a baby bottle. She stated she was "mortified" to see the patient being fed from a baby bottle and felt it was completely inappropriate and undignified. NF6 said when she visited again with NF8, NF8 had been almost in tears from seeing the patient being fed from a baby bottle.

During an observation on 3/28/22 at 3:42 p.m., patient #1 was lying flat in his bed, his lips were dry and peeling and his tongue was dry and cracked. On his bedside table was clear baby bottle with a plastic nipple which had the nipple cut to a larger opening that was half full of non-thickened water.

During an interview on 3/28/22 at 4:05 p.m., staff member G stated patient #1 had a significant change in his condition approximately three months ago which resulted in him having a difficult time swallowing regular liquids and also decreased his ability to feed himself due to limited upper extremity mobility. She said they had tried thickening his liquids and he did not like his liquids thickened, so to get him to drink more fluids they used a baby bottle with the nipple opening cut larger. Staff member G said they had limited options for him and felt the baby bottle worked well to get him to drink his fluids. Staff member G also stated they did not have a special diet ordered for patient #1 but would order a mechanical soft from the kitchen because he preferred that consistency of food, even before he started having difficulty swallowing.

During an interview on 3/28/22 at 4:15 p.m., staff member I stated they would order a mechanical soft diet for him from the kitchen since he preferred that texture. She stated they would feed patient #1 water from the baby bottle because he could not hold a regular cup without spilling, and the baby bottle allowed them the opportunity to have him give himself fluids without spilling all over.

During an interview and record review on 3/28/22 at 5:09 p.m., staff member B stated patient #1 started having difficulty swallowing following a change in his condition on 1/23/22. She stated staff had tried many different interventions to help him drink and eat without spilling. She said the nurses had decided to use the baby bottle to help him drink since they did not have other methods to provide him fluids. Staff member B said she could understand how being fed from a baby bottle may be a violation of the patient's dignity. Staff member B stated the nursing staff order his food every day from the kitchen. She stated she did not know what the patient's specific diet order was, but believed he preferred a soft food diet. Staff member B reviewed patient #1's diet orders, dated 11/5/21, which showed, "1800 Calorie ADA, Texture: None." On 12/29/21, diet order showed, "Regular, Texture: None." She stated they did not have an order for a mechanical soft diet, but the staff were ordering one for the patient.

During an observation and interview on 3/29/22 at 11:52 a.m., patient #1 was being assisted with his meal by staff member F. The patient would cough intermittently after bites of food and swallowing milk. Staff member F said the patient had eaten pureed meat and potatoes with gravy and she had "smashed" the cauliflower for him. She stated they usually ordered a mechanical soft because he preferred soft food because of his dentition. She stated they used the baby bottle to give him fluids because of his limited vision and mobility.

Review of patient #1's Medical Record, did not show a therapeutic diet was ordered.

Review of Accepted Plan to Remove Immediacy, 3/30/22 at 3:48 p.m., showed, "Speech therapy and Occupational therapy have been scheduled to come and assess the patient on 3/30/22..."

Review of patient #1's Occupational Therapy Assessment, dated 3/30/22, showed:

- Plan of Treatment: "adaptive equipment" for fluid and meal intake.

4. Emergency Supplies for Aspiration

During an observation on 3/28/22 at 3:42 p.m., patient #1 was lying flat in his bed, he had regular consistency liquids available on his bedside table. The patient was observed in a sitting position, and he attempted to drink his sports drink through a bendable straw. The patient stopped to cough several times while drinking. The patient coughed hard enough while he was drinking the sports drink through the straw that his eyes started to water. On the wall of the patient's room was the connection for suction, but there was no canister attached to the wall suction and there were no readily available supplies in the patient's room to assist the patient should he need to be immediately suctioned due to aspiration.

During an interview on 3/28/22 at 4:15 p.m., staff member I stated they would order a mechanical soft diet for him from the kitchen since he preferred that texture. She stated he would cough and choke at times while eating and drinking.

During an interview and record review on 3/29/22 at 9:50 a.m., staff member M stated patient #1 had a change in his condition which had caused him difficulty with swallowing. She stated there had been several times when nursing had to provide suction for the patient because he started to choke. She stated there was equipment to suction the patient in his room.

During an interview on 3/29/22 at 11:20 a.m., staff member B stated the patient should have suction equipment available at all times in his room in case of aspiration. She stated he has had episodes of aspiration which required suctioning in the past.

During an observation and interview on 3/29/22 at 11:52 a.m., patient #1 was being assisted with his meal by staff member F. The patient would cough intermittently after bites of food and swallowing milk. Staff member F said the patient had eaten pureed meat and potatoes with gravy and she had "smashed" the cauliflower for him. She stated he often coughed when eating his meals. She stated there had been times when the patient needed to be suctioned when he was eating because he could not swallow.

During an observation and interview on 3/29/22 at 12:03 p.m., staff member I stated there was emergency suction equipment in the patient's room. During an observation there was no suction equipment available in the patient #1's room. Staff member I stated they had to use the suction on the patient a couple days ago because he had aspirated, and they did not replace the canister or other equipment in his room after that event. She stated they could get equipment from the storage room across the hall.