Facility Evaluation Report

On 10-11-23 at 1:45pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding a previous incident reported on 9-26-23. LPA met with Administrator Digna Cabrera and explained the purpose of the visit. LPA conducted interview with Administrator and reviewed additional facility file documentation including needs and service plan for resident1 (R1), training records, and physician's report for R1. Based on interview and record review, R1 experienced a coughing and vomiting episode on 9-25-23 at 5:45pm which required hospitalization. Based on scheduled feeding times for R1, R1 was not being fed at the time of the incident. Staff member on duty recognized the coughing and vomiting and called 9-1-1. Incident report was sent to licensing within appropriate regulatory time frames. R1 was diagnosed with aspiration pneumonia in hospital and was later transferred to an intermediate care facility (ICF) for new placement.

Based on record review, it was determined that R1 was receiving G- tube feeding since 7-28-23 with restrictive care plan in place as well as completed staff training on procedures and care for G- tube feeding last conducted and updated on 8-1-23 by a registered nurse (RN) consultant and signed by R1's physician. Additionally, needs and service plan last dated 8-2-23 indicates a history of aspiration pneumonia with associated interventions in place. Incident reports dated between January 2022 and March 2023 further describe a history of R1's coughing and vomiting along with aspiration pneumonia.

Based on today's case management, no citations are issued. An exit interview was conducted with Digna Cabrera and a copy of this report was provided to Digna.