Hartland Park Health & Rehabilitation

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

asked the resident how he received the granola bar, and Resident R1 stated to RN1, I have my connections. In an

interview with the Activities Director on 10/21/2025 at 2:32 PM, she stated, during an activity on 09/19/2025 at 2:00 PM, Resident R1 and Resident R2 were watching a movie in the dining room with other residents and staff. She stated popcorn was offered to Resident R2, and Resident R2 shared his popcorn with Resident R1. She stated the activities staff saw Resident R1 with popcorn, and as they moved toward him, he started to cough. She stated staff took Resident R1 to the nurses' station, and Resident R1 had emesis. She stated Resident R1 was offered water and could not swallow. In an interview with Certified Nurse Aide (CNA) 2, from Unit B, on 10/22/2025 at 1:08 PM, she stated Resident R1 did wander occasionally over to Unit B. She stated she was present in the joint Unit B-C dining room, on 10/16/2025, at

the assisted residents table when Resident R1 visited with the male residents that sat there. She stated the male residents left the table, and she went to bring Resident R1 to his assisted table for his food when he grabbed the pineapple off one of the male residents' trays. She stated she was not aware the resident would grab regular food off another resident's tray. Review of Resident R1's three documents Hospital Discharge summary, dated [DATE REDACTED], 09/21/2025, and 10/18/2025 revealed Resident R1 was readmitted to the hospital, after each incident, with vomiting and the inability to swallow liquids. Per the summaries, Resident R1 had an esophageal obstruction, chronic dysphagia, chronic esophageal strictures, and gastroesophageal reflex disease (GERD). Each time, Gastroenterology was consulted. Resident R1 had an EGD on 10/17/2025 with removal of food from the upper esophagus as well as dilation of the esophagus. In continued interview with Certified Nurse Aide (CNA) 2, from Unit B, on 10/22/2025 at 1:08 PM, she stated Resident R1 resided on Unit C, and she did not know where to find care plan information on Unit C. She stated she did not receive any information in report concerning Resident R1's behavior of trying to obtain regular food. In an interview with the Licensed Practical Nurse (LPN) Minimum Data Set (MDS) Coordinator on 10/22/2025 at 10:10 AM, she stated CCPs were updated quarterly or as needed for a change. She stated the Unit Manager could update the care plan. She stated

she attended the interdisciplinary morning meeting and made changes to the care plan. She stated the other disciplines were responsible to make changes to their specific care plan area and make the changes timely. In an interview with the Director of Nursing (DON) on 10/23/2025 at 10:29 AM, she stated care plans were updated in the interdisciplinary team clinical meeting and as needed, too. She stated the different disciplines could update the care plan as needed. She stated Resident R1's care plan should have been updated in 09/2025. She stated the Quality Assurance and Performance Improvement (QAPI) committee, at their meeting, discussed the event with Resident R1 and formulated a plan of action. In an interview with the Administrator

on 10/22/2025 at 2:32 PM, she stated she had been informed about the events of Resident R1 choking on food. She stated the CCP interventions should be to pick up trays before Resident R1 could collect food off another resident's tray; and Resident R1 to sit with staff supervision at the assisted table at meals, and the daughter, when she visited, would take him over to the male residents table to talk with his friends. She stated Resident R1's daughter voiced no concern to them and stated he just had dementia. She stated Resident R1's Activity Care Plan intervention should be not to give popcorn. She stated the concern with Resident R1's non-compliance in food choices resulted in hospital stays.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Hartland Park Health & Rehabilitation

1500 Trent Boulevard Lexington, KY 40515

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0743 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

In an interview with the Registered Dietitian (RD) Licensed Dietitian (LD) on 10/22/2025 at 4:00 PM, she stated she was made aware of the incidents when Resident R1 was offered or asked for foods from other residents.

She stated Resident R1 had an esophageal stricture and had the esophageal area stretched as needed. She stated foods not allowed on a pureed diet included popcorn, a granola bar, and pineapple. In an interview with the Speech Therapist on 10/21/2025 at 1:33 PM, she stated she had seen Resident R1 for cognition and speech. She stated, at the time of the evaluation, she was not aware there were any concerns with Resident R1's swallowing. She stated she asked the daughter about that, and she told her there were no concerns with his swallowing.

She stated a Speech reevaluation was done on 10/02/2025, and there were no concerns for swallowing.

She stated with Resident R1, all foods were pureed, with no whole foods allowed on the diet. She stated she followed

the orders from the Hospital Discharge Summary for Resident R1 to follow a pureed diet. In an interview with the Director of Nursing (DON) on 10/22/2025 at 3:00 PM, she stated Resident R1 did not move around as much as he used to. She stated he took himself to the dining room (DR) and would return. She stated she was told RN1 found a granola bar in his room and got it away from him. She stated the incident about the popcorn occurred while doing activities, and activities reported that to nursing. She stated the Activity Director instructed the residents not to share food with others. She stated Resident R1 was quick to take food off the other residents' trays when the opportunity was available at the other or his own table. She stated he liked to sit with his male resident friends, and they would offer him food. The DON stated they had educated staff that Resident R1 needed to stay at the assist table to be monitored, and staff was to sit and supervise him. The DON stated Resident R1's last esophageal stent placement was on 05/22/2024, and Resident R1 had received several esophageal dilatations over the years as his esophagus needed to be stretched. In an interview with the Administrator

on 10/22/2025 at 2:32 PM, she stated she had been informed about the events of Resident R1 choking on food. She stated the CCP interventions should be to pick up trays before Resident R1 could collect food off another resident's tray; and Resident R1 to sit with staff supervision at the assisted table at meals, and the daughter, when she visited, would take him over to the male residents table to talk with his friends. She stated Resident R1's daughter voiced no concern to them and stated he just had dementia. She stated Resident R1's Activity Care Plan intervention should be not to give popcorn. She stated the concern with Resident R1's non-compliance in food choices and staff not preventing it resulted in hospital stays.

Event ID:

Facility ID:

If continuation sheet