Seaview Rehabilitation & Wellness Center, LP

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was treated with dignity and respect during the provision of incontinent care when Certified Nursing Assistant A (CNA A) interacted with Resident 1 in a rude and disrespectful manner, causing Resident 1 to repeatedly call for help and request that CNA A be removed from the room. This finding had the potential to result in diminished dignity, trust, and emotional well-being for Resident 1 during personal care, as well as increased anxiety, reluctance to seek assistance, and a negative perception of the facility's caregiving environment. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure timely completion of a physician ordered psychological evaluation for one (1 ) of three (3 ) sampled residents (Resident 1). This failure resulted in an 11 month delay in needed mental health services, with potential exacerbation in Resident 1's continued confusion, agitation, and psychological distress. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident and the resident's family members were notified and invited to participate in care conferences (a collaborative meeting between a resident, their family, and the healthcare team to discuss the resident's health status, treatment progress, and update or establish a personalized care plan) for one resident (Resident 1) of three sampled residents. This failure decreased the facility's potential to ensure the resident and resident's family were given the opportunity to make decisions regarding Resident 1's healthcare goals and treatment.

Inspectors wroteBased on interview and record review the facility failed to ensure the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week for a census of 39. This failure had the potential for residents to have unmet care needs and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure person centered, comprehensive care for seven residents (Resident 7, Resident 6, Resident 3, Resident 39, Resident 24, Resident 34, and Resident 10) out of a census of 36 when the Interdisciplinary Team (IDT-a group of healthcare professionals collaborating to develop and implement a resident centered treatment plan) did not plan quarterly care conferences or involve residents and/or Responsible Party (RP, a person or entity responsible for making healthcare decisions). These failures resulted in lost opportunities for the residents to be included in decisions regarding their care, treatment and interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate reconciliation, accountability and disposition (the process of returning and/or destroying unused medications) of controlled medications (medications with high potential for abuse or addiction) and medication administration for a census of 39 residents when:Random controlled medication audits for two residents (Resident 20, and Resident 36) did not reconcile. The medications were signed out of Individual Narcotic Record (INR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) to indicate they were given to the residents; and,The Controlled Substance Disposition Log was not provided for medications that were destroyed on 7/17/25 and 8/21/25. [...]

Inspectors wroteBased on observations and interviews, the facility failed to protect the health of nine residents (Resident 37, Resident 38, Resident 35, Resident 3, Resident 14, Resident 34, Resident 1, Resident 21 and Resident 22) out of a census of 36 residents when:1. Hand hygiene was not performed prior to dining; and,2. Toilet plungers were placed directly on resident bathroom floors without being in receptacles. These failures decreased the facility's potential to prevent resident illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician orders for one of 14 sampled residents (Resident 22) when the oxygen order did not match the amount of oxygen the resident was administered. This failure caused Resident 22 to receive the incorrect amount of oxygen.

Inspectors wroteBased on observation, interview and record review the facility failed to provide treatment and service to maintain or improve mobility for one resident (Resident 38) out of a census of 36 when Resident 38 did not receive Restorative Nurse Assistance (RNA-program designed to help residents maintain or regain maximum physical potential) sessions as ordered and was not evaluated for proper wheelchair height. This failure decreased the facility's potential to ensure Resident 38's ability to do activities of daily living (ADL, basic self-care tasks that are typically performed independently daily, i.e. dressing, bathing, toileting) did not diminish.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure: 1. staff were knowledgeable of the abuse reporting guidelines: whom to report abuse allegations and the time frame for reporting abuse allegations, and 2.an abuse allegation was reported within the two-hour reporting time frame. These failures could put all facility residents at risk to experience abuse without timely reporting to the designated agencies.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure staff followed the facility's enhanced barrier precautions (EBP, an infection control intervention, that involves the use of gowns and gloves during high-contact care activities to reduce the transmission of Multidrug-Resistant Organisms [MDROs, bacteria, that have become resistant to multiple antibiotics]) for one out of two sampled residents (Resident 2) when staff did not wear gown while changing Resident 2's incontinence brief (a type of absorbent undergarment, similar to an adult diaper). This failure could result in a higher risk of transmitting MDROs to residents and could make residents sick. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an injury of unknown origin potentially resulting from abuse to the Department within two hours. This failure delayed the Department's investigation of the injury and potential abuse. The facility further failed to ensure staff were trained on reporting abuse allegations. This failure placed residents at risk of abuse. During an interview on 5/21/24 at 2:00 PM, the Administrator in Training (AIT) stated injury of unknown origin for Resident 1 was reported on 5/17/24. During an interview on 5/21/24 at 2:35 PM, Unlicensed Staff A stated she entered Resident 1's room on 5/17/24 to assist him with getting dressed. Unlicensed Staff A helped Resident 1 remove his shirt and she observed bruising on his left upper chest and going into his left armpit. The bruising was all shades - purple, blue, yellow, and green. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its abuse prevention policy for one of two sampled residents, Resident 1, when staff did not implement Resident 1's care plan for a behavior that put him at high risk for conflict, and staff were not trained on how to respond to his aggression. This resulted in Resident 1 arguing aggressively with a staff member while no staff intervened for approximately 10 to 20 minutes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report potential abuse timely when a nurse witnessed a certified nursing assistant yell and cuss at a resident, Resident 1, and facility staff did not report the incident, or Resident 1's grievance about the incident, to the Department for three days. This failure resulted in a delayed suspension of a potentially abusive staff member and a delayed investigation into an allegation of abuse of a vulnerable resident.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide behavioral management care according to the care plan of one of two sampled residents (Resident 1) when staff argued with Resident 1, who had a known behavior of verbal and physical aggression towards staff, and staff did not remove or redirect Resident 1 from the source of agitation. This failure resulted in Resident 1's behavior escalating and to continue his aggression for 10 to 20 minutes.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to treat six residents (Resident 6, Confidential Resident 30, Confidential Resident 34, Confidential Resident 2, Confidential Resident 3 and Confidential Resident 202.) out to 12 sampled residents with dignity when staff would assist a resident to the bathroom and then leave for an extended period of time, answer a call light and then not return to provide care. These failures resulted in residents feeling like they were worthless or invisible.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Replace the roof which had been leaking for at least three years, and 2. Had shower doors which locked and were not easily accessed by staff. These failures resulted in residents living in an environment that was visibly in need of repair and upkeep.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or their responsible party with a summary of the resident's Baseline Plan of Care for two of 24 sampled residents (Resident 21 and 102). This failure had the potential to limit communication with the resident and/or their responsible party on how the facility planned to manage the resident's needed services and treatments while at the facility, which could have led to the resident feeling stressed, uneasy and lack of trust with the staff providing care, leading to negatively affecting the resident's physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to : 1. Identify failure of staff to follow hand hygiene procedure (Cross Reference F880), 2. Identify failure to provide new residents and families with baseline care plans (Cross Reference F655), 3. Identify the failure of staff to respond to residents' requests for help (Cross Reference F550). These failures prevented the QAPI committee from developing, implementing, and evaluating action plans to correct systematic deficient practices.

Inspectors wroteBased on interview and record review the facility failed to offer COVID-19 ( an infectious disease caused by the SARS-CoV-2 virus and those infection could experience mild to moderate or severe respiratory illness) immunizations (a process by which a person becomes protected against a disease through vaccination.) as appropriate to four (Confidential Resident 30, Confidential Resident 34, Confidential Resident 2 and Confidential Resident 3) out of 12 sampled residents. This failure had the potential for residents to acquire COVID-19 and suffer a more serious illness without the added benefit of having the vaccine in their system.

Inspectors wroteBased on interview and record review the facility failed to ensure one of one sampled residents' (Resident 18) Responsible Party (RP) Family Member X was able to participate in care conferences. This failure resulted in Resident 18's RP Family Member X not being involved in the overall plan of care with regard to Resident 18's decline in health.

Inspectors wroteBased on observation, interview and record review the facility failed to safeguard one of one sample residents when Resident 18 had lost his glasses and the facility did not know nor replace his glasses. This failure resulted in Resident 18 wearing non- prescription glasses until his eyes were re-examined and potentially injuring himself by running into obstacles not in focus.

Inspectors wroteBased upon interview and record review the facility failed to keep one of one sampled resident (Resident 38), safe from verbal abuse. This failure resulted in Resident 38 suffering verbal abuse from a staff member.

Inspectors wroteBased on interview and record review, the facility failed for have an individualized care plan for two of 24 sampled residents (Resident 21 and 23) when: 1. Resident 21 was not care planned for being on Eliquis (Apixaban: blood thinner medicine that reduces blood clotting). 2. Resident 23 was not care planned for Hospice [A type of care and philosophy of care that focuses on the palliation (easing the severity of a pain or a disease without removing the cause) of a chronically ill, terminally ill, or seriously ill patient's pain and symptoms, and attending to their emotional and spiritual needs]. The lack of care plans had the potential for direct care staff not to monitor, treat, and reassess and/or prevent: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Verify the identity of a resident prior to medication administration; and 2. Carry out a physician order for a referral to an out-of-town physical therapy clinic (Resident 19). These failures had the potential to result in a medication error or delay treatment for Resident 19's back pain.

Inspectors wroteBased on interview and record review the facility failed to provide an annual review for one (Unlicensed Staff F) out of one sampled unlicensed staff. This failure had the potential for unlicensed staff working in the facility to be either incompetent or inappropriately working with residents. During a concurrent interview and record review on 1/12/24 at 10:22 a.m. with Director of Staff Development (DSD), DSD indicated that Unlicensed Staff F was initially hired at the facility on 3/16/16. DSD was unable to locate the annual review document for 2022 or 2023. DSD indicated Unlicensed Staff F had been terminated as of 10/24/23 but could not locate the paperwork to indicate cause for termination. DSD was reviewing piles and piles of loose papers in folders and unable to locate the annual review documents or cause for termination. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 24 sampled residents (Resident 21) was being monitored closely while on Eliquis (Apixaban: blood thinner (anticoagulant) medicine that reduces blood clotting). Not monitoring for the risks for blood thinner side effects, which include higher risk of bleeding, bruise more easily, may take longer than usual for any bleeding to stop, and may have a higher risk of bleeding if resident takes blood thinners in combination with other medicines that increase ones risk of bleeding, unexpected pain, swelling or joint pain, headaches or weak or dizzy, serious fall or hit on the head could impact one's physical wellbeing, lead to harm and even death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that its staff performed hand hygiene when entering and exiting residents' bedrooms and between doffing and donning of gloves when providing resident care as indicated in the facility's policy and procedure on hand hygiene. This failure had the potential to lead to the spread on infection among other residents. During an observation on 01/09/24 at 08:35 a.m., Unlicensed Staff (Staff B) entered a resident's shared room without performing hand hygiene. Staff B picked up a meal tray and brought it to the cart in the hallway. No hand hygiene was observed being performed by Staff B. During an observation on 01/09/24 at 08:38 a.m. Staff B returned to pick up another meal tray and did not perform hand hygiene prior to entering the resident's room. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient nursing staff to deliver nursing care to residents when 11 of 31 days in the month of July 2023 only one licensed nurse worked the evening shift. This failure had the potential to cause delayed response to call for assistance making residents feel unattended and irritated, or cause falls and other accidents.

Inspectors wrote2) Record review indicated Resident 146 was admitted to the facility on [DATE] with medical diagnoses including Fracture of Head and Neck of Left Femur (Thigh bone) and Benign Prostatic Hyperplasia (Prostate gland enlargement), according to the facility Face Sheet (Facility Demographic). During a concurrent observation and interview on 5/03/22 at 10:48 a.m., Resident 146 was observed in bed, in a hospital gown. He stated he had been in a lot of pain for several days. Resident 146 stated the night of 5/02/22, he pressed the call light because he needed pain medicine. Resident 146 stated his pain level was 8 out of 10. Resident 146 stated Unlicensed Staff A responded to the call light, and he requested pain medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five of five sampled residents (Resident 36, Resident 28, Resident 35, Resident 10, and Resident 17) were informed, and had access to the binder containing survey findings from the last State survey. This failure had the potential to result in lack of information regarding facility deficiencies and inability to receive information from agencies acting as client advocates, which could have resulted in residents not having the opportunity to contact these agencies.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan consistent with residents' rights, when: 1. Two (2) of thirteen (13) sampled residents (Resident 146 and Resident 24) with high pain levels, did not have comprehensive person-centered care plans for pain management, and the ones they had did not mention non-pharmacological (Interventions not consisting of medications) interventions in helping the residents with pain control. This had the potential to result in lack of information to facility staff on techniques and interventions to control the residents' pain to tolerable levels, which could have caused harm and suffering to the residents. 2. One (1) of thirteen (13) sampled residents (Resident 35), who spent most of the time in his room, did not have a comprehensive person-centered care plan for activities. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure nursing staff utilized professional standards when providing resident care when: 1) Licensed Staff did not place a pressure-relieving mattress on the bed of one resident (Resident 94) when she had restricted mobility due to pain. This failure caused potential for Resident 94 to experience skin breakdown and potentially develop pressure ulcers (bed sores), that could lead to increased pain and poor quality of life (Pressure Ulcers are areas of localized damage to the skin and underlying tissue resulting from prolonged pressure on the skin); 2) One Licensed nurse (Licensed Nurse D ) crushed an Enteric-coated tablet (designed to resist dissolving and being absorbed in the stomach. Reduce gastric irritation associated with uncoated tablets) for Resident 26 without a physician's order. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide activities of daily living (ADLs-A term used in healthcare to refer to people's daily self-care activities) to dependent (Residents that depended on staff for ADLs) residents when: 1. Eight (8) of thirteen (13) sampled residents (Resident 35, Resident 39, Resident 36, Resident 24, Resident 6, Resident 26, Resident 17 & Resident 10), and nine (9) of thirty-five (35) unsampled residents (Resident 4, Resident 30, Resident 37, Resident 25, Resident 20, Resident 21, Resident 16, Resident 19 & Resident 28), did not receive their scheduled showers or baths for weeks, with some not having received any baths or showers in over one month, and; 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the Activities Program met the needs of all the residents in the facility when no residents were observed, or confirmed participating in activities throughout the Recertification Survey from 5/02/22 through 5/09/22. This failure had the potential to result in boredom, depression, and anxiety for the residents of the facility.

Inspectors wroteBased on interview and record review, the facility did not ensure 23 residents, out of a census of 48, (Resident 36, Unsampled Resident 25, Resident 29, Resident 7, Resident 194, Resident 4, Resident 10, Resident 15, Resident 9, Resident 26, Resident 20, Resident 19, Resident 4, Resident 3, Resident 33, Resident 196, Resident 201, Resident 40, Resident 2, Resident 147, and Resident 28) had in-person, onsite physician visits when Physician P only provided telemedicine consults/visits. (Telemedicine allows health care professionals to evaluate, diagnose and treat patients at a distance using telecommunications technology - computers, video, phone, messaging). This failure prevented Physician P from physically assessing 23 residents and potentially prevented him from providing an in-depth evaluation of the each resident's condition and total program of care.

Inspectors wroteBased on interview, and record review, the facility did not have sufficient staff to meet the residents' needs when: 1. Call lights were not answered promptly, and; 2. There were insufficient staff to provide residents with their Activities of Daily Living (ADLs-A term used in healthcare to refer to people's daily self-care activities) when sixteen (16) of forty-eight (48) residents were found to not be receiving their scheduled showers/baths. These findings had the potential to result in inability for the residents to obtain assistance when they needed it, inability for staff to respond to medical emergencies, and lack of health services provided to the facility residents.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure medication error rate was below 5% when one (1) of three (3) Licensed Nurses (Licensed Nurse D) did not follow the manufacturer's recommendations and doctor's order regarding administration of medication for five residents (Residents 6, 9, 15, 26 and 31) which resulted in seven (7) medication administration errors out of 33 administration opportunities (21% error rate). This failure had the potential to compromise the absorption of the medication and the risk of compromising the resident's health and well-being for not getting the required dose of medication according to the doctor's order and according to the manufacturer's recommendation.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure sanitary conditions in the kitchen when: 1) One dietary staff member (Staff L) did not wear an N95 respirator (face mask designed to achieve a very close facial fit and very efficient filtration of airborne particles) per policy; dietary staff did not wear face coverings (masks) per policy; and dietary staff did not wash their hands after touching and repositioning their face masks/respirators, and 2) The facility did not monitor documented mold inside the ice machine and on fans utilized within the kitchen. These failures caused potential for transmission of disease-causing microorganisms, including Covid-19 and mold, to vulnerable residents with multiple health issues, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to identify quality deficiencies, and develop and implement plans to resolve them in their QAPI (Quality Assurance and Performance Improvement-a data driven and proactive approach to quality improvement to ensure services are meeting quality standards and assuring care reaches a certain level) program, when: 1. The facility did not have a QAPI project focused on sixteen (16) of forty-eight (48) residents not getting their regular showers and baths for weeks. This had the potential to result in continuous lack of ADL (Activities of daily living-a term use to describe self-help skills) services, which could have caused skin breakdown and infections, discomfort and loss of dignity to the residents involved. 2. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement measures to reduce the risk of disease and infection transmission when: 1. Two of three Licensed Nurses (Licensed Nurse D and Licensed F) did not perform proper hand hygiene before and after medication administration to residents. This failure had the potential to result in a spread of infections and/or transmission of diseases to the residents. 2. Two of 11 sampled residents (Resident 35 and Resident 194) received oxygen therapy via nasal cannula and the cannula tubing was not changed and dated per facility policy. This failure could result in bacteria build up which could potentially lead to respiratory infections. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an antibiotic stewardship program (A coordinated program that promotes the appropriate use of antibiotics) that included antibiotic use protocols and a system to monitor antibiotic use. This failure had the potential to result in unnecessary and inappropriate use of antibiotics, and the development of antibiotic resistant organisms, which could have caused superinfections (Infection occurring after or on top of an earlier infection, especially following treatment with broad-spectrum antibiotics) and poor clinical outcomes to the residents of the facility.

Inspectors wroteBased on interview and record review, the facility failed to appoint a qualified individual for the Infection Preventionist role, when: 1. The Infection Preventionist did not have the qualifications and training to implement an antibiotic stewardship program to promote and monitor appropriate antibiotic use. This failure had the potential to result in the development of antibiotic resistant organisms, which could have caused superinfections (Infection occurring after or on top of an earlier infection, especially following treatment with broad-spectrum antibiotics) and poor clinical outcomes to the residents of the facility. 2. The Infection Preventionist was not educated on the state requirements for checking visitors' vaccination status. This failure had the potential to result in spread of COVID-19, a potentially deadly virus, to the residents and staff at the facility. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide 1 of 5 sampled residents (Resident 35) and his family, the opportunity to participate in care planning when no care conference meetings (A meeting between healthcare professionals, the resident, and family members to decide the resident's needs, discuss the medical team's goals, and discuss the family's ideas for meeting those needs) were held inviting him and his family to help develop his plan of care. This failure had the potential to result in inability for the Resident 35 and his family to advocate for his needs and receive information regarding his care.

Inspectors wroteBased on interview and record review, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC - Completed by the facility to notify the resident of his or her right to an expedited review of skilled services provided (Nursing and Rehab services (Physical Therapy, Occupational and Speech therapy)) to one (1 ) of three (3) sampled residents (Resident 34) who received Medicare Part A (Federal Health Insurance) benefits. This failure resulted in Resident 34 not given the choice to appeal the facility's decision to discontinue her treatment. During a clinical record review for Resident 34, the Face Sheet (A one-page summary of important information about a resident) indicated Resident 34 was admitted to the facility on [DATE] under Medicare Part A Skilled Services with diagnosis including Fractures and other multiple traumas. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the room of 1 of 5 sampled residents (Resident 17), was kept safe, and in good repair, when a hole, the size of a US (United States) quarter, was observed in the bathroom door facing the room, containing wooden splinters with sharp edges. This room and bathroom were shared with Resident 33, who had vision impairments. This failure had the potential to result in residents accidentally placing a finger inside the hole, causing serious cuts and scrapes.

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive assessment for one (1) of thirteen (13) sampled residents (Resident 39) when a Minimum Data Set (MDS - an assessment tool completed by clinical staff to identify potential resident problems, strengths, and preferences) was not completed within 14 days of Resident 39's admission to hospice care. This failure resulted to an inaccurate representation of Resident 39's current clinical status and had the potential to cause inadequate care based on a delinquent comprehensive assessment and care planning. (Reference F686)

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide services to prevent the worsening of a pressure ulcer for one (1) of thirteen (13) sampled residents (Resident 39) when the facility did not provide low air loss mattress and followed their policy and procedure. This failure contributed to the increased size of the wound since admission.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the safety of one(1) of two (2) sampled residents (Resident 29) , when he attempted to light a cigarette while wearing a nasal cannula (A small, flexible plastic tube worn around the head that directs oxygen from a source to a person's nostrils), that administered oxygen. This resulted in burns to Resident 29's face, lip, cheek and nose, melted the nasal cannula and had the potential for substantial harm and possibly death.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its own Policy and Procedure when one of two sampled residents (Resident 146) with a indwelling suprapubic catheter (Hollow, flexible tubes inserted into the bladder through a small cut in the abdomen to drain urine into a bag) draining dark red urine, did not have his urine output monitored. This failure had the potential to result inability to identify blockage of the urinary catheter, which could have caused serious bladder conditions, and urinary tract infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the consulting Pharmacist's (Consultant CC) review of Resident 7's medications identified and addressed irregularities with her physician's order for Insulin Lispro (rapid-acting insulin; medication to treat high blood sugar in diabetics; onset of action is within 15 minutes). This failure resulted in nursing staff administering Insulin Lispro at 9 p.m. and 3 a.m., which potentially contributed to Resident 7 experiencing hypoglycemia (low blood sugar).

Inspectors wroteThe facility failed to ensure a large chewable tablet was administered safely to one (1) of eight (8) sampled residents (Resident 31) when Licensed Nurse D did not instruct Resident 31 to chew a chewable tablet before medication administration. This failure resulted to a choking experience for Resident 31 that caused him to feel distressed. (Reference F759)