Based on interview and record review, the facility failed to identify and ensure one of three sampled residents (Resident 43), who had difficulty swallowing and was at risk for aspiration (accidentally inhaling your food or liquid into your airway), received necessary care and services in accordance with professional standards of practice by failing to: -Follow the Physician's Order dated 2/12/2024, for Resident 43 to receive a pureed diet (food has been ground, pressed, and/or strained to a soft, smooth consistency, like a pudding). - Assess for tolerance of diet, per the Alteration in Oral / Dental Status care plan dated 2/12/2024. - Develop comprehensive person-centered Dysphagia (difficulty swallowing) care plan, per the facility's Comprehensive Plan of Care policy. -Monitor Resident 43 for any changes in condition and inform the physician, per the Activities of Daily Living care plan dated 2/12/2024. -Perform assessments consistently and accurately, during each shift or Resident 43's change in condition and report to physician timely. As a result, on 2/21/2024 at 12:38 AM, after eating a regular food brought in by the family, Resident 43 became congested, had difficulty breathing, and cyanotic (blue- indicating reduced blood oxygen levels). Resident 43 became unresponsive, required cardiopulmonary resuscitation (CPR - medical intervention used to restore circulatory and/or respiratory function that has stopped) and at 1 AM, Resident 43 was pronounced dead (nine days after his admission). On 4/28/2024 at 8:11 PM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the Administrator (ADM), regarding the facility's failure to identify and ensure Resident 43, who had difficulty swallowing and was at risk for aspiration, received necessary care and services in accordance with professional standards of practice. On 4/30/2024 at 1:12 PM, while onsite at the facility, the IJ was removed in the presence of the ADM, after the ADM submitted an acceptable Removal Plan (interventions and implementation to correct the deficient practices) which was verified and confirmed through observation, interview, and record review. The acceptable removal plan was as follows: On 4/29/2024, the Minimum Data Set (MDS) nurse reviewed the diet orders of all current residents (42) to determine if their diet texture and fluid consistency needed to be clarified with the physician. 39 residents needed clarification of their diet orders. The MDS completed the clarification of diet orders on the same day. Starting 4/28/2024, the Nurse Consultant provided an in-service to 6 Interdisciplinary Team (IDT - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) members to inform the resident's family, during the initia1 IDT meeting and subsequent IDT meetings as needed, about the resident's prescribed diet order and the facility's policy on Food for Resident from Outside Sources. The resident's family will be asked to sign a form acknowledging that they have received this information. The DON was the remaining IDT member who will be provided with an in-service by the Nurse Consultant upon their return to work. Starting 4/29/2024, the IDT reviewed 36 current residents who were on a therapeutic diet and informed their family members via telephone conversation about the resident's prescribed diet order and the facility's policy on Food for Resident from Outside Sources. The information was provided using the family members' native language. The IDT members documented in the resident's chart that the family has been informed. The consultant provided an in-service to RNs, Licensed Vocational Nurses, Certified Nursing Assistants and Restorative Nurse Aides (60% of staff) regarding the facility's policy on Food for Resident from Outside Sources and the different diet textures available in the facility. The in-service emphasized the following: o Diet orders will be printed daily by the licensed nurse and will be made available as a reference at the nurses' station. o Food brought in by family from outside sources must be consistent with the resident's prescribed diet; o Food brought in by family from outside sources should be shown to the licensed nurse for evaluation if it matches the resident's prescribed diet. o The licensed nurse must be notified if the resident is observed to be eating food that does not match the diet order or when the family is observed to have brought in food for the resident that is different from the diet order. o The licensed nurse will check on residents who have food brought in by family every two hours and as needed; and, o The licensed nurse will record both the evaluation of the food brought from outside and the q2 hour visual checks in a log that will be submitted to the DON or designee for further review. Licensed nurses and CNAs were asked questions at the end of the in-service to evaluate their knowledge of the information provided in the in-service. In-services will be completed for all the active nursing staff by the Nurse Consultant on or before 4/30/2024. Staff who were currently on vacation or on leave will be provided the in-service upon their return to work. Starting 4/29/2024, the Nurse Consultant checked competencies of two RNs, eight LVNs, and 16 CNAs in identifying different diet textures by presenting them with different sample meal trays and asking them to correctly identify different diet textures and fluid consistencies. Competency evaluations will be performed by the Nurse Consultant and completed for all active nursing staff by 4/30/2024. Staff who were currently on vacation or on leave will have their competencies evaluated upon their return to work. On 4/29/2024, the Nurse Consultant provided a one-to-one in-service with CNA 1 regarding the facility's policy on Food for Resident from Outside Sources, emphasizing the importance of reporting to the licensed nurse when the resident was observed to be eating food that was different from the diet order. At the end of the in-service, the CNA was asked questions to evaluate his knowledge about the information provided to him and was able to answer questions correctly. On 4/29/2024, the Nurse Consultant provided an in-service to 15 CNAs and two RNAs (50%) regarding the importance of immediately reporting to the licensed nurse any observed changes in the resident's condition and acting upon any actions that do not match the facility's policy on Food for Resident from Outside Sources. The Nurse Consultant would complete the in-service for all the active CNAs and RNAs by 4/30/2024. Staff who were currently on vacation or on leave will be provided the in-service upon their return to work. Starting 4/28/2024, the Nurse Consultant provided an in-service to 2 RNs and 8 LVNs (60%) regarding the facility's policy on Change of Condition. The in-service addressed the importance of identifying significant changes in condition, performing a timely assessment, providing appropriate interventions, and immediately notifying the physician of a resident's change in condition. The in-service also addressed notifying the alternate physician or the medical director of the changes in condition within a two -hour timeframe if unable to contact the primary physician, except during medical emergencies. A post-test was given to evaluate the staff's knowledge about the information they received. Passing score was three out of three Licensed nurses who did not pass will be asked to attend the in-service and take the posttest again. The Nurse Consultant will complete the in-service and post-test for all of active licensed nurses by 4/30/2024. Staff who were currently on vacation or on leave will be provided the in-service and post-test upon their return to work. Starting 4/29/2024, the Medical Records staff will conduct changes in condition audits daily Monday through Friday, five times a week to identify changes in condition, determine completeness of documentation, and determine if physician notification had occurred. On Mondays, the audit will cover changes in condition that occurred during the weekend. The DON or RN designee will review the audits daily five times a week to review the timeliness and appropriateness of the assessment and interventions in response to the change in condition. RN 2 was dismissed from facility and no longer an employee of the facility since 3/14/2024. Starting 4/29/2024, the Director of Nursing (DON) or Director of Staff Development (DSD) would evaluate licensed nurses' competencies related to identifying, managing, and notifying the physician, alternate physician, or medical director of any changes in condition upon hire and annually. On 4/28/2024, the Nurse Consultant provided a one-to-one in-service with the Administrator regarding the statute on Reporting Unusual Occurrences, emphasizing the definition of an unusual occurrence and the requirement to report unusual occurrences to the state survey agency within 24 hours of the incident. Starting 4/28/2024, the Nurse Consultant provided in-service to 48 facility staff (60%) regarding the statute on Reporting Unusual Occurrences, emphasizing the definition of an unusual occurrence, the importance of reporting unusual occurrences to the Administrator, the requirement to report unusual occurrences to the state survey agency within 24 hours of the incident, and to report to the state survey agency unusual occurrences that constitute abuse within 2 hours of the incident. The Administrator will review changes of condition during the stand-up meeting daily five times a week to identify abuse, suspicious deaths, major injuries, and other types of unusual occurrences and ensure that they are reported timely. The outcome of the review will be recorded in the stand-up meeting minutes. Findings: A review of Resident 43's admission Record indicated the facility admitted the resident on 2/12/2024, with diagnoses including but not limited to history of stroke, adult failure to thrive, repeated falls and presence of cardiac pacemaker. A review of Resident 43's admission Assessment, dated 2/12/2024, indicated the resident was admitted with a regular heartbeat and a strong pulse. The admission Assessment indicated Resident 43 did not have a cough, breath sounds were clear, and was not receiving respiratory therapy. A review of Resident 43's Nursing Progress Notes, dated 2/12/2024, indicated Resident 43 was awake, alert and oriented to name. Resident 43 was able to make his needs known, responsive to all stimuli, had no complaints of pain or discomfort and his breathing was even and unlabored. According to a review of the Physician's Order Summary Report, dated 2/12/2024, Resident 43 was to receive a pureed diet, speech therapy (ST), physical therapy (PT) and occupational therapy (OT) evaluations. A review of Resident 43's Alteration in Oral / Dental Status care plan initiated 2/12/2024, indicated the resident did not have teeth and the goal was for Resident 43 to not have unrecognized signs and symptoms of oral or dental problems daily. The care plan interventions indicated to provide the diet as ordered and monitor percentage of intake, ensure good oral hygiene and for staff to assess for tolerance of prescribed diet. A review of the Activities of Daily Living (ADLs -essential and routine activities include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) care plan, dated 2/12/2024, indicated Resident 43 required limited assistance with eating and the interventions included to monitor the resident for any changes in condition and inform physician. A review of the Nursing Progress notes, dated 2/15/2024, indicated Resident 43 was able to make his needs known, responsive to all stimuli, there were no significant changes, was calm and compliant, denied pain or discomfort, and the resident's breathing was even and unlabored. A review of Resident 43's admission Interdisciplinary Team (IDT) conference record dated 2/16/2024, indicated Resident 43's diagnoses, physical therapy and the resident's pain were discussed. The IDT conference record indicated Resident 43's diet and diet texture was not mentioned. According to a review of the Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 2/17/2024, Resident 43 had moderate cognitive impairment (problems with a person's ability to think, learn, remember, use judgement) and required setup or clean up assistance with eating. The MDS indicated the resident had a mechanically altered diet (required change in texture of food or liquids [pureed food, thickened liquids]) and did not have a problem with vomiting. The MDS indicated Resident 43 had complaints of difficulty or pain with swallowing and had no natural teeth or tooth fragments. A review of the Speech-Language Pathologist (SLP) Evaluation and Plan of Treatment, dated 2/18/2024, indicated Resident 43's oral motor (movements of the muscles in the mouth, jaw, tongue, lips and cheeks) structure and function was impaired. The SLP evaluation indicated a recommendation for Resident 43 to receive pureed food. A review of the Physician's Order, dated 2/18/2024, indicated Resident 43 was to receive Speech Therapy (ST) three times a week for dysphagia (difficulty swallowing) and the treatment included diet assessment, compensation strategies (learning new ways to perform tasks in an alternative manner) and resident / caregiver education. A review of the Skilled ST care plan dated 2/18/2024, indicated the goals for Resident 43 included to demonstrate improved oral motor strength for functional swallowing, the progression of his diet and for Resident 43 to tolerate his diet without signs and symptoms of aspiration. The care plan interventions included safe swallowing strategies, ongoing assessment of swallow efficiency and skilled ST evaluation and treatment. A review of the Nutritional Assessment, dated 2/20/2024, indicated Resident 43's current diet order was a mechanically altered diet, pureed with regular consistency liquids due to dysphagia. A review of the Nutritional Assessment, dated 2/20/2024, indicated Resident 43's current diet order was a mechanically altered diet (foods that can be safely and successfully swallowed) pureed with regular consistency liquids (no chewing required) due to dysphagia. According to a review of the Situation, Background, Assessment, Recommendation (SBAR - a technique that can be used to facilitate prompt and appropriate communication between the different disciplines caring for the resident) dated 2/20/2024 at 11:21 PM, it was reported by the prior shift (3-11 PM staff) that Resident 43 vomited a large amount of undigested food (around 5PM). At 12:38 AM, on 2/21/2024, Resident 43 had congestion which worsened, manifested by an acute change in the resident's level of consciousness (LOC), shallow and labored breathing with cyanotic nail beds and cold, clammy skin. The SBAR indicated code blue (a person is in need of immediate medical attention) was announced, 911 (a telephone number used to reach emergency medical, fire, and police services) was called and pulmonary resuscitation CPRP with high flow oxygen support through ambu bag (a device used to provide respiratory support to patients in emergency situations) was initiated, while active chest compression were performed by a trained support staff. At 12:55 AM, paramedics arrived and assumed care. A review of Resident 43's Certificate of Death indicated the resident expired on 2/21/2024 at 1 AM, with the cause of death as acute cardiopulmonary arrest (the heart and lungs suddenly and unexpectedly stop working), with acute myocardial infarction (heart attack). The Certificate of Death indicated Resident 43 passed away at the facility. During an interview on 4/28/2024 at 10:21 AM, Registered Nurse 1 (RN 1) stated on 2/20/2024, RN 1 worked the 11 PM to 7 AM shift, and the prior shift nurse, Registered Nurse (RN) 2, told RN 1 that during the 3PM to 11 PM shift, Resident 43 had eaten foods with a regular texture including a tortilla, and subsequently vomited a large amount of undigested food. RN 1 stated Resident 43 later became congested with difficulty breathing. After review of Resident 43's electronic chart, RN 1 stated RN 2 had not documented any progress notes, had not completed an SBAR and had not notified the primary physician regarding any of these changes of condition for the resident (eating regular textured food, vomiting). RN 1 stated he left a message for the primary physician due to Resident 43's congestion and difficulty breathing, the resident became more congested and then was unresponsive around 12:38 AM, on 2/21/2024. RN 1 stated he started CPR, called emergency services and the paramedics took over the CPR upon their arrival. Resident 43 was pronounced dead several minutes later. RN 1 further stated Resident 43's congestion may have resulted from the resident ingesting regular textured foods. During an interview on 4/28/2024 at 12:06 PM, the Registered Dietician (RD) 1 stated Resident 43 was on a pureed diet and if Resident 43 received a regular texture while prescribed a puree diet, this would make the resident at risk for aspiration or choking. During an interview on 4/28/2023 at 12:53 PM, the Dietary Supervisor (DS) stated a pureed diet was to be creamy soft, as it was placed in a food processor to have a smooth texture with no pieces inside of it. The primary physician did not respond to requests for interview. RN 2 did not respond to voicemail requests for interview. During a phone interview on 4/28/2024 at 4:35 PM, Certified Nursing Assistant 1 (CNA) 1 stated he saw from outside the room that the family brought in food for Resident 43. CNA 1 stated he saw Resident 43 eating the food and did not attempt to stop the resident. CNA 1 stated he did not enter the room because he was busy. CNA 1 further stated Resident 43 then vomited about 30 minutes later and that was when he notified RN 2 that Resident 43 had eaten the wrong texture food. During an interview on 4/30/2024 at 11:03 AM, the Director of Staff Development (DSD) stated the facility policy indicated that food brought in by family should be shown to the charge nurse or RD prior to giving it to the resident. The DSD stated when CNA 1 knew Resident 43 was eating the wrong diet, he should have gone in and reminded the resident and his family that the resident was eating the wrong food. Resident 43 had difficulty swallowing, choking could be very imminent, and the food could go to the lungs. The DSD stated RN 2 should have assessed the resident once Resident 43 vomited and should have notified the physician. The DSD stated if the resident's doctor was not responding, staff can contact the physician's alternate physician or the medical director. The DSD also stated there was a delay in care after the resident was found to have eaten the wrong type of food, after the resident vomited, and also when the resident was found to be congested. During an interview on 4/30/2024 at 12:29 PM, the Medical Director (MD) stated she was not aware of Resident 43's death in the facility and the primary physician should be notified of all changes in condition. The MD further stated she was always available if staff were unable to contact the primary physician. During a phone interview on 5/1/2024 at 12:26 PM, Family Member (FM) 1 stated he called the facility and received permission to bring in food for Resident 43. FM 1 stated he brought in chicken quesadillas for Resident 43, and no one educated him on any special diet or texture that Resident 43 was to receive. A review of the facility's Certified Nursing Assistant (CNA) Job Description, undated indicated essential responsibilities and job functions were to ensure that any change in resident condition or unusual circumstances was reported immediately to the charge nurse. A review of the facility's Registered Nurse (RN) Job Description, undated, indicated the RN was under the general supervision of the Director of Nursing. The Registered Nurse performs a variety of resident care functions and closely observes residents for changes in medical status. Consistently and accurately performs reassessments during each shift and when the resident condition changes and reports all abnormal test results to physician in a timely manner; triages activities based on borderline and/or abnormal and/or unusual findings. A review of the facility's policy and procedure (P&P) titled, Change of Condition, reviewed 1/18/2024, indicated to promptly notify the resident, his or her Attending Physician, and representative (sponsor), of changes in the resident's medical/mental condition and/or status. Under 'Procedure,' the P&P indicated acute medical changes or any sudden or serious change in condition manifested by a marked change in physical, mental and psychosocial status: -a Licensed Nurse will notify the physician, -If unable to contact attending physician or alternate physician, notify the Medical Director, -Notify and inform legal surrogate for any change of condition. -Using the Interact Tool SBAR - notify physician for all signs and symptoms manifested by the patient. The form will be used to initiate change of condition documentation for any decline or improvement. The P&P also indicated nurses notes would record information relative to changes in the resident's medical/mental condition or status. A review of the facility's P&P titled, Comprehensive Plan of Care, reviewed 1/18/2024, indicated to provide each resident with comprehensive plan of care that includes goals, measurable objectives, and timetables to meet their medical, nursing, psychosocial needs identified during comprehensive assessment. The comprehensive care plan would address resident's needs, strengths, and preferences, would include treatment goals with measurable objectives, interventions to prevent avoidable decline in function or functional level and would be periodically reviewed and revised by the IDT team as changes in the resident's care and treatment occur. The comprehensive care plan was required to be maintained in the resident's current chart.

Based on interview and record review, the facility failed to ensure one of three sampled resident (Resident 43), who had difficulty swallowing and was at risk for aspiration (accidentally inhaling your food or liquid into your airway), received care and monitoring of the resident's food consumption within the guidelines of the diet order by failing to: - Implement the facility's policy and procedure (P&P) titled, Food for Residents from Outside Sources, that food brought in from outside the facility for a resident would be first shown to the Charge Nurse for approval that the food was within the diet order (therapeutic and texture). - Implement the facility's P&P titled, Food for Residents from Outside Sources, by providing the family of Resident 43 with the information sheet, Bringing in Food for A Resident. - Ensure facility staff had ongoing communication and coordination to support the nutritional well-being and safety of Resident 43, when Family Member (FM) 1 brought food into the facility. -Report to charge nurse when Certified Nursing Assistant (CNA) 1 observed Resident 43 eating regular textured food brought by FM 1. As a result, on 2/21/2024 at 12:38 AM, after eating a regular textured food brought in by the family, around six hours prior, Resident 43 became congested, had difficulty breathing, and cyanotic (blue- indicating reduced blood oxygen levels). Resident 43 soon became unresponsive, required cardiopulmonary resuscitation (CPR - medical intervention used to restore circulatory and/or respiratory function that has stopped) and at 1 AM on 2/21/2024, Resident 43 was pronounced dead (nine days after his admission). On 4/28/2024 at 8:11 PM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the Administrator (ADM), regarding the facility's failure to identify and ensure Resident 43, who had difficulty swallowing and was at risk for aspiration, received necessary care and services in accordance with professional standards of practice. On 4/30/2024 at 1:12 PM, while onsite at the facility, the IJ was removed in the presence of the ADM, after the ADM submitted an acceptable Removal Plan (interventions and implementation to correct the deficient practices) which was verified and confirmed through observation, interview, and record review. The acceptable removal plan was as follows: -On 4/29/2024, the Minimum Data Set (MDS - a standardized assessment and care screening tool) Nurse reviewed the diet orders of all current residents (42) to determine if their diet texture (qualities of a food that can be felt with the fingers, tongue, palate, or teeth) and fluid consistency (refers to the thickness of the liquid) needed to be clarified with the physician. Thirty-nine residents needed clarification of their diet orders. The MDS Nurse completed the clarification of diet orders on the same day. -Starting 4/28/2024, the Nurse Consultant provided an in-service to six Interdisciplinary Team (IDT members Activities Director, MDS Nurse, Director of Rehab, Dietary Supervisor, Administrator, Social Services Director, and Director of Staff Development) to inform the resident's family, during the initial IDT meeting and subsequent IDT meetings as needed, about the resident's prescribed diet order and the facility's policy on Food for Resident from Outside Sources. The resident's family would be asked to sign a form acknowledging they received this information. The DON was the only remaining IDT member who would be provided with an in-service by the Nurse Consultant upon their return to work. -Starting 4/29/2024, the IDT reviewed 36 current residents who were on a therapeutic diet (meal plan that controls the intake of certain foods or nutrients in the treatment or management of certain diseases, illnesses, or medical conditions) and informed their family members via telephone conversation about the resident's prescribed diet order and the facility's policy on Food for Resident from Outside Sources. The information was provided using the family members' native language. The IDT members documented in the resident's chart that the family has been informed. -Consultant provided an in-service to Registered Nurses (RNs), Licensed Vocational Nurses (LVN), Certified Nursing Assistants (CNA) and Restorative Nurse Aides (RNA), 60% of staff, regarding the facility's policy on Food for Resident from Outside Sources and the different diet textures available in the facility. The in-service emphasized the following: -Diet orders will be printed daily by the licensed nurse and will be made available as a reference at the nurses' station. -Food brought in by family from outside sources must be consistent with the resident's prescribed diet; -Food brought in by family from outside sources should be shown to the licensed nurse for evaluation if it matches the resident's prescribed diet. -The licensed nurse must be notified if the resident is observed to be eating food that does not match the diet order or when the family is observed to have brought in food for the resident that is different from the diet order. -The licensed nurse will check on residents who have food brought in by family every 2 hours and as needed; and, -The licensed nurse will record both the evaluation of the food brought from outside and every two-hour visual checks in a log that would be submitted to the DON or designee for further review. -Licensed nurses and CNAs were asked questions at the end of the in-service to evaluate their knowledge of the information provided in the in-service. In-services would be completed for all the active nursing staff by the Nurse Consultant on or before 4/30/2024. Staff who were currently on vacation or on leave will be provided the in-service upon their return to work. -Starting 4/29/2024, the Nurse Consultant checked competencies of two RNs, eight LVNs and 16 CNAs, as in identifying different diet textures by presenting them with different sample meal trays and asking them to correctly identify different diet textures and fluid consistencies. Competency evaluations would be performed by the Nurse Consultant and completed for all active nursing staff by 4/30/2024. Staff who were currently on vacation or on leave would have their competencies evaluated upon their return to work. -On 4/29/2024, the Nurse Consultant provided a one-to-one in-service with CNA 1 regarding the facility's policy on Food for Resident from Outside Sources, emphasizing the importance of reporting to the licensed nurse when the resident was observed to be eating food that was different from the diet order. At the end of the in-service, the CNA was asked questions to evaluate his knowledge about the information provided to him and was able to answer questions correctly. -On 4/29/2024, the Nurse Consultant provided an in-service to 15 CNAs and 2 RNAs (50%) regarding the importance of immediately reporting to the licensed nurse any observed changes in the resident's condition and acting upon any actions that do not match the facility's policy on Food for Resident from Outside Sources. The Nurse Consultant would complete the in-service for all the active CNAs and RNAs by 4/30/2024. Staff who were currently on vacation or on leave would be provided the in-service upon their return to work. -The RD would review diet orders once a week to ensure diet orders were clear and correct. She would conduct rounds once a week to ensure that residents were provided the correct diet texture and fluid consistency. Findings would be reported to the Director of Nursing (DON) and Administrator weekly for follow-up. Findings: A review of Resident 43's admission Record indicated the facility admitted the resident, on 2/12/2024, with diagnoses including but not limited to history of stroke, adult failure to thrive, and presence of cardiac pacemaker. A review of Resident 43's admission Assessment, dated 2/12/2024, indicated the resident was alert and oriented x 1, had a regular heartbeat with a strong pulse, he did not have a cough and breath sounds were clear. A review of the Physician's Order Summary Report, dated 2/12/2024, indicated Resident 43 was to receive a pureed diet texture. regular consistency. According to a review of Resident 43's Nursing Progress Notes, dated 2/12/2024, the resident was able to make his needs known, responsive to all stimuli, and had no complaints of pain or discomfort. A review of Resident 43's Alteration in Oral / Dental Status care plan initiated 2/12/2024, indicated the resident did not have teeth and the goal was for Resident 43 to not have unrecognized signs and symptoms of oral or dental problems daily. The care plan interventions indicated to provide the diet as ordered and monitor percentage of intake, ensure good oral hygiene and for staff to assess for tolerance of prescribed diet. A review of the Activities of Daily Living care plan, dated 2/12/2024, indicated Resident 43 required limited assistance with eating and the interventions included to monitor the resident for any changes in condition and inform the physician. A review of the Nursing Progress notes, dated 2/15/2024, indicated Resident 43 was able to make his needs known, responsive to all stimuli, there were no significant changes, was calm and compliant, denied pain or discomfort, and the resident's breathing was even and unlabored. A review of Resident 43's admission Interdisciplinary Team (IDT) conference record dated 2/16/2024, indicated Resident 43's diagnoses, physical therapy and the resident's pain were discussed. The IDT conference record indicated Resident 43's diet and diet texture was not mentioned. A review of Resident 43's Minimum Data Set (MDS, standardized assessment and care-planning tool) dated 2/17/2024, indicated Resident 43 had moderately impaired cognition (problems with a person's ability to think, learn, remember, use judgement), required setup or clean up assistance with eating and had a mechanically altered diet (required change in texture of food or liquids [pureed food, thickened liquids]). The MDS indicated the resident did not have a problem with vomiting, had complaints of difficulty or pain with swallowing and the resident had no natural teeth or tooth fragment(s). A review of the Physician's Order, dated 2/18/2024, indicated Resident 43 was to receive Speech Therapy (ST) three times a week for dysphagia (difficulty swallowing) and the treatment included diet assessment, compensation strategies (learning new ways to perform tasks in an alternative manner) and resident / caregiver education. According to a review of the Speech-language pathologist (SLP) Evaluation and Plan of Treatment, dated 2/18/2024, Resident 43's oral motor structure (movements of the muscles in the mouth, jaw, tongue, lips and cheeks) and function was impaired and the recommendation was for Resident 43 to receive pureed food. A review of the Skilled Speech Therapy care plan dated 2/18/2024, indicated the goals for Resident 43 included to demonstrate improved oral motor strength for functional swallowing, the progression of his diet and for Resident 43 to tolerate his diet without signs and symptoms of aspiration. The care plan interventions included safe swallowing strategies, ongoing assessment of swallow efficiency and skilled ST evaluation and treatment. A review of the Nutritional Assessment, dated 2/20/2024, indicated Resident 43's current diet order was a mechanically altered diet (foods that can be safely and successfully swallowed) pureed with regular consistency liquids due to dysphagia. According to a review of the Situation, Background, Assessment, Recommendation (SBAR - a technique that can be used to facilitate prompt and appropriate communication between the different disciplines caring for the resident) dated 2/20/2024 at 11:21 PM, it was reported by the prior shift (3 -11 PM staff) that Resident 43 vomited a large amount of undigested food (around 5pm). At 12:38 AM, on 2/21/2024, Resident 43's had congestion which worsened manifested by an acute change in the resident's level of consciousness (LOC), shallow and labored breathing with cyanotic nail beds and cold / clammy skin. The SBAR indicated code blue was announced, 911 (a telephone number used to reach emergency medical, fire, and police services) was called and pulmonary resuscitation (CPR) with high flow oxygen support through ambu bag (type of device known as a bag valve mask, which is used to provide respiratory support to patients) was initiated, while active chest compression was performed by a trained support staff. At 12:55 AM, paramedics arrived and assumed care. A review of Resident 43's Certificate of Death indicated the resident expired on 2/21/2024 at 1 AM, with the cause of death as acute cardiopulmonary arrest (the heart and lungs suddenly and unexpectedly stop working), with acute myocardial infarction (heart attack). The Certificate of Death indicated Resident 43 passed away at the facility. During an interview on 4/28/2024 at 10:21 AM, Registered Nurse 1 (RN 1) stated on 2/20/2024, RN 1 worked the 11 PM to 7 AM shift, and the prior shift nurse, Registered Nurse (RN) 2, told RN 1 that during the 3PM to 11 PM shift, Resident 43 had eaten foods with a regular texture including a tortilla, and subsequently vomited a large amount of undigested food. RN 1 stated Resident 43 later became congested with difficulty breathing. After review of Resident 43's electronic chart, RN 1 stated RN 2 had not documented any progress notes, had not completed an SBAR and had not notified the primary physician regarding any of these changes of condition for the resident (eating regular textured food, vomiting). RN 1 stated he left a message for the primary physician due to Resident 43's congestion and difficulty breathing, the resident became more congested and then was unresponsive around 12:38 AM, on 2/21/2024. RN 1 stated he started CPR, called emergency services and the paramedics took over the CPR upon their arrival. Resident 43 was pronounced dead several minutes later. RN 1 stated Resident 43's congestion may have resulted from the resident ingesting regular textured foods. During an interview on 4/28/2024 at 12:06 PM, the Registered Dietician (RD) 1 stated Resident 43 was on a pureed diet and if Resident 43 received a regular texture while prescribed a puree diet, this would make the resident at risk for aspiration or choking. During an interview on 4/28/2023 at 12:53 PM, the Dietary Supervisor (DS) stated a pureed diet was to be creamy soft, as it was placed in a food processor to have a smooth texture with no pieces inside of it. RN 2 did not respond to voicemail requests for interview. During a phone interview on 4/28/2024 at 4:35 PM, Certified Nursing Assistant 1 (CNA) 1 stated he saw from outside the room that the family brought in food for Resident 43. CNA 1 stated he saw Resident 43 eating the food and did not attempt to stop the resident. CNA 1 stated he did not enter the room because he was busy. CNA 1 further stated Resident 43 then vomited about 30 minutes later and that was when he notified RN 2 that Resident 43 had eaten the wrong texture food. On 4/30/2024 at 11:03 AM, during an interview, the DSD stated the facility policy indicated that food brought in by family should be shown to the charge nurse or RD prior to giving it to the resident. The DSD stated when CNA 1 knew Resident 43 was eating the wrong diet, he should have gone in and reminded the resident and his family that the resident was eating the wrong food. Resident 43 had difficulty swallowing, choking could be very imminent, and the food could go to the lungs. During a phone interview on 5/1/2024 at 12:26 PM, Family Member (FM) 1 stated he called the facility and received permission to bring in food for Resident 43. FM 1 stated he brought in chicken quesadillas for Resident 43, and no one educated him on any special diet or texture that Resident 43 was to receive. A review of the facility's policy and procedure (P&P) titled, Food for Residents from Outside Sources, reviewed 1/18/2024, indicated food brought in from outside the facility kitchen for residents' consumption would be monitored. This was done to measure the effectiveness of this intervention in residents with low food intake, to be sure the food was within the guidelines of the diet order, and to better assess nutrient intake. Nursing and/or Admissions would provide the family of new admits with the information sheet, Bringing in Food for A Resident (Section 6, page 6.24). The P&P indicated the following was to be done to ensure the above was accomplished: -Food brought in from outside the facility for a resident would be first shown to the Charge Nurse for approval that the food was within the diet order (therapeutic and texture). If there were any questions, the Nurse would consult with the FNS Director or the Facility Registered Dietitian. -The Nurse would alert the resident's CNA to the food brought in. The CNA would be responsible for recording the food and the amount consumed, in accordance with the facility meal percentage documentation standard.