**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of eight sampled residents' (Resident 1) food consistency and texture brought in by Resident 1's son on 9/18/23 was allowed and in compliance with her mech soft, finely chopped diet being the food was fed to the resident, and that Resident 1 was assisted, supervised, and monitored for choking when eating. The facility failed to ensure: 1.There was a system in place to check/screen food brought into the facility from outside for consistency and texture to match that which the physician had ordered.2.The physician's order was followed to monitor choking signs and symptoms while feeding the resident.3. Certified Nursing Assistant (CNA 1) did not feed Resident 1 while resident is drowsy on 9/19/2023. Resident 1 who had a diagnosis of dysphagia (difficulty swallowing) oropharyngeal phase (second stage of swallowing when the food goes from the back of the mouth to into the esophagus [tube that connects the throat to the stomach]) and had a choking incident a day prior (9/18/2023).As a result of these failures, Resident 1 had a choking incident at dinner time on 9/18/2023, when the resident was being fed a noodle soup brought in from outside the facility. The second choking incident the next morning on 9/19/2023 during breakfast time which resulted in Resident 1 being found in his room by LVN (Licensed Vocational Nurse) 1 unresponsive (not reacting or moving at all) with no pulse (the number of times the heart beats) and not breathing with egg custard on her bib and inside her mouth. Resident 1 expired at the facility on 9/19/2023.On 7/25/2025 at 4:43 pm, the Department called an Immediate Jeopardy Situation (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the facility's Administrator (ADM) and the Director of Nursing (DON) and the Director of Staff Development (DSD) related to the failures to ensure Resident 1 received care and services in accordance with Resident 1's physician's orders, care plan, and the facility's policies and procedures. The above failures resulted in Resident 1 being fed outside food on 9/18/2023 for dinner, which was not screened for consistency or texture resulting in a choking incident and not providing assistance with eating, as well as not monitoring for choking the next morning on 9/19/2023 during breakfast as per the physician's orders and care plan.On 7/26/2025 at 5:30 pm, the Department removed the IJ situation in the presence of the ADM, DON, and DSD, while onsite after the surveyors verified the facility's implementation of the IJ removal plan through observation, interview and record review, which included:1.On 9/19/2023 Resident 1 expired.2.On 7/25/2025 at 5:15 pm DON/designee (a person selected or designated to carry out a duty or role) audited the diets of 49 residents with ordered modified diets (eating plan designed to address specific nutritional needs or health conditions) for dinner service to determine any discrepancies in diet order and meal trays - none found.3.On 7/25/2025 at 7:30 pm and outside consultant provided an in-service (ongoing, job-related training provided to staff to enhance their knowledge and skills, ensuring they can deliver high-quality care to residents) to DON and ADM and later the consultant provided in-service training to licensed nurses and nursing assistants in the facility at 10 pm and 11 pm on:Understanding the importance of checking and inspecting food brought in from outside sources for residents. Verifying that outside food aligns with the resident's dietary orders and texture requirements. Identifying the risks of non-compliance with prescribed diets, including choking, aspiration, and medical complications. Communicating effectively with residents and families about dietary restrictions, food safety and associated risks. Providing education to family members who prepare to feed the resident, including proper feeding techniques and the risks associated with feeding. And recognizing and responding appropriately to suspicious or potentially unsafe food items. Also, understanding the importance of education family members about residents' special dietary needs. Identifying appropriate foods and feeding techniques for residents on various special diets (e.g., diabetic, low sodium, pureed and mechanical soft). Effectively communicating dietary restrictions, risks, and safe feeding practices to family members. Demonstrating how to train family members in proper feeding techniques that reduce risks such as choking and aspiration. Documenting education provided and family member understanding in resident records.4.On 7/25/2025 at 10 pm, ADM and DON created Log for Visitors who bring in food from the outside. The log included name of the resident, visitor/family member who is visiting, what food was brought/texture, Education training column if done, and/or modified and last column will have nurse initial to confirm and/or provide comment if necessary.5.On 7/26/2025 at 10:45 am, DSD created new sign was posted in English and Korean at front door and garage entrance for visitors with outside food to go to Nurses station when bringing in food. Attn: all family members & visitors. If you bring outside food or beverages for the residents, please do not provide them with until you have spoken with our licensed nurse and received permission. If any food/beverage brought in does not meet the resident's current diet, food will be denied and not allowed for safety concerns. Please head directly to the nursing station for screening. Thank you for your cooperation to ensure the safety of our residents.6.The Interdisciplinary Team (IDT - collaborative meeting where various healthcare professionals discuss and coordinate a resident's care plan), which involved Nurse Consultant, ADM, DON, Staff Developer (DSD), Social Worker, and Activities convened on 7/25/2025 at 7 pm to revise the food brought from home policy, includes education and training of family members on what food is appropriate and when feeding the resident.7.Starting 7/26/2025, all admissions, residents and families will be given a copy of this new policy and offered a handout on safe food handling practices.8.In-service training for staff license nurses started on 7/25/2025 at 10 pm on how to address food coming from outside and how nurses will check food brought in for patients. A total of 42 out of 67 nurses have been trained and will continue training until all staff nurses have attended by 7/28/2025. The four of the 67 nursing staff members who are on vacation or out on leave, will be in-serviced prior to them working on the floor.9.Ad hoc (for this purpose) Quality Assurance and Performance Improvement (QAPI, data-driven approach to improving the quality of care and services in healthcare settings) Committee, which includes Medical Director, ADM, DON, DSD, Social Services, and Activities will be conducted on 7/26/2025, a root cause analysis (RCA) will be completed to determine key issues for food brought from home, including communication breakdowns, inconsistent documentation, and training gaps in high-risk monitoring protocols/interventions. During a review of Resident 1's Record of Admission (undated), indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body), lack of coordination, muscle weakness (generalized), dysphagia (difficulty swallowing) oropharyngeal phase (second stage of swallowing when the food goes from the back of the mouth to into the esophagus [tube that connects the throat to the stomach]).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/7/2023, indicated, Resident 1 had severe cognitive (ability to think, understand and make daily decisions) impairment. The same MDS further indicated Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one-person physical assist when eating.During a review of Resident 1's History and Physical (H&P), dated 7/10/2023 indicated, Resident 1 did not have the capacity to understand and make decisions. The H&P further indicated the resident had left side weakness due to a cerebrovascular accident (stroke), and dementia (a progressive state of decline in mental abilities). During a review of Speech Therapist (ST) notes titled, Recertification & Updated Plan of Treatment, Dysphagia Therapy, certification period 8/6/2023 - 9/4/2023, indicated objective progress/short-term goals' Patient will safely swallow mechanical soft and thin liquids, successive swallows using lingual sweeps/re-swallow, rate modification, bolus size modification, hard throat clear/re-swallow techniques/precautions with 80% of attempts and with 20% verbal cues in order to decrease s/s (signs and symptoms) of oral and/or pharyngeal dysphagia. The same ST notes indicated to please Resident 1 in an upright posture during meals and up to 30 minutes after meals. During a review of Resident 1's physician's orders dated 8/25/2023 indicated an order for mechanical soft finely chopped diet (foods that are modified in texture to be easier to chew and swallow, i.e., ground, chopped or mashed) with thin liquids.During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers when there is a change of condition among the residents) progress note dated 9/18/2023, indicated the resident had an incident of choking at dinner time (at 5:30 pm), requiring the Heimlich maneuver (a first-aid procedure used to treat choking by dislodging a foreign object from a person's airway) to be performed in addition to a finger sweep (a first aid technique used to remove a visible foreign object from a choking victim's mouth or throat) of mouth and suction of oropharynx (middle part of the throat, behind the mouth, soft palate [the back muscular part of the roof of the mouth], the side and back walls of the throat, the tonsils, and the back one-third of the tongue), to remove the food and clear the airway.During a review of Resident 1's physician's orders dated 9/18/2023 at 5:30 pm, indicated an order to have oral suction (procedure to remove mucus or saliva from a person's mouth when they are unable to clear it themselves through coughing or swallowing with a suction device) as needed and monitor every shift for signs and symptoms of choking.During a review of Resident 1's care plan for high risk for choking due to dysphagia and requiring assistance during meals but she wants to initiate eating by herself (undated), indicated an intervention of monitor for signs and symptoms of aspiration (the inhalation of food, liquid, or other material into the lungs, instead of the esophagus and stomach) such as coughing, trouble breathing, choking, wheezing, etc. and Restorative Nurse Assistant (RNA, a specialized certified nursing assistant, CNA, who is trained to help patients regain or maintain their physical abilities and independence) if needed. During a review of Resident 1's Nursing Assistant Activities of Daily Living (ADL, fundamental self-care tasks that individuals perform independently to maintain their well-being and independence such as eating and dressing) flow sheet for September 2023 indicated the resident needed supervision (oversight, encouragement, cueing) with one person physical assist for breakfast and lunch and was dependent (full staff performance) at dinner times., indicating a discrepancy in the amount of help the resident needed during the meal times. Further review of the same ADL flow sheet indicated no entries for breakfast on 9/19/2023, lunch and dinner were strike through and indicated expired 9/19/2023.During a review of Resident 1's Nursing Notes dated 9/19/2023 at 8:30 am, the note indicated CNA passed breakfast tray at 7:20 am. Helped the resident get up in bed in sitting position. resident had no SOB (shortness of breath) or respiratory distress (difficulty breathing, often involving rapid, shallow breaths or gasping), no cough, no complaint of pain, no facial grimacing during the passing the breakfast tray. When charge nurse went to give resident her morning medications around 7:35 am, the resident was found with yellow face, lips were not blue or purple in color, closed eyes, unresponsive to verbal and tactile (touching) stimuli, with soft egg pudding spilled on her bib. Charge nurse stated he didn't hear any coughing sounds or sounds of choking this morning.resident is unresponsive, no pulse, no breathing noted. removed about one tablespoon of visible soft egg pudding from mouth and provided oral suctioning nothing came out. started oxygen at 15 liters per minute via non-rebreather mask (an oxygen delivery system used during emergencies to deliver a high concentration of oxygen) and called 911 (universal emergency number) . paramedics called time of death at 7:59 am.During a review of Resident 1's autopsy report signed 4/2/2024, indicated date of death [DATE] and date of autopsy 9/21/2023, the report further indicated the cause of death asphyxia (a condition where the body is deprived of oxygen, leading to potential loss of consciousness and even death) resulting from obstruction of airway passages by food product, manner of death accidental.During an interview with CNA 1 on 7/24/2025 at 12:33 pm, she stated on that day (9/19/2023), she saw Resident 1 was sleeping so she put the tray to the side of the bed and went to her other residents to feed them. She stated when she returned to Resident 1's room, she tried to wake Resident 1 up and Resident 1 opened her eyes. CNA 1 stated she gave her (Resident 1) a spoonful of the egg (pudding), and then she (Resident 1) shut her eyes again. CNA 1 further stated she tried to wake Resident 1 again and then she called the charge nurse because Resident 1 was not swallowing. CNA 1 stated she didn't know of the choking incident a day before, if she knew she would not leave Resident 1 alone to eat. CNA 1 stated that she was present. However, there was no documentation to support her report nor was there any witness that confirmed that CNA was present in the room.During an interview with Licensed Vocational Nurse (LVN) 1 on 7/24/2025 at 12:47 pm, LVN 1 stated that at the beginning of the shift, huddle (a brief, structured meeting held by nurses and other healthcare professionals, usually at the start of a shift, to discuss patient care, safety concerns, and workload distribution) is completed between the oncoming and off-going shifts. After the huddle, LVN 1 then checks the communication notes (are the written or electronic records used by nurses and other healthcare professionals to document and share important information about a resident's condition, care, and progress) for events that may have occurred overnight and informs CNAs about safety instructions involving the residents they are assigned to, such as residents at high risk for falls and aspiration risks. LVN 1 stated that for residents who have a diagnosis of dysphagia or aspiration risk, nursing staff check the diet orders to ensure that they are receiving the appropriate diet and place a sign above their bed. If a resident has a history of choking, LVN 1 stated that the resident is monitored closely to ensure that they are swallowing ok because they are now at increased risk for choking and placed in a feeding program where the RNA assists or monitor them during meals. LVN 1 stated that the families of residents at risk of choking must be educated, and all food brought in carefully screened to ensure that it is compliant with the ordered diet, otherwise notify the supervisor and schedule an Interdisciplinary Team (IDT - collaborative meeting where various healthcare professionals discuss and coordinate a resident's care plan) meeting.During a follow up interview with LVN 1 on 7/24/2025 at 2:52 pm, LVN 1 stated that Resident 1, was not on the feeding program, even though she was an aspiration risk, but the facility staff monitored her because she slept most of the time and did not like to participate in activities. LVN 1 stated that on 9/19/2023 while reviewing the communication notes, they learned that Resident 1 had a choking incident which required staff to perform a Heimlich maneuver on her. LVN 1 finished reviewing the notes and started looking for CNA 1 (who was assigned to Resident 1) to inform her about the incident and to be extra cautious. LVN 1 stated that when he walked in Resident 1's room, Resident 1 was noted to be in bed and sitting upright and appeared to be yellowing. LVN 1 stated that Resident 1 was not responsive and was not breathing so he went to look for his supervisor to assist. LVN 1 stated that many staff came to the room to assist with Resident 1 and that one of the staff (does not recall whom) swept (a first aid technique used to clear an obstructed airway in an unconscious person by using a finger to remove a visible object from the mouth or throat) her mouth. LVN 1 stated that cardiopulmonary resuscitation (CPR, a medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered cardia arrest) was not performed because Resident 1 was a Do Not Resuscitate (DNR, order is a medical order instructing healthcare professionals not to perform CPR if a person's heart stops or they stop breathing).During a concurrent telephone interview and record review of Resident 1's nursing notes with Registered Nurse (RN) 1 on 7/24/2025 at 3:57 pm, RN 1 stated that she recalled a staff member informing her that Resident 1 was unresponsive, so she rushed to the room and found that Resident 1 was unresponsive and was not breathing. The breakfast tray was in the room at the bedside of Resident 1. RN 1 stated that when she checked Resident 1's mouth, she (RN 1) found about two tablespoons of food residual which appeared to be a yellow egg pudding. RN 1 confirmed that leaving food in a resident's mouth or not supervising them could result in a resident choking. RN 1 stated that when a resident chokes, that food blocks their airway depriving them of oxygen and may result in death. RN 1 confirmed that Resident 1 had an order for aspiration monitoring which must be completed at every meal or anytime anything is placed in the mouth.During the same telephone interview RN 1 stated that she did not personally see the resident eat but found out from the CNA that she (CNA 1) had taken the tray to Resident 1 and fed Resident 1 a little because she appeared (Resident 1) to refuse the food. RN 1 stated she does not recall if the resident was an aspiration risk and was not aware that the resident had a choking incident the day before. RN 1 further stated staff need to make sure that they (facility staff) do not leave a resident with food in her mouth, resident could be at risk for aspiration which may result in a blocked airway and result in death.During an interview with the ST on 7/24/2025 at 4:58 pm, ST stated that dysphagia oral pharyngeal phase required a lot of queueing and cannot clear the mouth of residual. She stated that training included reminding the residents to sweep their mouth but if they are not at that point, then supervision is required.During a concurrent interview and record review on 7/25/2025 at 11:23 am with DON (Director of Nursing), Resident 1's progress notes, physicians orders and care plans reviewed as above. The DON verified there was no documentation in the resident's records indicating the CNA stayed in the room to monitor the resident after passing the trays and positioning the resident to eat on 9/19/2023 at 7:20 am. DON stated resident should be fully awake, if the resident is drowsy staff should stop the feeding.During an interview with ADM on 7/25/2025 at 2:19 pm, he stated that the facility talked about the post incident of choking in 9/2023 but didn't know if the facility documented it. He also stated that there is no policy specific to the outside food being brought in for the residents that is on a specialized diet for screening the food to comply with the diet ordered.During an interview with DON on 7/25/2025 at 3:05 pm, she stated that there was no specific facility policy at this time (time of interview) to address the process when residents or family members bring in outside food. She stated that a system and a policy will be added to include IDT must be implemented, a care plan initiated, and an order placed if resident or family bringing outside food.During the same interview and record review of the facility policy for Resident Nutritional Services and Assistance with Meals dated 6/2025, were the exact same policies that were used and active at the facility in September 2023.During an interview with CNA 4 on 7/25/2025 at 4:14 pm, he stated family should not bring food from outside.During an interview with LVN 4 on 7/25/2025 at 4:17 pm, he stated that when a family brings food from home, they need to check the chart for the diet, check the food and inform the facility if they bring in a different diet. He stated that he was not aware about an order should be entered in the resident's chart about food brought from outside. He stated that he was not sure about making a care plan for food brought from home. He further stated that he would have to check with the supervisor because he was new to the facility. LVN 4 also stated he was not aware of the facility of having a policy of having an IDT and care planning when family will be bringing food.During an interview with the Medical Director (MD) for the facility on 7/26/2025 at 9:58 am, MD stated that residents diagnosed with dysphagia must have Speech Therapy (ST) consult for evaluation, treatments, and recommendation on the appropriate diet as bedside nursing is not enough. MD stated that food brought in by family from outside must adhere and be consistent with residents ordered diets. MD stated that residents on aspiration risk must be monitored by nursing not only during meals, but also at any point that a resident is consuming anything orally which includes snacks, candy, etc. the MD stated that it was really important to have a policy and procedure on dysphagia, aspiration precautions, and outside food to ensure resident safety.During a review of the facility's policy and procedures (P&P), titled, Resident Nutritional Services, reviewed June 2024 and the active P&P during the time of the incident, the P&P indicated, Each resident shall receive the correct diet, with preferences accommodated as feasible and shall receive prompt meal service and appropriate feeding assistance.During a review of the facility's P&P, titled, Assistance with Meals, reviewed June 2024 and the active P&P during the time of the incident, the P&P indicated, The facility shall provide assistance for all patients with meals in a manner that meets the individual needs of each patient. Ensure that all patients are assisted with meals according to physician's orders and preferences. Nursing staff and/or Feeding Assistants will serve the patient trays and will help patients who require assistance with eating. Patients who cannot feed themselves will be fed with attention to safety, comfort and dignity.