**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews for six (6) residents and one (1) of three (3) of the six (6) residents with an active diagnosis of Dysphagia, it was determined that the facility's staff failed to ensure that Resident #1 was provided with adequate monitoring during meals, had a physician order to provide close supervision while eating, ensured speech documentation contained accurate information related to diet and liquid consistency, completed speech recommendations following a Modified Barium Swallow Study that showed laryngeal aspiration and failed to implement special dietary instructions for the resident whose diagnoses include oropharyngeal dysphagia. Subsequently, these failures resulted in the resident choking on food while eating alone in his room.During this survey an Immediate Jeopardy (IJ) was identified on July 2, 2025, at 2:14 PM at 42 CFR 483.25 (d)(2), F684, for Resident #1, with an active diagnosis of Oropharyngeal Dysphagia, who choked on food while eating alone in his room on June 25, 2025, at approximately 5:00 PM. The facility's Administrator submitted a corrective action plan to the Survey Team that was accepted on July 2, 2025, at 11:02 PM. The Survey Team verified implementation of the corrective plan while onsite and the Immediate Jeopardy was lifted on July 10, 2025, at 6:45 PM.The findings included:An undated facility policy titled ‘Out of Facility Guidelines' documented, in part: To protect and safeguard the safety and health state of the resident during out of facility activities and Give necessary instructions for special care such as dietary restrictions, fluid requirements.An undated facility policy titled ‘Gastrostomy Tube (GT) Feeding for Resident on Pureed, Mechanical or Regular Diet' documented, in part: GT feeding and oral diet will be administered per physician/dietitian orders and under close interdisciplinary monitoring and Monitor for signs of aspiration (coughing, choking, wet voice) or difficulty chewing/swallowing.An undated facility policy titled ‘Communication With Physicians' documented, in part: When a resident returns from consultation, the nurse will inform the attending physician or NP (Nurse Practitioner) of the recommendation for validation. Based on the validated recommendation, new orders are transcribed into the resident's medical record and a progress note is created to document the consultation, the recommendations, and physician's/NP's validation. A follow-up appointment is scheduled by the unit secretary if indicated.A review of the Resident #1's medical record revealed:Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included: Oropharyngeal Dysphagia, Gastrostomy on Tube Feeding, Aphasia, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Congestive Heart Failure and Gastroesophageal Reflux Disease.A care plan dated 03/15/24 documented in part, Focus: The resident requires tube feeding r/t (related to) Dysphagia, Swallowing problem. Goal: The resident will remain free of side effects or complications related to tube feeding through review date. Interventions: Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) of: Aspiration.A care plan dated 03/26/24 documented in part, Focus: [Resident's name] is at risk for Ineffective Airway Clearance Hx (history) of Dysphagia Oropharyngeal phase.Goal: Resident will maintain airway patency. Interventions: Evaluate secretions; Monitor for signs/symptoms of dysphagia; Monitor Resident's ability to expectorate secretions; Position Resident upright.A care plan dated 03/26/24 documented in part, Focus: The resident has nutritional problem r/t (related to) Dysphagia. Goal: The resident will comply with recommended diet for weight reduction daily through review date. Interventions: Monitor/document/report PRN any s/sx of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Appears concerned during meals.A care plan dated 03/26/24 documented in part, Focus: The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t Stroke. Goal: The resident will maintain current level of function in (Specify) through the review date. Interventions: Assess functional level, Therapy referrals . Note changes in functional level; Eating: Setup; The resident requires assistance to [from] staff to eat.A care plan dated 04/23/24 documented in part, Focus: The resident has GERD (Gastro-Esophageal Reflux Disease) r/t poor cardiac sphincter control. Goal: The resident will remain free from discomfort, complications or s/sx related to dx (diagnosis) of GERD through review date. Interventions: Avoid lying down for at least 1 hour after eating. Keep HOB (head of bed) elevated. Encourage to stand/sit upright after meals. Avoid overeating. Provide small frequent meals rather than 3 large ones. Encourage the resident to take their time eating. Encourage resident to avoid [NAME] [sodas]. Monitor/document/report PRN s/sx of GERD: increased salivation, swallowing problems, Dysphagia.A care plan dated 06/13/24 documented in part, Focus: The resident has Congestive Heart Failure. Goal: The resident will verbalize less difficulty breathing (Dyspnea) and be more comfortable through the review date. Interventions: Offer small frequent feedingsA Dietitian progress note dated 01/21/25 at 22:06 (10:06 PM) documented in part, Resident will frequently order takeout meals or purchase snacks from the facility gift shop, as well.A Nurse Practitioner Health Status Note dated 01/21/25 at 21:47 (10:47 PM) documented in part, Seen and examined at the request of nursing team to address clinical change noted today-he appeared weak, unable to swallow. Assessment: Dysphagia, Generalized Weakness.Plan: he was sent out 911 (emergency number for police, fire or medic) to R/O (rule out) CVA (Cerebrovascular Accident).A Modified Barium Swallowing study dated 01/24/25 at 11:58 AM performed at a local hospital documented in part, Impression: Intermittent silent versus sensate aspiration of mildly thick liquids demonstrated. Penetration seen with moderately thick liquids. Please see the speech pathology report for full details.A Hospital Discharge summary dated [DATE] documented in part, Suspected TIA (Transient Ischemic Attack)/Stroke, with baseline dysarthria and dysphagia (uses PEG (Percutaneous Endoscopic Gastrostomy tube) but can tolerate some [food and drink] PO (by mouth/oral). SLP (Speech Language Pathology) evaluation: Must repeat MBSS (Modified Barium Swallow Study) in 6 weeks. Can start regular diet w (with) moderately thick liquids, will keep tube feeds a reduced rate to ensure optimal caloric intake. For PO Diet; Regular diet/no dietary restrictions, Food/Fluid: moderately thick liquids, Avoid: Large sips/bites, Patient must utilize single sips or about 10cc (cubic centimeter, equivalent to one milliliter). No straws, sit upright, small bites, slow pace. Follow up Modified Barium Swallow study in 6 weeks (~ (around) 03/07/2025).A physician's order dated 01/25/25 documented, Aspiration Precautions every shift.A physician's order dated 01/25/25 documented, Lovaz Oral Capsule 1 GM (gram) Give 2 capsule by mouth two times a day for Hypertriglycerimia Please Provide liquid if available.It should be noted that Resident #1's medical record revealed 11 additional medications that could be administered by mouth, but were ordered on 01/25/25 by the physician to be administered via the resident's G-Tube as documented below: Acetaminophen 30 ML (milliliter) oral liquid, Atorvastatin Calcium 80 MG (milligram) oral tablet, Calcium Plus Vitamin D3 600-10 MG-MCG (microgram) oral tablet, Eliquis 5 MG oral tablet, Famotidine 20 MG oral tablet, Gabapentin 100 MG oral capsule, Jardiance 10 MG oral tablet, Metformin HCl (Hydrochloride) 1000 MG oral tablet, Metoprolol Succinate ER (extended release) 50 MG oral tablet, Polyethylene Glycol 17 GM 3350 powder and Spironolactone 25 MG oral tablet. A physician's order dated 01/25/25 documented, Repeat Modified Barium Swallow Study (MBSS) in 6 weeks. A physician's order dated 01/27/25 documented, Modified Barium Swallow Studies on 3/7/25 at 9:30 AM @ (at) [Hospital's name] Radiology Dept (Department). It should be noted that the repeat MBSS was scheduled as ordered and the appointment was documented in the resident's record. A physician's order dated 01/27/25 documented, Regular diet Regular texture, Honey/Moderately Thick consistency, No dietary restrictions. A physician's order dated 01/27/25 documented, No straw, sit upright, small bites and slow pace while eating and drinking every shift. It should be noted that Resident #1 was ordered a Regular Diet, no dietary restrictions, while medications that could also be taken orally were ordered to be administered through his Gastrostomy Tube.A physician's order dated 01/27/25 at 11:15 AM documented, Speech Consult.A care plan dated 01/27/25 documented in part, Focus: The resident has a swallowing problem r/t difficulty with thin liquids. Goal: The resident will have no choking episodes when eating through the review date. The resident will have clear lungs, no signs and symptoms of aspiration through the review date. Interventions: All staff to be informed of resident's special dietary and safety needs. Alternate small bites and sips. Use a teaspoon for eating. Do not use straws. Assistive device (i.e. (such as) Sippy cup) for liquids. Check mouth after meal for pocketed food and debris. Report to nurse. Provide oral care to remove debris. Instruct resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly. Monitor shortness of breath, choking. Monitor/document/report PRN any s/sx of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Appears concerned during meals. Refer to Speech therapist for Swallowing Evaluation.A Nurse Practitioner Late Entry Health Status Note dated 01/28/25 at 22:15 (10:15 PM) documented in part, readmission visit following a brief hospitalization where he was admitted to r/o (rule out) CVA (Cerebrovascular Accident). He underwent work up and was found to have possible silent aspiration on thin liquid and was instructed to [have] moderately thickened all liquids but was cleared for regular meals.A Speech Therapy Evaluation and Plan of Treatment with a Certification Period of 02/05/2025-05/05/2025 revealed an Initial Assessment note dated 02/05/25 that documented in part, Gastrointestinal Disrupted Swallow = 7, that indicated Resident #1 had a high level of disruption or difficulty with swallowing. The Speech Therapy treatment note also documented the reason for therapy was Pt (patient) presents deficits in cognitive linguistic and swallowing deficits and Diagnosis: Dysphagia, oropharyngeal phase and Treatment of swallowing dysfunction and/or oral function for feeding; Eval (evaluation) of oral and pharyngeal swallow function; Recommended: Thin liquids (No modifications).It should be noted that the findings from the Modified Barium Swallow Study completed on 01/24/25 revealed Intermittent silent versus sensate aspiration of mildly thick liquids, subsequently Resident #1 was ordered to drink only liquids with moderately thick consistency.A Nurse Practitioner Skin/Wound Note dated 02/03/25 at 22:17 (10:17 PM) documented in part, I addressed the issue of Dysphagia and reiterated to the staff that all meds and supplemental meal - should be given via (through) feeding tube, all liquids should be moderately thickened.Further review of the facility's Speech Therapy Evaluation and Treatment notes from 02/06/25 - 04/01/25 revealed that the Speech Therapist documented in part, Pt is on mech (mechanical) soft textures with nectar thick liquids and Current Drinks = Thin Drinks; Current Foods/Solids = Regular/Easy to Chew Foods.It should also be noted that nectar-thick liquid has a level of thickness between thin liquid like water, but not as thick as honey-thick liquid which was ordered for the resident as of 01/27/25 due to his difficulty with swallowing.A Nurse Practitioner Skin/Wound Note dated 02/17/25 at 22:58 (10:58 PM) documented in part, All liquids ‘MUST' be thickened moderately, only regular meals should be taken by mouth, this has been discussed with the resident and staff at bedside.A Diagnostic Radiology Exam dated 03/06/25 at 12:29 [PM] documented in part, [Resident #1's name]. Reason for Exam: XR (x-ray) Modified Barium Swallow MBS w (With) SCT (Swallowing Competence Test) NK (Not Known), Report/Clinical Indication: Dysphagia. History of silent aspiration. Technique: Thick, pureed and solid consistencies of barium were administered to the patient in the upright/lateral position. Fluoroscopic images were videotaped for imaging assistance provided to the speech pathologist. Findings: Silent laryngeal aspiration was noted with mildly thickened, thick nectar barium utilizing a cup, straw and or chin tuck. Note, thin consistency barium send was not trialed. Impression: Laryngeal aspiration. Please refer to speech pathology for further evaluation.A [Skilled Nursing Facility's Name] Consultation Form dated 03/06/25 and signed by the consultant Speech Therapist documented in part, [Resident #1's name], Report Requested Regarding: Modified Barium Swallow, Findings: Silent Aspiration of mildly thick liquids. [NAME] tuck intermittently helped with silent aspiration; thin liquids not trialed. Continue to recommend a regular diet with moderately thick liquids. Recommend speech therapy to complete swallow exercises and practice chin tuck. Follow up MBSS (Modified Barium Swallow Study) in 8 weeks. May have thin liquids (water) via spoon for effortful swallows.It should be noted that effortful swallows is a swallowing exercise used to strengthen the muscles involved in swallowing and improve swallowing efficiency. It involves consciously squeezing the throat muscles and swallowing with more effort than usual, often imagining a bolus (food or liquid) getting stuck and needing to be cleared).A Dietitian progress note dated 03/07/25 at 18:27 (6:27 PM) documented in part, Per recent consultation on 3/9/25 regarding MBS (Modified Barium Swallow) for this resident, the following recommendations were made: 1. Con't (continue) Regular diet with moderately thick liquids 2. SLP to complete swallow exercises & chin tucks 3. F/u (follow-up) MBSS in 8 weeks; Current diet: Regular with honey/moderately thickened liquids.A Nurse Practitioner Health Status Note dated 04/24/25 at 22:14 (10:14 PM) documented in part, The resident is known for drinking multiple cans of sodas.A care plan dated 04/25/25 documented in part, Focus: The resident refuses to eat/resists feeding r/t does not like [the] food [offered at the facility], dysphagia. Goal: The resident will not have weight loss. Interventions: Encourage the resident's family members to bring in favorite food items from home or favorite restaurant items; The resident needs encouragement/support to be independent with eating. Allow the resident to feed self if desired, regardless of skill; The resident needs privacy as meal time is messy.A physician's progress note dated 05/18/25 at 10:26 (10:26 AM) documented in part, Patient is aphasia [aphasic]. Oropharyngeal phase dysphagia. Aspiration precaution.A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of ‘13,' indicating the resident was cognitively intact. Eating- 09 that indicated the resident did not perform this activity; Swallowing/Nutritional Status- none of the above that indicated the resident had no signs or symptoms of possible swallowing disorder.A care plan dated 05/31/25 documented in part, Focus: [Resident's first name] has potential for alteration in nutrition r/t: 1. h/o (history of) swallowing difficulty, oropharyngeal dysphagia per diagnosis. Interventions: Monitor intake, tolerance of diet.A Dietitian progress note dated 05/31/25 at 04:16 (4:16 AM) documented in part, Diet Order Type: regular, regular texture, thin liquids.It should be noted that according to the result of the Modified Barium Swallow Study completed on 03/06/25 and the recommendation of the consultant Speech Language Pathologist, the resident was ordered a regular diet with moderately thick liquids.A Treatment Administration Record (TAR) dated 06/01/2025 - 06/25/2025 documented in part, No straw, sit upright, small bites and slow pace while eating and drinking every shift and revealed the facility's nursing staff indicated with their electronic signature that they were monitoring Resident #1 during all meals to ensure he had no straw, was sitting upright, had small bites at a slow pace while eating and drinking.A nursing progress note dated 06/25/25 at 16:14 (4:14 PM) documented in part, Resident received in bed in good spirit watching TV (television) at 3:40pm, alert and verbally responsive no acute distress noted.A physician's order dated 06/25/25 at 5:45 PM documented, Transfer resident to ER (Emergency Room) for Unresponsiveness.A nursing incident note dated 06/25/25 at 18:05 (6:05 PM) documented in part, Around 5:10PM, Supervisor was called to the unit due to change in one of the resident's conditions. Upon arrival the resident was met on the chair at the nursing station being assisted by other nursing staff. Resident was not fully responding, presented with some difficulty breathing. Charge nurse reported that resident came out of the room pointing to his mouth like something was stuck in his throat. Charge nurse reported that Heimlich Maneuver was done but no pieces came out of resident's mouth. Upon assessment, no object was seen in resident's mouth, but resident was noted with some drooling. Call was placed to 911 (emergency number for police, fire or medic) at 5:11PM and Code blue (facility's emergency announcement) was called . 911 instructed [facility staff] to lay [the] resident on the floor. CPR (cardiopulmonary resuscitation) continued until paramedic arrived on the unit at 5:20PM and took over the CPR. Upon assessing the resident's room, an open box of [fast food restaurant's name] chicken with remains [remaining] chicken pieces was [were] found at resident bedside, on the bed and on the floor.It should be noted that documentation revealed that Resident #1 was last seen by facility staff at 3:40 PM watching TV then not seen again until suddenly appearing in the hallway running towards the nurse's station at approximately 5:10 PM, after choking on food while eating alone in his room.An SBAR (Situation, Background, Appearance, Review/Notify) Communication Form dated 06/25/25 at 19:47 (7:47 PM) documented in part, The change in condition, symptoms, or signs observed and evaluated is/are: Altered level of consciousness, Unresponsiveness, Swallowing difficulty, Labored or rapid breathing.A nursing progress note dated 06/25/25 at 20:11 (8:11 PM) documented in part, Resident was observed coming down the hallway to the nursing station pointing to his mouth and holding his stomach around 5:10PM. When writer asked the resident what happened[,] the resident was unable to answer, but keep [kept] pointing to his mouth. Upon assessing resident['s] mouth nothing was seen. Writer immediately initiated Heimlich Maneuver with nothing coming out of the mouth.A nursing incident note dated 06/25/25 at 20:30 (8:30 PM) documented in part, Around 8:18pm, call was received from the detective, [Detective's name and telephone number], informing resident just expired at the hospital.A Nurse Practitioner's note dated 06/25/25 at 22:23 (10:23 PM) documented in part, I was called urgently to come to [nursing unit] earlier this evening to asses[s] the resident who was unresponsive, I arrived on the unit around 5:15pm and found the resident lying on the floor in front of the nurse station, he was unresponsive and had no pulse. A review of a DC (District of Columbia) And EMS (Emergency Medical Services) Department's Patient Care Record dated 06/25/25 documented in part: [Resident #1's name], Pick Up: Nursing Home, Destination: [Hospital name], Dispatched as: ALS (Advanced Life Support)-Cardiac Arrest; Patient initially complained of choking and fell uncon (unconscious)/unresponsive. Two attempts made for intubation - unsuccessful. Patient airway is filled with bolus of food. Suctioning is only moderately useful. Airway patency unable to be obtained due to excessive boluses of food in trachea and throughout airway. A DOH (Department of Health) Notice of Discharge Transfer or Relocation Form dated 06/26/25 at 9:18 AM documented in part, [Resident #1's name] was transferred to [Hospital Name] due to choking/shortness of breath.A Facility Reported Incident [Intake Number: DC00013792] received by the State Agency on 06/27/2025 at 15:08 (3:08 PM) documented the following in part: History of CVA ([DATE]) w/ aphasia, dysphagia. Resident is taking all his medications via G-tube; however, his diet is regular texture, Honey/Moderately Thick consistency. On 06/25/2025, around 5:10 PM, the resident was noted by one of the CNA (Certified Nursing Assistant) in the hallway pointing at his mouth and holding his stomach; charge nurse was immediately called to address his concern. The Evening nurse stated that the resident was unable to answer any of her questions but kept pointing at his mouth. During her assessment, nothing was seen in the resident mouth. Heimlich Maneuver was immediately initiated, still no substance was coming out of the resident mouth, except drooling, and resident became unresponsive. Code Blue was called O2 (oxygen) and CPR (cardiopulmonary resuscitation) initiated and 911 called. The resident was transferred to [Hospital name] at 5:50 PM for further evaluation. Upon assessing the resident's room, an open box of [fast food restaurant's name] chicken with remaining pieces of chicken was found at resident bedside, on the bed and on the floor. During a telephone interview conducted on 06/30/25 at 2:15 PM, Employee #6 (Speech Language Pathologist, SLP) stated that, He (Resident #1) was being seen for dysphagia. He had a feeding and a modified barium swallow that cleared him for his swallowing.It should be noted that the findings from the MBSS completed on 03/06/25 documented in part: Silent Aspiration of mildly thick liquids. Continue to recommend a regular diet with moderately thick liquids. Laryngeal aspiration.During a face-to-face interview conducted on 06/30/25 at 2:35 PM, Employee #5 (Director of Dietary/Dietitian) stated that, He was recently upgraded to regular texture, but cannot have thin liquids. There are four (4) types of Liquids: thin liquid, nectar thick, honey thick and pudding thick, which is the thickest. Honey is a little bit thicker than nectar. If [the order] just say moderately thick, [the] Speech Therapist will determine if nectar or honey then we would order from our vendor. I think we ordered nectar for him.It should be noted that Resident #1's prescribed liquid diet order was Honey/Moderately Thick consistency.During a face-to-face interview conducted on 06/30/25 at 2:42 PM, Employee #21 (Registered Dietitian) stated that, He was evaluated and in January was upgraded with precautions with little amounts at a time, chew properly and swallowing with honey consistency thickened liquid. But it's my understanding that the resident had food stuck in his airway which caused his demise and some chunks of food in his mouth. He may have been eating larger amounts of bites at a time.During a face-to-face interview conducted on 06/30/25 at 3:15 PM, Employee #22 (Licensed Practical Nurse, LPN) confirmed what she documented in her written statement during the facility's investigation stating that, Resident #1 was observed coming down the hallway to the nurse's station pointing to his mouth and stomach around 5:10 PM [on 06/25/25]. [The] resident was unable to answer when asked what happened but kept pointing to his mouth. I immediately performed the Heimlich [technique used to dislodge an object blocking a person's airway], but nothing came out of his mouth. We started CPR. They (other nursing home staff) said he was eating [fast food restaurant's name] chicken. He eats by himself, in his room all the time. He supposed to eat with thickener and small bites. I've never seen him when he's eating.During a face-to-face interview conducted on 06/30/25 at 3:27 PM, Employee #4 (Registered Nurse (RN), Unit Manager) confirmed what she documented in her written statement during the facility's investigation stating that, she was the evening nurse supervisor and received a call from [Unit name] that something was going on with [Resident #1's name]. I saw him at the nurse's station in a chair. The resident was not responding to name and presented with some difficulty breathing. The charge nurse reported that [the] resident came out of the room pointing to his mouth like something was stuck in his throat. He was on a regular diet with thickened liquids. Later after he left [the nursing home facility with paramedics] I saw a little piece of chicken in the hallway. Upon assessing the resident's room, an open box of [fast food restaurant's name] chicken that was almost finished, just maybe a little crumbs and bones left [was] found at the bedside, on the bed and on the floor [in the resident's room].During a follow-up face-to-face interview conducted on 07/01/25 at 10:10 AM, Employee #6 (Speech Therapist) stated that, I looked at swallowing, but it was not a concern. I know he was cleared for a regular diet. He did have coughing sometimes [when eating]. Honey [thick] versus Nectar [thick] is sometimes used interchangeably, but it is not the same thing. The recommendation from the Modified Barium Swallow Study on 03/06/25 for the chin-tuck [exercises], I never saw that recommendation. A chin-tuck is very vague because it's dozens of swallowing exercises. I didn't work with him on that; I really didn't see that there was a need for that [chin-tuck swallowing exercises].During a face-to-face interview conducted on 07/01/25 at 10:50 AM, Employee #24 (Licensed Practical Nurse, LPN) stated that, He was on tube feeding and he was [also] eating by mouth soft foods, regular diet and thickener for all the liquids - sometimes comes up on [meal] tray already thick like Nectar. He would eat by himself, he can set up his tray and did everything by himself.Employee #24 was asked about any special instructions for Resident #1 while eating and she stated that, Watch close because sometimes he would choke. He never ate in the Solarium (multipurpose/dining room), always in his room. We (facility staff) would just pass by his room when eating. His meds were crushed because I think he had swallowing problems, I don't know the reason; he had [an] order for it and was on a regular diet. I'm not aware of any swallow studies or recent stroke. It should be noted that Employee #24 was unsure why and was unaware that Resident #1 had the following instructions during meals: No straw, sit upright, small bites and slow pace while eating and drinking every shift. During a follow up interview conducted on 07/01/25 at 11:14 AM, Employee #4 (RN, Unit Manager) was asked about any special feeding instructions for Resident #1 and she stated that, He was [required] supervision to oversee. He received a regular tray (regular diet) and he just wanted you to put the tray in front of him. He always ate in his room, he didn't socialize. He preferred his medications through his feeding tube. He had a Stroke some time ago in January and we sent him out [to the hospital]. He can have regular meals with thickened liquids, no straw. For the Modified Barium Swallow Study, we called but they said it was too early to schedule, and we called back. The unit clerk has her own book to track appointment scheduling, I don't know where she keeps it [resident appointment book]. For the consult recommendations, we hand deliver a copy of the Speech Therapy consult recommendations, but not sure if that was done. The chin-tuck (swallowing exercises) is done by the Speech Therapist, not by the nursing staff.During a face-to-face interview conducted on 07/01/25 at 11:25 AM, Employee #25 (Certified Nursing Assistant, CNA) stated that, Resident #1 would feed himself and we would make sure food was warm. He would always eat in his room alone. He needed thick liquids but sometimes would buy his own Coke soda and I saw [had seen] him drinking it recently.During a face-to-face interview conducted on 07/01/25 at 11:30 AM, Employee #26 (CNA) stated that, He could feed and eat by himself. You can put the food there [at his bedside], but he wouldn't eat right away. He stayed in his room most of the time, so I never watched him eat. Sometimes we would find sodas and milk in his room.During a face-to-face interview conducted on 07/01/25 at 11:40 AM, Employee #23 (Registered Nurse, RN) confirmed what she documented in her written statement during the facility's investigation that stated, At 5:10 PM the resident from [room number] was noted to be running down the hallway pointing at his mouth. Upon assessment, nothing was noted in the [resident's] mouth. Heimlich maneuver was performed; nothing came out. 9-1-1 [was] called, Code Blue was initiated. We followed the instructions provided by the 9-1-1 operator, and started CPR until Paramedics arrived. Employee #23 was asked if there were any special instructions ordered for the resident while eating and she stated, He was on a regular diet. When I checked [entered the order for] moderate thick, [the word] honey came up [was selected]. I don't remember if I saw an option for nectar, that would mean the consistency should've been thick [like honey consistency].During a face-to-face interview conducted on 07/01/25 at 11:53 AM, Employee #3 (Nurse Practitioner) was asked about follow-up consult appointments and consult recommendations and he stated that, The nurse review the consult recommendations and let me know about it. I read the instructions, signed off and it goes back to the nurse. I agreed with the recommendations from the Modified Barium Swallow Study (MBSS) from 03/06/25 that Speech Therapy [should be] doing the chin-tuck (swallowing exercises). The unit clerk schedules the [follow-up] appointment. There's no new order because there was already a recommendation to have the follow-up [MBSS] done in eight (8) weeks, but I don't know if this [follow-up MBSS scheduled] was done. If it wasn't done, we would go off of what's already in place and the most recent assessment. Potentially the new follow-up [MBSS] could provide new information but wouldn't know if we don't have the new MBSS results. Diet orders are very specific so should be followed and goes specifically by what was written from the hospital discharge note and we would not change it.During a face-to-face interview conducted on 07/01/25 at 12:10 PM, Employee #27 (LPN) stated that, He was on a regular diet, fed himself, would eat in his room. We would leave the tray there for him. No special instructions for eating.During a face-to-face interview conducted on 07/01/25 at 1:15 PM, Employee #7 (Director of Rehab/Occupational Therapist) stated that, It's up to the [nursing home facility's] Speech Therapist to make a determination of what to assess based off of the consult recommendations.During a face-to-face interview conducted on 07/01/25 at 1:57 PM, Employee #13 (Unit Clerk) stated that, It [Modified Barium Swallow Study] was scheduled for July 21, 2025, at 9:00 AM. I started calling for that appointment on March 7, 2025. They said it was a little too early [to schedule] because they didn't have their schedule. The next call was placed on April 22, 2025, and they said they would give me a call back. I made the Unit Manager [Employee #4's name] aware. I finally got the appointment scheduled a week or two weeks ago.A review of Employee #13's resident appointment book revealed a handwritten entry on 07/21/25 that documented, [Resident #1's name], B. (Barium) Swallow [Hospital name] 9:45 [AM].During the same interview with Employee #13 (Unit Clerk), Employee #4 (Unit Manager) stated that, I knew there was a delay, the unit clerk mentioned it to me that she was having problems getting the appointment. I docume

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, staff and resident interviews for one (1) of 59 sampled residents, facility staff failed to ensure that adequate supervision was provided to Resident #21, as evidenced by documentation in the residents medical records of staff observing Resident #21 smoking and possessing smoking paraphernalia while using supplemental oxygen continuously and the surveyor observing the facility staff failing to provide one to one monitoring of Resident #21 as instructed by physician orders on multiple occasions during the survey. Resident #21. Due to these failures, an immediate jeopardy situation was identified on July 9, 2024, at 4:36 PM. The facility submitted a plan of action to the survey team that was onsite at 1:12 AM on July 10, 2024, and the plan was accepted. The survey team validated the facility's plan of removal on July 12, 2024, and the immediate jeopardy was lifted on July 12, 2024, at 3:59 PM. After removal of the immediacy, the deficient practice remained at a potential for more than minimal harm for the residents at a scope and severity of D. The findings included: According to the National Center on Aging and the American Lung Association, .While oxygen itself is not flammable, it can make flammable materials ignite faster and burn more rapidly. While using supplemental oxygen, always stay at least five feet away from an open flame or heat source. You should also never smoke (cigarettes, vape pens, or otherwise) while using oxygen, and prohibit smoking nearby. https://www.ncoa.org/adviser/oxygen-machines/home-oxygen-safety/ A review of the facility's policy titled Oxygen Administration-Nasal Cannula that was undated [#NSD04-12] documented in part, Oxygen is administered according to the physician's orders and in observance of all safety precautions . post No smoking sign on the door and in the resident's room-oxygen is highly combustible. A review of the facility's policy titled One-to-One Monitoring for Residents was undated and documented the following: One-to-one monitoring is a type of care that can be provided to residents at (facility name abbreviation) to ensure their safety whenever they are alone especially in their room. One-to-one monitoring can help staff prevent falls, redirect residents from harmful actions. A review of the facility's policy titled Smoke Free Environment with a review date of 01/03/24 documented the following: Smoking is prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area is posted with signs that read No Smoking or with the international symbol for no smoking. Resident #21 was admitted to the facility on [DATE] with multiple diagnoses including, Chronic Obstructive Pulmonary Disease (COPD), Shortness of Breath, Heart Failure, and Bipolar Disorder.On 07/02/24 at 10:54 AM Resident #21 was observed in her room lying in bed with oxygen in use. At the time of the observation, Resident #21 stated I do smoke, but I haven't been outside to smoke. I don't smoke in the room. It should be noted that there was no one-to-one (1:1) staff monitoring Resident #21 at the time of the Surveyor observation. Review of Resident #21's medical record revealed the following: A Smoking assessment dated [DATE] indicated that the resident was an unsafe smoker. A physician order dated 03/01/24 directed, Oxygen at 2 liter per minute via nasal cannula continuously every shift for COPD (chronic obstructive pulmonary disease) A nursing progress note dated 03/27/24 at 5:10 PM documented Social worker was informed by security staff that [Resident #21] was smoking in the facility on 3/23/2024 and on today 3/27/2024 .it appeared she was in the crystal room in a corner smoking with an oxygen tank on the back of her chair. A nursing progress note dated 03/28/24 at 11:25 PM documented, [Resident #21] came to unit twice with cigarettes. Charge nurse took the cigarettes from her. Security police reported her twice that she was trying to smoke in the living room. Resident educated that she is on oxygen and the risks explained to her. Continue on O2 (oxygen) therapy at 2L (liters) via (by) nasal cannula with SPO2 (Saturation of peripheral oxygen) 96%. Continue on hourly monitoring, resident propel herself throughout the building. There was no documented evidence in the resident medical record of new interventions or orders after these incidents. A social services progress note dated 04/19/24 at 10:32 AM documented, SW (social worker) smelled the odor of smoke around 10:12 AM, coming from the far-left corner of the [NAME] room and observed [sitting] in her wheel chair smoking a cigarette. Resident had lighter and plastic bag with portions of other cigarettes. Resident agreed to give the smoking items to the social worker, and was counseled on the dangers of smoking and jeopardizing the health and safety of all persons in the building. A health status progress note dated 04/20/24 at 10:21 PM documented, At around 10:10 PM the writer was alerted by security guard that the resident was seen downstairs smoking a cigarette while on oxygen. A nursing progress note dated 04/24/24 at 3:25 PM documented, [Resident #21- who resides in room ## A] assisted with care, out of bed and propel self around unit. Continue on oxygen at 2liters, [Resident #21] was found in another resident bathroom in room ## trying to smoke. Writer found three cigarettes and a lighter with resident, took it to social worker. And later [Resident #21] went to another resident room ##, the resident in ## gave [Resident #21] another cigarette and was asking for lighter and in the process writer took the cigarette and made social-worker aware . It is important to note that following the unsupervised smoking incidents reported on 04/19/24, 04/20/24, and 04/24/24, staff began documenting on an hourly log that the resident was on one-to-one monitoring as of 4 PM on 04/26/24. A care plan dated 04/29/24 documented in part, Focus-[Resident #21] has a behavior on oxygen . Interventions- Resident on One-to-One monitoring, involve psych[iatric services] and psycho-therapy, resident was transfer room . closer to nursing station A social services progress note dated 04/29/24 at 3:28 PM documented, Resident continues to violate regulatory and facility smoking policies. Resident acknowledges she is unable to control urges to smoke, even around her oxygen . Staff reported she continued to smoke . Due to persistent involvement with smoking, resident is currently monitored by a 1:1 staff assigned as of April 26, 2024. Smoking observed . on 4/25/2024, 4/23/2024, 4/19/2024, and 3/27/2024. A physician order dated 05/06/24 directed, Resident is on one-to-one monitoring Q (every) shift to prevent resident from smoking while on oxygen. A review of the Quarterly Minimum Data (MDS) assessment dated [DATE] revealed that the facility staff coded the following for Resident #21: intact cognition, rejected an evaluation or care occurred 1-3 days, has no impairment in the upper or lower extremity, and receives oxygen therapy. A physician order dated 05/02/24, directed Target behavior: 1) Monitor for refusal of medications. 2) Refusal of care. #) Smoking while on continuous oxygen. A nursing progress note dated 05/2/24 at 1:25 PM documented, Resident was noted with cigarette stick on her and the CNA (certified nursing assistant) monitoring her retrieved it and gave it to the charge nurse, but she did not have lighter or matches on her . During an observation on 07/03/24 at 09:10 AM, Resident #21 was observed in her room without staff present or in proximity. The resident was lying in bed with oxygen in use. During a face-to-face interview on 07/03/24 at 9:10 AM, Employee #4 (Unit Manager 3 Blue) acknowledged there was no one-to-one staff present with Resident #21. During a face-to-face interview on 07/03/24 at 9:24 AM, Employee #2 (Director of Nursing) was made aware that the resident was observed without a one-to-one monitor. The employee then said that one-to-one monitoring means for resident safety we have to monitor the resident. The employee failed to explain why the one-to-one was not in place at the time of the surveyor's observation. Based on these findings, July 9, 2024, at 4:36 PM an Immediate Jeopardy (IJ) situation was identified. On July 10, 1:09 AM, the facility's Administrator provided a corrective action plan to the State Agency Survey Team that was accepted. The plan included: F-689 Immediate Jeopardy - Removal Plan 1. Immediate Action Taken - Resident # 21 was reassessed (smoking assessment) by the social worker as it pertains to smoking on 7/9/24 I. DON. ADON. and managers conducted rounds on all residents on oxygen for no smoking signs on 7/9/2024. All these residents who utilized oxygen have no smoking signs posted on the door and/or in room. II. The Care plan for resident #21 was updated by the manager and social worker on 7/9/2024. Based upon the smoking reassessment and her use of oxygen the resident #21 was on one-to-one monitoring, the care plan was updated to reflect (a)consistency of one- to - one monitoring (b)new smoking. Assessment completed 7/9/2024 (c)new smoking contract on 7/9/2024(d)Oxygen sign completed 7/9/2024. The Evening shift staff on the unit and the security on duty have been re-educated by DON, ADON regarding the one-to-one monitoring on 7/9/2024. The resident is to always have assigned staff on one to one. The monitoring nurse will document that she is on one to one on the treatment administration record. The individual assigned will sign the one to one hourly log in the room. Staff member must be monitoring one to one at all times. Resident #21 was re-educated by the DON regarding the danger of smoking when on oxygen 7/9/2024. She has signed a contract in the past; however, the contract has been updated and she has signed the contract dated today, 7/9/24 that she will not have any smoking paraphernalia on her person. III. The evening shift security staff have been re-educated by the DON on 7/9/2024 regarding smoking and the danger of smoking when on oxygen. Further they were instructed that if someone is observed smoking and on oxygen, they will contact the nursing supervisor immediately and ensure residents have no smoking items. All other security officers will be instructed on 7/10/2024. Any smoking paraphernalia found will be removed immediately. IV. DON, ADON, Nurse managers including all other supervisors will ensure that one to one monitoring is in place while performing their shift rounds starting on 7/10/2024. V. The roommate of Resident #142 who uses oxygen was relocated to another room on 7/9/2024 (room [ROOM NUMBER]) per resident request. All residents with oxygen were identified and none shared a room with a smoker. 2. Immediate Action Taken - Residents who smoke I. All residents who smoke are on a smoking list and have been advised on 7/9/2024 that while there are designated smoking areas the facility is a smoke free facility. Staff found no smoking items on residents #131, #1 and 167. Resident #142, turned in an empty pack of cigarettes. II. A review of the care plan conducted on 7/10/2024 for all residents who smoke will be updated to include residents will not have any smoking paraphernalia on their person or in their room. These items will be maintained at the security desk. III. The nursing staff who are on units with residents that smoke were re-educated on 7/9/24 by the DON, ADON on the smoking policy. All disciplines will be re-educated on the smoking policy by 7/10/2024. All other staff not on schedule to work will be re -educated prior to returning to work. IV. List of smokers will be updated to reflect current residents that smoke cigarette on 7/10/2024.The smoking list will be kept by the unit managers, security, social workers and administration. V. Each resident will be assigned a zip lock clear bag that would contain their cigarettes and lighters. Starting on 7/10/2024, these bags will be kept at the security desk. Assigned smoking aides/monitors will hand out one cigarette at a time and ensure that no resident keep/store smoking paraphernalia. Education will be provided by DON, ADON, and social worker on 7/10/2024. Assigned staff will light the cigarettes and keep the lighter. VI. To mitigate future smoking deficiency, the social worker will ensure that smoking policy is shared during the next schedules resident council and family council meetings. Robocall, letters or email will be used to inform family members of smoking policy on 7/10/2024. With resident permission, nursing managers, nurses, security will make random weekly rounds on residents that smoke cigarettes to ensure no smoking paraphernalia are kept in the rooms. Additional posting signs will be placed in the facility regarding smoking policy on 7/10/2024. A meeting will be held with residents 7/10/2024 reminding each of them of the contract they signed indicating discharge from the facility for smoking policy infraction. Corrective action completion date: 07/10/2024 Verification of the removal of the immediacy was performed by the survey team onsite on July 12, 2024, at 3:59 PM. Cross Reference- 22 B DCMR Sec 3211.1(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility's staff failed to protect a vulnerable resident from Resident #90. This was evidenced by Resident #90 being observed by staff kissing Resident #16 who did not have the capacity to consent. As a result of these failures, an immediate jeopardy (IJ) was identified on August 31, 2023, at 2:33 PM. The facility provided a plan of action to address the immediate concerns on August 31, 2023, at 11:41 PM and it was accepted. On September 6, 2023, at 1:20 PM, while the survey team was onsite the plan was verified and immediacy was lifted. After removal of the immediacy, the deficient practice remained for the potential for more than minimal harm at a scope and severity of D. The findings include: Resident #90 was admitted to the facility on [DATE]. The resident had a history of multiple diagnoses including Alcohol Use. A review of Resident #90's quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMs) summary score of 12, indicating moderate cognitive impairment. Resident #16's medical record revealed the resident was admitted to the facility on [DATE] with multiple diagnoses including Dementia and Bipolar. Additionally, the medical record showed the resident had a court-appointed guardian. A review of a quarterly Minimum Data Set assessment dated [DATE] documented Resident #16 had a Brief Interview for Mental Status summary score of 13, noting intact cognition. The resident was coded for requiring extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of a facility policy titled, Prohibition of Resident Abuse/ Abuse Prevention (Policy NO: 99-12) with a revision date of 09/24/22 instructed the following but not limited to: Report the incident to the Nursing Supervisor or Department Head immediately, but not less than 2 hours, if the alleged violation involves abuse or results in serious bodily injury. The Nursing Supervisor/Department Head will immediately initiate an investigation and give an oral report to the Administrator, If suspected abuse/inappropriate behavior between two residents, residents will be immediately separated from each from each other and monitored until appropriate interventions are implemented, and Notify DC Regulatory Agency and Ombudsman. A nursing note dated 09/03/22 12:31 AM [Recorded as Late Entry on 09/06/22 12:49 AM] documented, At around 2:35 AM call light was on in [Room #] when caregiver [Employee #12, Certified Nursing Assistant] went there. The caregiver called the nurse [Employee #13, Licensed Practical Nurse] and reported that he saw [Resident #90] kissing [Resident #16]. By the time the nurse went there [Resident #90] was leaving the room. The nurse explained to [Resident #90] that it was very late to be in a female room. [Resident #90] verbalized understanding and promised not to go there anymore. A social worker's note dated 09/05/22 10:59 AM [Recorded as Late Entry on 09/15/2022 4:11 PM] documented, While conducting business with residents on 2 [NAME] Unit [Employee #14, Social Worker] was approached by [Resident #90] who asked if he could leave the facility on a date with another resident [Resident #16]. At that time, he explained his interest in [Resident #16] living across from him stating that they were seeing each other [Resident #90] was advised not to go into her room and that they could talk with each other from the hallway, in part because there are two other female residents in the room. [Resident #90] acknowledged and understood what was said to him. It should be noted according to this social worker's note the conversation with Employee #14 and Resident #90 occurred on 09/05/22 which was two days after the incident where Resident #90 was found kissing Resident #16 on 09/03/22. The note was entered into Resident #90's electronic health record on 09/15/22 which was 12 days after the incident (09/03/22). A unit manager's [Employee #18] progress note dated 09/06/22 at 3:20 PM documented, [Resident #90] was transferred from Unit 2 Greenroom to Unit 3 Orange room. He was transferred off the unit because he was caught several times in the room inappropriately touching [Resident #16] on the bed. [Resident #90] is alert and oriented x3 (name, time, and place), he was advised not to go into the room the first time he was caught in the room in a compromised position with the resident [Resident #16] in question. [Resident #90] verbalized understanding and promised to stay away from [Resident #16], but [Resident #90] continued to sneak into the room during the odd hours of the night. [Resident #90] was caught on 9/6/22 at 2:25 AM in the room inappropriately feeling on [Resident #16]. All related disciplines were notified. [Resident 90's responsible party] was called and a message was left for him to call the unit. NP (nurse practitioner) was also informed. A review of Resident #90's progress notes including nursing, physician, and social work notes dated from 09/03/22 to 09/15/22 revealed Resident #90 was moved to a different unit on 09/06/22, three days after the incident. Additionally, the previously mentioned progress notes lacked documented evidence that the facility's staff made the State Agency or the Ombudsman Office aware of Resident #90's kissing and inappropriately touching Resident #16 which was observed by staff on 09/03/22 or that the staff on Unit 3 Orange where Resident #90 was transferred to was made aware of his previous behaviors. During a face-to-face interview on 08/29/23 at 4:16 PM, Employee #18 (Unit Manager/LPN) stated that Resident #90 and Resident #16 would talk and laugh with each other in the hallway but at night Resident #90 would sneak into Resident #16's room. The employee said that Employee #12 (CNA) and Employee #13 (LPN) informed her that Resident #90 was observed in Resident #16's room in a compromising position during the night shift on 03/06/23, Later that day Resident #90 was moved to 3 Orange. In addition, the employee said that she did not develop a care plan to address protecting the resident from Resident #90. However, she did develop a care plan to address Resident #16's behavior of being attracted to the opposite sex on 09/01/23. During a face-to-face interview on 08/30/23 starting at approximately 8:00 AM, Employee #13 (LPN) and Employee #12 (CNA) stated that around 2:00 AM Resident #90 was observed in Resident #16's room trying to kiss her. When asked what date this happened, they stated that they believed it was the day Resident #90 was moved to 3 Orange (3/6/22 Employee #12 (CNA) said when he walked into Resident #16's room Resident #90 was standing beside the resident's bed. Resident #16's covers were pulled down and the resident's gown was pulled up. Employee #13 stated that she instructed Resident #90 not to be in the resident's room this late. During a telephone interview on 08/30/23 starting at 9:46 AM, Employee #23 (Social Worker) stated that staff did not inform her of the incident that happened between Residents #90 and #16 on 3/3/22 Employee #23 said she learned about the incident when she looked at the electronic record and saw the nursing progress notes. The employee also stated that Resident #90 made her aware that he wanted to take Resident #16 out on a date, but she informed him that he could not do that, and he verbalized understanding. Employee #23 stated that she did inform Employee #18 (Unit Manager) of Resident #90's interest in Resident #16. During a face-to-face interview on 08/31/23 at 11:06 AM, Resident #90 stated that Resident #16 was his girlfriend and everybody [staff] knew it. Additionally, Resident #90 admitted to kissing Resident #16. A review of Resident #16's current and discontinued care plans revealed that the facility's staff did not develop a care plan to protect the resident from Resident #90's sneaking into her room at odd hours at night and Resident #90's inappropriate physical behavior toward her. However, Employee #18 (Unit Manager) developed the following care plan dated 09/01/23 (after the State Agency's intervention) that documented the following but not limited to: Problem: [Resident #16] has a behavior of being attracted to the opposite sex. Goal: Resident will interact with others using socially and culturally acceptable behavior. Approach: maintain resident's safety by monitoring her whereabouts on the units, redirect inappropriate sexual behavior, and staff to ensure that resident is not in any scheduled [secluded] area with males. During a face-to-face interview on 09/01/23 starting at 11:08 AM, Employee #1 (Administrator), Employee #2 (DON), and Employee #3 (ADON) stated that the incident of sexual inappropriateness occurred during the night shift on 03/03/22. The nurse (Employee #13, LPN) failed to inform the nursing supervisor or administration about the incident. Instead, she informed Employee #18 (Unit Manager) during the morning report on 03/06/22. After learning about the incident, Employee #18 had Resident #90 transferred to Unit 3 Orange. During a telephone interview on 09/07/23 starting at 11:26 AM, Resident #16's legal guardian stated that she found it weird that the facility recently made her aware of an incident that happened a year ago between Resident #16 and a male resident. The legal guardian stated, I asked them how are you going to treat something that happened a year ago? A review of Resident #90's current and discontinued care plans revealed the facility's staff failed to develop care plans to address the incident when Resident #90 was found in a compromised position with Resident #16 and the incident when Resident 90 was found sneaking in Resident #16's room at odd hours at night as documented in the unit manager's note dated 09/06/22. Based on these findings, on August 31, 2023, at 2:33 PM, an Immediate Jeopardy (IJ) situation was identified. On August 31, 2023, at 11:41 PM, the facility's Administrator provided a corrective action plan to the State Agency Survey Team that was accepted. The plan included: 1. Immediate Action Taken - Resident was moved to another unit in March - no additional issues since he was moved. I. Resident #90 identified in the survey was transferred to a different unit, from 2 [NAME] to unit 3 Orange, after the first incident on 9/6/2022. II. The residents on unit 2 green were interviewed and it was determined that no other resident was found to have a similar situation on 9/6/2022. III. Hourly monitoring program for Resident #90 continued 9/6/2022. A meeting was conducted on 3/29/2023 with the Administrator, DON, ADON, Social work staff, and nurse managers. All components of the abuse investigation form (tool) were addressed including resident-to-resident abuse. VIII. A meeting with Resident #90 was held on 3/29/23. Revised hourly rounding documentation was implemented on 3/29/2023 to include a signage sheet located in the nursing station. This is in addition to the TAR. This is to ensure the safety of other female residents. As a result, it is believed that it would be unlikely that this behavior would occur again. IX. The staff on unit 2 blue, on 8/30/2023, were re-educated regarding the Resident's #90 prior history. During this training, the staff acknowledged that [pronoun] had not exhibited any of that behavior since being moved to Unit 2 Blue. 2. Immediate Action Taken - Monitoring of the Resident I. The unit managers and charge nurses will monitor residents who exhibit abuse toward another resident, including sexual abuse every shift. The residents identified as exhibiting abusive behavior will be corrected immediately and provide safety for the victim. The affected residents will be monitored every 30 minutes to ensure the safety of other residents. This information will be provided to DON who will provide the information to the QAPI committee quarterly and more frequently as indicated. II. A review of the care plan of Resident #90 was developed and updated to reflect the potential issues as it pertains to sexual inappropriateness. III. All Staff were informed on 8/30/2023 of Resident #90 sexual inappropriateness, and they indicated willingness to monitor resident #90 sexual inappropriateness. IV. The assigned caregiver would ensure Resident #90's location, and whereabouts is known at all times. 3. INVESTIGATION - Decision Making § Facility Administration - identification of Abuse and actions taken during/following an investigation I. Meeting held with Administrator, DON and ADON regarding Resident #90's sexual inappropriateness. II. The DON and ADON reviewed all incidences of unusual occurrences from January 2023 through March 2023. No other allegations of sexual abuse were noted. III. Each month the Investigation Committee will review any allegations of abuse. This committee ensures that all aspects of the Investigation form/tool is complete. This is reported to the QAA Committee Quarterly and/or more often as needed. 4. SUPPORTING DOCUMENTS 1. Hourly monitoring from March 29th, 2023, to present. 2. Updated care plan March 30th, 2023, to present. 3. Re-education on Abuse prevention for staff 3/31/23 4. The need for every thirty-minutes monitoring of resident #90 behavior of sexual inappropriateness (previously hourly) 5. Evidence of Abuse Training 3/31/23 6. Updated Care Plan 7. Investigation Tool 8. [NAME] between resident #90 and SBGC regarding consequences for sexual inappropriateness The plan was verified by the State Agency on 09/06/23 at 1:20 PM.