**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident representative interviews, the facility failed to protect residents' rights to be free from neglect. The facility failed to provide the necessary services to a resident to avoid physical harm, pain, mental anguish, or emotional distress, by failing to develop an appropriate care plan and closely supervise 1 (Resident #1) of 5 sampled residents with dysphagia (impaired swallowing) with known multiple incidents of choking during meals. Staff failed to address family's previous reports of Resident #1 stuffing food and choking during meals. On 12/22/22 Resident #1 was left unsupervised during meals. Resident #1 was found unresponsive. Staff performed CPR (Cardiopulmonary Resuscitation) and called EMS (Emergency Medical Services). EMS removed a golf size clump of food out of the resident's throat. Resident #1 was transferred to the hospital where she expired on 12/22/22. The facility's failure to provide the necessary structures to prevent neglect and closely supervise residents with dysphagia with known incidents of choking during meals resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of isolated (J) starting on 12/22/22. The Administrator was notified of the Immediate Jeopardy (IJ) on 2/6/23 at 3:15 p.m. and provided the IJ templates. The Immediate Jeopardy was ongoing. The census was 114, with five current residents with dysphagia. The findings included: Cross reference F641, F684, F689 and F835. The facility policy, Abuse, Neglect, Exploitation & Misappropriation with a revision date of 11/16/22 noted, Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Failure to take precautionary measures to protect the health and safety of the residents. Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Parkinson's disease (Long term degenerative disorder of the central nervous system). Review of the clinical record revealed a Speech Therapy (ST) evaluation dated 11/27/20 which noted Resident #1 was having more difficulty with mastication and swallowing, exhibiting coughing. The resident was now completely dependent on staff for feeding due to her Parkinson's. The Speech Language Pathologist noted she witnessed Resident #1 gagging on food and coughing after swallowing at times. The SLP documented a diagnosis of Oropharyngeal Dysphagia, (Swallowing issues in the mouth and/or the throat) phase. On 12/30/20 the ST documented in a discharge summary, Patient education on . compensatory strategies to improve oral management of the bolus (ball-like mixture of chewed food and saliva) and clear lingual residue. use of compensatory strategies and exercises for more effective and safe swallowing. Staff education on cueing and feeding strategies. The ST noted Resident #1 was controlling the bolus more effectively, the resident's Parkinson's disease was progressing, and she was no longer able to feed herself. Review of the Quarterly Minimum Data Set (MDS) v1.17.1 Assessment with an assessment reference date of 9/11/22 noted Resident #1 required set up and supervision (oversight, encouragement, cueing) for eating. The facility provided an Activity of Daily Living (ADL) MDS coding instruction sheet which noted set up meant opening food containers, cutting up food and providing one food at a time. Supervision meant observation during meals due to history of choking, orientation to food and fluid location on tray or plate, food to be given one item at a time. The physician's orders dated 9/10/20 noted Resident #1 received a regular texture diet with thin liquids, and two handled cups with lid for all meals. Resident #1's care plan initiated on 6/3/20 noted a diagnosis of Parkinson's disease. The interventions included to monitor, document, report to the physician as needed signs and symptoms of aspiration, or dysphagia, choking, coughing. Staff was to refer to Speech Therapy for any dysphagia problem. As of 6/17/20, the care plan indicated the resident was able to eat independently. The care plan was not updated to reflect the Speech Therapist's statement of 12/30/30 which noted Resident #1's Parkinson's disease had progressed, and she was no longer able to feed herself independently. On 6/6/21 the care plan was updated to provide meals in separate bowls as to not overwhelm the resident. As of 10/25/22 staff was to monitor, document, report PRN (as needed) any signs and symptoms of dysphagia including pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned at meals. Review of the Certified Nursing Assistants (CNAs) Activities of daily living tracking forms for November 2022 noted the CNAs were to answer Y(Yes) or N(No) to the question: Has the resident been coughing during meals; has the resident held food in mouth or cheeks or had food in mouth after meals? The form was blank for 50 of the 90 meals offered in November 2022. Six times the CNAs documented N/A meaning not applicable. On 11/21/22 for day and evening the CNA answered Y (Yes) twice during the shift to the question Has the resident been coughing during meals. There was no documentation the CNA reported the observation of Resident #1's coughing during meals on 11/21/22, despite the care plan's specific instructions. On 1/31/23 at approximately 3:30 p.m., the Director of Nursing (DON) said she did not know why the care plan said Resident #1 required supervision as needed. She said Resident #1 should have been observed during meals. Review of the progress notes revealed on 7/23/22 at 9:44 p.m., Registered Nurse (RN) Staff A documented, Resident had visitors in the morning up until 3:30 p.m. When she returned with her brother and daughter, the latest told me that while having lunch outside, Resident #1 choked with a piece of chicken nugget, she had to press her epigastric to make her expel the piece. Resident is currently ok, she is breathing without issues . On 7/25/22 at 2:31 p.m., Licensed Practical Nurse Staff B documented, Daughter [name] called to report when they brought patient out on Sunday that she choked on a chicken nugget. She states she kept shoving food into her mouth, noted no problems with her swallowing. States she had to do the Heimlich (abdominal thrusts to clear upper airway obstruction) . states patient has done this before . The clinical record lacked documentation the physician or speech therapist were notified of the resident's episodes of coughing and choking during meals for further evaluation as necessary. On 1/31/23 at 12:45 p.m., in a telephone interview Resident #1's daughter said in the last three to four months, Resident #1 had bad choking episodes while eating. She would tell the nursing staff each time it occurred. She said, you could only give her a couple of pieces of food on her tray at a time, like a toddler since she would stuff it into her mouth. She was a danger to herself, which is why she was at the facility. She said, I have reported it to the nurse, but I don't know if they ever did anything about it. Pretty much every time we visited there in the morning, she was by herself with her breakfast tray. They used to have someone to help feed and watch her when she first got there but that has stopped. On 1/31/2023 at 1:20 p.m., RN staff A said Resident #1 was at risk for choking. He confirmed he wrote the note on 7/23/22 when the family reported the resident choked on a chicken nugget. He said he could not recall any other information. On 1/31/23 at 3:15 p.m., the Director of Rehab said she was not aware of the concerns of choking during meals Resident #1's family members reported to the staff. She said if she had known they would have done an evaluation. On 1/31/23 at approximately 3:30 p.m., the Director of Nursing (DON) said based on the notes dated 7/23/22 and 7/25/22 documenting the family reported Resident #1 choking on her food, she would expect a nursing assessment, communication with the physician and a referral for a Speech evaluation. After reviewing the clinical record, the DON said there was no documentation the physician was notified of the resident's choking during meals. She also verified there was no referral for a speech evaluation. On 2/1/23 at 2:17 p.m., Resident #1's brother who is the power of attorney said due her Parkinson's disease, Resident #1 had trouble with controlling her throat. She was supposed to always be supervised directly during eating or taken to a group dining room. But when he would come to visit her, she would be alone in her room with the food on her tray. He said there were several times that she had trouble getting her food down, he would remove the food from her mouth and remind her to eat slower. He said he told the staff each time she tried to put too much food in her mouth. Further review of the progress notes showed on 12/22/22 at 8:15 a.m., the Unit Manager documented Resident #1 was up in a wheelchair eating breakfast, took all her morning medications, yelling out at times. On 12/22/22 at 9:24 a.m., Registered Nurse Staff C documented, CNA informed nurse that resident was unresponsive. Nurse called Code Blue., resident a full code per chart 0925 CPR (cardiopulmonary resuscitation) started, crash cart in room, no v/s [vital signs] detected, 0930 911 called. Review of the EMS patient care record revealed they arrived onsite on 12/22/22 at 9:35 a.m. EMS noted what appeared to be signs of a foreign body airway obstruction. Patient had JVD (Jugular vein distention) and swelling in the throat. Patient also exhibited no chest rise and absent lung sounds during ventilations. EMS performed suction with no relief. EMS used a laryngoscope (tube with light to look at the voice box) and [NAME] forceps (angled forceps that can be used to remove foreign bodies) to open patient's airway. EMS was able to remove a golf ball size clump of oatmeal out of the patient's throat. EMS documentation noted Resident #1's cardiac arrest etiology (cause) was respiratory/asphyxia. Ventilation improved remarkably. Patient was transported to the local Emergency Room. Review of the local emergency room documentation dated 12/22/22 noted EMS found the resident unresponsive, pulseless, and apneic (not breathing) and took over CPR. EMS opened airway and noted airway obstruction; Large bolus (mass of chewed food) removed from airway by EMS and airway secured. The primary encounter diagnosis noted was airway obstruction due to foreign body. Resident #1 expired on 12/22/22 at the hospital. On 1/31/23 at approximately 3:30 p.m., the Director of Nursing said she did not know why the care plan said Resident #1 required supervision as needed. She said Resident #1 should have been observed during meals. On 2/2/23 at approximately 4:00 p.m., the Administrator said he thought Resident #1 expired due to cardiac arrest until 1/18/23 when the Department of Children and Families reported an allegation of neglect for the lack of supervision during meals for Resident #1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and resident representative interviews, the facility failed to have processes in place to ensure accurate assessment of swallowing ability for 2 (Resident #1 and #3) of 3 residents reviewed with a diagnosis of dysphagia (difficulty swallowing). Resident #1 had a diagnosis of Parkinson's disease and oropharyngeal dysphagia. Resident #1's power of attorney complained to several staff members of episodes of choking during meals. Resident #1's assessment did not accurately reflect Resident #1's episodes of coughing and choking during meals, resulting in an inadequate individualized care plan to ensure supervision and safe swallowing during consumption of food. On 12/22/22 Resident #1 did not receive the necessary supervision during meals. The resident was found unresponsive, staff performed CPR (Cardiopulmonary resuscitation) and called EMS (Emergency Medical Services). EMS removed a golf ball size clump of food out to the resident's throat. Resident #1 was transferred to the hospital and expired on 12/22/22. The facility's failure to follow the necessary steps to accurately assess residents' ability to swallow safely resulted in the determination of Immediate Jeopardy which started on 12/22/22. The Administrator was notified of the Immediate Jeopardy (IJ) on 2/6/23 at 3:15 p.m. and provided the IJ templates. The Immediate Jeopardy was ongoing. The census was 114, with five current residents with dysphagia. The findings included: Cross reference F600, F684, F689 and F835. The Resident Assessment Instrument (RAI) manual (Used to gather information on residents' strengths and needs which must be addressed in an individualized care plan) version 3.0, V1.17.1 notes section K is intended to assess the many conditions that could affect the resident's ability to maintain adequate nutrition and hydration. The RAI manual noted the ability to swallow safely can be affected by many disease processes and functional decline. Alterations in the ability to swallow can result in choking and aspiration. The RAI manual listed the following signs and symptoms of possible swallowing disorder: Loss of liquids/solids from mouth when eating or drinking. Holding food in mouth/cheeks or residual food in mouth after meals. Coughing or choking during meals or when swallowing medications, Complaints of difficulty or pain with swallowing. The steps for assessment listed in the RAI manual included: 1. Ask the resident if he or she has had any difficulty swallowing during the 7-day look-back period. 2. Observe the resident during meals or at other times when he or she is eating, drinking, or swallowing to determine whether any of the listed symptoms of possible swallowing disorder are exhibited. 3. Interview staff members on all shifts who work with the resident and ask if any of the four listed symptoms were evident during the 7-day look-back period. Care planning should include provisions for monitoring the resident during mealtimes and during functions/activities that include the consumption of food and liquids. Care plan should be developed to assist resident to maintain safe and effective swallow using compensatory techniques, alteration in diet consistency, and positioning during and following meals. 1. Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included Parkinson's disease (Long term degenerative disorder of the central nervous system). Review of the clinical record revealed a Speech Therapy (ST) evaluation dated 11/27/20 which noted Resident #1 was having more difficulty with mastication and swallowing, exhibiting coughing. The resident was now completely dependent on staff for feeding due to her Parkinson's. The Speech Language Pathologist noted she witnessed Resident #1 gagging on food and coughing after the swallow at times. The SLP documented a diagnosis of oropharyngeal dysphagia, (Impaired swallowing in the mouth and/or the throat) phase. On 12/30/20 the SLP documented in a discharge summary, Patient education on . compensatory strategies to improve oral management of the bolus and clear lingual residue. use of compensatory strategies and exercises for more effective and safe swallowing. Staff education on cueing and feeding strategies. The ST noted Resident #1 was controlling the bolus (ball-like mixture of food and saliva) more effectively, the resident's Parkinson's disease was progressing, and she was no longer able to feed herself . On 4/27/22 a Speech Therapist Evaluation showed documentation Resident #1 was declining in her ability to communicate effectively. The SLP documented Resident #1 had a severe impairment with expressive language skills, and a severe impairment with oral motor and speech production. The Discharge Summary completed on 5/7/22 showed the patient was uncooperative and unable to be tested clinically due to, perseverative crying and agitated behavior. At discharge The SLP recommended supervision and anticipation of patient needs for optimal safety and quality of life at this time. On 1/31/23 at 12:45 p.m., in a telephone interview Resident #1's daughter said in the last three to four months, Resident #1 had bad choking episodes while eating. She would tell the nursing staff each time it occurred. She said, you could only give her a couple of pieces of food on her tray at a time, like a toddler since she would stuff it into her mouth. She was a danger to herself, which is why she was at the facility. She said, I have reported it to the nurse, but I don't know if they ever did anything about it. Pretty much every time we visited there in the morning, she was by herself with her breakfast tray. They used to have someone to help feed and watch her when she first got there but that has stopped. On 2/1/23 at 2:17 p.m., Resident #1's brother who is the power of attorney said due her Parkinson's disease, Resident #1 had trouble with controlling her throat. She was supposed to always be supervised directly during eating or taken to a group dining room. But when he would come to visit her, she would be alone in her room with the food on her tray. He said there were several times that she had trouble getting her food down she he would take the food from her mouth and remind her to eat slower. He said he told the staff when it occurred that she tried to put too much food in her mouth. Review of the Quarterly Minimum Data Set (MDS) Assessment with an assessment reference date of 9/11/22 noted Resident #1 required set up and supervision (oversight, encouragement, cueing) for eating. The assessment noted Resident #1 did not display signs and symptoms of possible swallowing disorder as listed in the RAI manual, v1.17.1 The MDS noted the section related to the swallowing was completed by the Dietetic Technician , Registered (DTR) who signed the assessment verifying the information accurately reflected the resident assessment information and the information noted in the assessment was collected in accordance with applicable Medicare and Medicaid requirements. The clinical record lacked documentation of meal observation, or resident/representative interview as per the steps for assessment listed in the RAI manual. The Nutritional Review form completed by the DTR on 9/16/22 noted instructions to complete the review using information from the resident's medical record and resident/responsible party (as applicable). The form noted Resident #1 required assistance to feed herself. The DTR documented she was unable to obtain or update the resident's food preferences. There was no documentation Resident #1's family was contacted to participate in the nutritional review. On 2/1/23 at 2:00 p.m., in a telephone interview, the DTR verified she completed the swallowing section for the Quarterly MDS with an Assessment Reference Date of 9/11/22 indicating Resident #1 did not display signs or symptoms of possible swallowing disorder. She said she coded the assessment based on the answers the CNAs (Certified Nursing Assistants) documented about swallowing and looked for the information in Point Click Care (Electronic documentation software) to see how the resident was doing overall. She said she was not aware Resident #1 had choking episodes. She said she did not speak with Resident #1's family members before coding the MDS. She said the Registered Dietitian (who was no longer employed at the facility) was responsible to handle family communication. 2. Resident #3 was admitted to the facility on [DATE] with diagnoses including cerebrovascular accident and dysphagia. Resident #3 received a pureed diet. The Speech Language Pathologist (SLP) evaluation dated 1/16/23 noted Resident #3 required Speech Language Pathology services due to recent history of aspiration, and oropharyngeal dysphagia. Resident #3 completed a modified barium swallow (an imaging test that uses barium and X-rays to create images of the upper gastrointestinal tract) at the hospital resulting in recommendations for restorative exercises and compensatory strategies to improve safety and efficiency of swallowing function. The Speech Therapist noted during the clinical feeding evaluation of 1/16/23 Resident #3 completed small bites of pureed solids without overt signs and symptoms of aspiration. The therapist documented the Resident was a known silent aspirator (food or liquid enters the airway and eventually the lungs without any outward signs of swallowing difficulty) and required cues to re-swallow. Penetration aspiration of 6 noted with straw sips of nectar thick. The assessment summary noted Resident #3 demonstrated coughing or choking during meals or when swallowing medications. The therapist documented the resident required supervision and assistance at mealtime due to swallowing safety 91 to 100% of the time. The admission MDS v1.17.1. assessment with an assessment reference date of 1/17/23 noted Resident #3 required extensive physical assistance of one person for eating. The assessment also noted Resident #3 did not display any signs or symptoms of possible swallowing disorder, including coughing or choking during meals or swallowing medications, despite the Speech Therapist's evaluation dated 1/16/23 which noted Resident #3 demonstrated coughing or choking during meals or when swallowing medications. On 2/2/23 at 10:00 a.m., the current Registered Dietitian said she has been employed at the facility since October 2022. She said the section related to swallowing is completed by the Registered Dietitian and correlates with the dietary assessment. She said she gathers all information by looking back one to six months. The care plan initiated on 1/18/23 noted the resident had a potential for altered nutrition related to therapeutic/mechanically altered diet and multiple diagnoses. The care plan did not include the precautionary measures noted in the SLP evaluation completed at the hospital to ensure safe swallowing and prevent aspiration. On 2/3/23 at 1:30 p.m., the SLP said Resident #3 needed to be sitting at a 90 degree angle when eating and needed one to one supervision during meals to cue for second swallow with each bite of food. She verified the care plan was not individualized to meet the needs of the resident and ensure safe swallowing. She said the facility developed a care plan to address the resident's dysphagia on 2/2/23. Review of Resident #3's care plan developed on 2/2/23 showed Resident has a swallowing problem related to difficulty with thin liquids, nectar thick liquids. The interventions listed included to keep the head of the bed elevated at 45 degrees during meals, not the 90 degrees recommended by the SLP. The care plan did not include the necessary one to one supervision when consuming food and liquids to cue the resident to swallow twice with each bite of food. The care plan did not have an intervention Resident #3 was not to use straws when drinking due to the potential for choking.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff and resident representative interview, the facility failed to ensure ongoing clinical assessment, care planning and effective coordination to promptly identify and address significant decline in condition to meet the needs of 2 (Resident #1, and #3) of 3 sampled residents with a diagnosis of dysphagia (difficulty swallowing) requiring supervision. Resident #1 was a vulnerable resident with a diagnosis of Parkinson's disease. Resident #1 was diagnosed on [DATE] with oropharyngeal dysphagia (Swallowing issues in the mouth and/or the throat). The facility failed to have documentation of periodic accurate assessment to monitor for decline in ability to swallow safely. The facility failed to demonstrate effective coordination and address multiple complaints of coughing and choking with meals voiced by the family. On 12/22/22 Resident #1 was found unresponsive when left unsupervised during meal. Staff started CPR (Cardiopulmonary resuscitation) and called EMS (Emergency Medical Services). EMS removed a golf ball size clump of oatmeal in the resident's throat. Resident #1 was transferred to the hospital where she expired on 12/22/22. The facility's failure to ensure ongoing accurate assessment, development of individualized care plan to meet of residents with dysphagia, and the failure to coordinate and address multiple complaints of coughing and choking during meals resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of isolated (J) starting on 12/22/22. The Administrator was notified of the Immediate Jeopardy on 2/6/23 at 3:15 p.m. and provided the IJ templates. The Immediate Jeopardy was ongoing. The census was 114, with 5 current residents with dysphagia. The findings included: Cross reference to F600, F641, F689 and F835 The facility's policy and procedure for Therapy Screenings with a review date of 7/26/22 notes, Screens are provided as permitted according to professional standards of practice and ethics, and within site of service, state, and federal regulatory guidelines. Screens are used for preliminary information gathering, and do not require a physician's order. Screens may be conducted: Upon admission or readmission, upon change in condition, upon request of the interprofessional team. upon a regularly scheduled frequency to support optimal function, health, and wellness. The Center for Medicare and Medicaid Services Resident Assessment Instrument (RAI) version 3.0 Manual, v1.17.1, noted, Federal requirements dictate, at a minimum, three Quarterly assessments be completed in each 12-month period. The RAI manual specifies the steps for assessment for swallowing include an observation of the resident during meals. Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included Parkinson's disease (Long term degenerative disorder of the central nervous system). Review of the clinical record revealed a Speech Therapy (ST) evaluation dated for dysphagia on 11/27/20 which noted Resident #1 was having more difficulty with mastication and swallowing, exhibiting coughing. The resident was now completely dependent on staff for feeding due to her Parkinson's. The Speech Language Pathologist noted she witnessed Resident #1 gagging on food and coughing after the swallow at times. The ST documented a diagnosis of Dysphagia, oropharyngeal (impaired swallowing issues in the mouth and/or the throat) phase. The Speech Therapy Discharge Summary dated 12/30/22 noted Resident #1 was within functional limit on dysphagia advanced diet and thin liquids. The therapist documented the prognosis to maintain the current level of functioning was excellent with consistent staff support. Review of the physician's orders revealed Resident #1 as of 9/10/20 was receiving a Regular Diet regular texture/thin liquids consistency, fortified foods all meals, 2 handled cup with lid for meals. There was no documentation in the clinical record Resident #1 received the dysphagia advanced diet recommended by the Speech Therapist on 12/30/20. On 4/27/22 a Speech Therapist Evaluation showed Resident #1 was declining in her ability to communicate effectively. The Speech Therapist documented Resident #1 had a severe impairment with expressive language skills, and a severe impairment with oral motor and speech production. The Discharge Summary completed on 5/7/22 showed the patient was uncooperative and unable to be tested clinically due to, perseverative crying and agitated behavior. At discharge The Speech Language Pathologist recommended to continue supervision and anticipation of patient needs for optimal safety and quality of life at this time. There was no documentation the Speech Therapist assessed Resident #1's ability to swallow safely. Review of the Quarterly Minimum Data Set (MDS), v1.17.1, dated 6/9/22, and 9/11/22 showed no decrease in Resident #1's cognition. Her Brief Interview for Mental Score was 14 which showed no cognitive impairment. The MDS showed no swallowing difficulties were being assessed. A progress note dated 9/4/22 showed Resident #1 had a decline in weight of 10.3%. the Dietitian documented Weight stable the past week. Continue with current plan of care. RD [Registered Dietitian] will continue to monitor and follow up as needed. Resident #1's care plan initiated on 6/3/20 noted a diagnosis of Parkinson's disease. The interventions included to monitor, document, report to the physician as needed signs and symptoms of aspiration, or dysphagia, choking, coughing. Staff was to refer to Speech Therapy for any dysphagia problem. Review of the progress notes revealed on 7/23/22 at 9:44 p.m., Registered Nurse (RN) Staff A documented, Resident had visitors in the morning up until 3:30 p.m. When she returned with her brother and daughter, the latest told me that while having lunch outside, Resident #1 choked with a piece of chicken nugget, she had to press her epigastric to make her expel the piece. Resident is currently ok, she is breathing without issues . On 7/25/22 at 2:31 p.m., Licensed Practical Nurse Staff B documented, Daughter [name] called to report when they brought patient out on Sunday that she choked on a chicken nugget. She states she kept shoving food into her mouth, noted no problems with her swallowing. States she had to do the Heimlich (abdominal thrusts to clear upper airway obstruction) . states patient has done this before . On 1/31/23 at 12:45 p.m., in a telephone interview Resident #1's daughter said in the last three to four months, Resident #1 had bad choking episodes while eating. She would tell the nursing staff each time it occurred. She said, you could only give her a couple of pieces of food on her tray at a time, like a toddler since she would stuff it into her mouth. She was a danger to herself, which is why she was at the facility. She said, I have reported it to the nurse, but I don't know if they ever did anything about it. Pretty much every time we visited there in the morning, she was by herself with her breakfast tray. They used to have someone to help feed and watch her when she first got there but that has stopped. On 2/1/23 at 2:17 p.m., Resident #1's brother who is the power of attorney said due her Parkinson's disease, Resident #1 had trouble with controlling her throat. She was supposed to always be supervised directly during eating or taken to a group dining room. But when he would come to visit her, she would be alone in her room with the food on her tray. He said there were several times that she had trouble getting her food down she he would take the food from her mouth and remind her to eat slower. He said he told the staff when it occurred that she tried to put too much food in her mouth. The clinical record lacked documentation the facility addressed Resident #1 concerns of choking during meals voiced by the family. On 1/31/2023 at 1:20 p.m., RN staff A said Resident #1 was at risk for choking. He confirmed he wrote the note on 7/23/22 when the family reported the resident choked on a chicken nugget. He said he could not recall any other information. On 2/1/23 at 2:00 p.m., during a telephone interview, the Dietetic Technician, Registered (DTR) described her process for completing quarterly nutritional assessments. She said there are questions that the CNAs (Certified Nursing Asssistants) answer about swallowing which she reviews and also uses the facility communication. she goes through the questions on the assessment, pulls information from PCC (Electronic documentation system) in terms of how the resident is doing overall. The DTR stated she did not discuss the resident's status with the family. She said the resident had not been able to communicate her needs during the time of the MDS assessments. the DTR did not say she observed the resident during meals to determine if the resident was experiencing swallowing difficulties. Review of the Certified Nursing Assistants (CNAs) Activities of daily living tracking forms for November 2022 noted the CNAs were to answer Y(Yes) or N(No) to the questions: Has the resident been coughing during meals; has the resident held food in mouth or cheeks or had food in mouth after meals. On 11/21/22 for day and evening the CNA answered Y twice during the shift to the question Has the resident been coughing during meals. There was no documentation the CNA reported the observation of Resident #1's coughing during meals, despite the care plan's specific instructions. There was no documentation for December 2022 the CNAs observed Resident #1 during meals for signs and symptoms of dysphagia. On 1/31/23 at 3:15 p.m., the Director of Rehab said she was not aware of the concerns of choking during meals Resident #1's family members reported to the staff. She said if she had known they would have done an evaluation. On 1/31/23 at approximately 3:30 p.m., the Director of Nursing (DON) said based on the notes dated 7/23/22 and 7/25/22 documenting the family reported Resident #1 choking on her food, she would expect a nursing assessment, communication with the physician and a referral for a Speech evaluation. After reviewing the clinical record, the DON said there was no documentation the physician was notified of the resident's choking during meals. She also verified there was no referral for a speech evaluation. She said it was the Unit Manager's responsibility to check the 24 hours report and discuss concerns during morning meetings with the interdisciplinary team. She said back in July when the family complained of Resident #1 choking during meals, she was on vacation and did not know why the concern was not addressed. On 1/31/23 at 3:15 p.m., the Director of Therapy said therapy does not do routine speech therapy evaluations. Therapy does quarterly and annual screenings which do not include observing the resident during meals. She said Therapy was not aware of the family complaining of the resident choking during her meals in July 2022, and did not screen Resident #1 for a decline in ability to swallow safely. She said if she would have known she would have evaluated the resident's swallowing ability. On 1/31/23 at approximately 3:30 p.m., the Director of Nursing said she did not know why the care plan said Resident #1 required supervision as needed. She said Resident #1 should have been observed during meals. On 2/2/23 at 10:30 a.m., the Registered Dietitian (RD) said it was the responsibility of the RD to complete Section K of the MDS every three months. The RD verified Section K of the MDS had four specific questions related to swallowing ability which needed to be answered during the assessment. She said she reviewed the record and spoke with staff and at times if they were available she would speak with the resident's family. the RD said it was not part of her assessment to observe the residents eat during the comprehensive assessment period. On 12/22/22 at 9:24 a.m., Registered Nurse Staff C documented, CNA informed nurse that resident was unresponsive. Nurse called code blue., resident a full code per chart 0925 CPR (cardiopulmonary resuscitation) started, crash cart in room, no v/s [vital signs] detected, 0930 911 called. Review of the EMS patient care record revealed they arrived onsite on 12/22/22 at 9:35 a.m. EMS noted what appeared to be signs of a foreign body airway obstruction. Patient had JVD (Jugular vein distention) and swelling in the throat. Patient also exhibited no chest rise and absent lung sounds during ventilations. EMS performed suction with no relief. EMS used a laryngoscope (tube with light to look at the voice box) and [NAME] forceps (angled forceps that can be used to remove foreign bodies) to open patient's airway. EMS was able to remove a golf ball size clump of oatmeal out of the patient's throat. EMS documentation noted Resident #1's cardiac arrest etiology (cause) was respiratory/asphyxia. Ventilation improved remarkably. Patient was transported to the local Emergency Room. Review of the local emergency room documentation dated 12/22/22 noted EMS found the resident unresponsive, pulseless, and apneic (not breathing) and took over CPR. EMS opened airway and noted airway obstruction; Large bolus (mass of chewed food) removed from airway by EMS and airway secured. The primary encounter diagnosis noted was airway obstruction due to foreign body. Resident #1 expired at the hospital on [DATE]. 2. Resident #3 was admitted to the facility on [DATE] with diagnoses including cerebrovascular accident and dysphagia. Resident #3 received a pureed diet. The Speech Language Pathologist evaluation dated 1/16/23 noted Resident #3 required Speech Language Pathology services due to recent history of aspiration, and oropharyngeal dysphagia. Resident #3 completed a modified barium swallow at the hospital resulting in recommendations for restorative exercises and compensatory strategies to improve safety and efficiency of swallowing function. The Speech Therapist noted during the clinical feeding evaluation of 1/16/23 Resident #3 completed small bites of pureed solids without overt signs and symptoms of aspiration. The therapist documented the Resident was a known silent aspirator (food or liquid enters the airway and eventually the lungs) and required cues to re-swallow. Penetration aspiration of 6 noted with straw sips of nectar thick. The assessment summary noted Resident #3 demonstrated coughing or choking during meals or when swallowing medications. The therapist documented the resident required supervision and assistance at mealtime due to swallowing safety 91 to 100% of the time. The admission Minimum Data Set (MDS) assessment with an assessment reference date of 1/17/23 noted Resident #3 required extensive physical assistance of one person for eating. The assessment also noted Resident #3 did not display any signs or symptoms of possible swallowing disorder, including coughing or choking during meals or swallowing medications, despite the Speech Therapist's evaluation dated 1/16/23 which noted Resident #3 demonstrated coughing or choking during meals or when swallowing medications. The care plan initiated on 1/18/23 noted the resident had a potential for altered nutrition related to therapeutic/mechanically altered diet and multiple diagnoses. The care plan did not include provision to cue the resident to re-swallow as per the Speech Therapy's swallowing assessment to ensure swallow safety. On 2/3/23 at 1:30 p.m., the Speech Therapist said Resident #3 needed to be sitting at a 90 degree angle when eating and needed one-to-one supervision during meals to cue for second swallow with each bite of food. She verified the care plan was not individualized to meet the needs of the resident and ensure safe swallowing. Review of Resident #3's care plan developed on 2/2/23 showed Resident #3 has a swallowing problem related to difficulty with thin liquids, nectar thick liquids. The interventions listed included to keep the head of the bed elevated at 45 degrees during meals, not the 90 degrees recommended by the Speech Therapist. The care plan did not include the necessary one-to-one supervision when consuming food and liquids to cue the resident to swallow twice with each bite of food. The care plan did not specify Resident #3 was not to use straws when drinking due to the potential for choking.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, residents' representatives and staff interviews, the facility failed to implement processes to ensure adequate supervision of residents with dysphagia (Impaired swallowing) and known episodes of choking during meals for 3 (Resident #1, #2 and #3) of 5 sampled residents with dysphagia. On 12/22/22 Resident #1 who had dysphagia did not receive the necessary supervision during meals. Resident #1 was found unresponsive. Staff performed CPR (Cardiopulmonary Resuscitation) and called Emergency Medical Services (EMS). EMS noted signs of foreign body airway obstruction and removed a golf ball size of oatmeal out of the resident's throat. Resident #1 was resuscitated and transferred to the hospital where she expired on 12/22/22. The facility failure to ensure adequate supervision of residents with dysphagia to prevent choking which could lead to serious injury or death resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of isolated (J) starting on 12/22/22. The Administrator was notified of the Immediate Jeopardy on 2/6/23 at 3:15 p.m. and provided the IJ templates. The Immediate Jeopardy was ongoing. The census was 114, with five current residents with dysphagia. The findings included: Cross reference F600, F641, F684, and F835. Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included Parkinson's disease (Long term degenerative disorder of the central nervous system). On 9/10/20 Resident #1's physician's orders included a Regular Diet regular texture/thin liquids consistency, fortified foods all meals, 2 handled cup with lid for meals. Review of the clinical record revealed a Speech Language Pathology (SLP) evaluation dated 11/27/20 which noted Resident #1 was having more difficulty with mastication and swallowing, exhibiting coughing. The resident was now completely dependent on staff for feeding due to her Parkinson's. The SLP noted she witnessed Resident #1 gagging on food and coughing after the swallow at times. The SLP documented a diagnosis of oropharyngeal dysphagia, (impaired swallowing in the mouth and/or the throat) phase. On 12/30/20 the ST documented in a discharge summary, Patient education on . compensatory strategies to improve oral management of the bolus and clear lingual residue . use of compensatory strategies and exercises for more effective and safe swallowing . Staff education on cueing and feeding strategies. The ST noted Resident #1 was controlling the bolus more effectively, the resident's Parkinson's disease was progressing, and she was no longer able to feed herself . The Speech Therapist diagnosis was documented as WFL [within functional limits] on Dysphagia Advanced diet [referring to the National Dysphagia Diet, Dysphagia-Advanced Level 3 (soft foods that require more chewing ability)] and thin liquids. On 4/27/22 a SLP Evaluation showed Resident #1 was declining in her ability to communicate effectively. The SLP documented Resident #1 had a severe impairment with expressive language skills, and a severe impairment with Oral Motor and speech production. The Discharge Summary completed on 5/7/22 showed the patient was uncooperative and unable to be tested clinically due to, perseverative crying and agitated behavior. At discharge The SLP recommended supervision and anticipation of patient needs for optimal safety and quality of life at this time. There was no documentation the SLP assessed Resident #1's ability to swallow safely. Review of the Quarterly Minimum Data Set v1.17.1, Assessment with an assessment reference date of 9/11/22 noted Resident #1 required set up and supervision (oversight, encouragement, cueing) for eating. The assessment showed no swallowing or choking issues were observed during the 7 day look back period. Resident #1's care plan initiated on 6/3/20 and revised on 12/23/22 (one day after the resident expired) noted a diagnosis of Parkinson's disease. The interventions included to monitor, document, report to the physician as needed signs and symptoms of aspiration, or dysphagia, choking, coughing. Staff was to refer to Speech Therapy for any dysphagia problem. As of 10/25/22 staff was to monitor, document, report PRN (as needed) any signs and symptoms of dysphagia including pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned at meals. Review of the Certified Nursing Assistants (CNAs) Activities of daily living tracking forms for November 2022 noted the CNAs were to answer Y(Yes) or N(No) to the question: Has the resident been coughing during meals; has the resident held food in mouth or cheeks or had food in mouth after meals?. The form was blank for 50 of the 90 meals offered in November 2022. Six times the CNAs documented N/A meaning not applicable. On 11/21/22 for day and evening the CNA answered Y twice during the shift to the question Has the resident been coughing during meals?. There was no documentation the CNA reported the observation of Resident #1's coughing during meals, despite the care plan's specific instructions. On 12/22/22 at 9:24 a.m., Registered Nurse Staff C documented, CNA informed nurse that resident was unresponsive. Nurse called Code Blue., resident a full code per chart 0925 CPR (cardiopulmonary resuscitation) started, crash cart in room, no v/s [vital signs] detected, 0930 911 called. Review of the EMS patient care record revealed they arrived onsite on 12/22/22 at 9:35 a.m. EMS noted what appeared to be signs of a foreign body airway obstruction. Patient had JVD (Jugular vein distention) and swelling in the throat. Patient also exhibited no chest rise and absent lung sounds during ventilations. EMS performed suction with no relief. EMS used a laryngoscope (tube with light to look at the voice box) and [NAME] forceps (angled forceps that can be used to remove foreign bodies) to open patient's airway. EMS was able to remove a golf ball size clump of oatmeal out of the patient's throat. EMS documentation noted Resident #1's cardiac arrest etiology (cause) was respiratory/asphyxia. Ventilation improved remarkably. Patient was transported to the local Emergency Room. Review of the local emergency room documentation dated 12/22/22 noted EMS found the resident unresponsive, pulseless, and apneic (not breathing) and took over CPR. EMS opened airway and noted airway obstruction; Large bolus (mass of chewed food) removed from airway by EMS and airway secured. The primary encounter diagnosis noted was airway obstruction due to foreign body. Resident #1 expired at the hospital on [DATE]. Review of the witness statement dated 12/22/22 showed the agency CNA assigned to care for Resident #1 documented on 12/22/22 she provided care to Resident #1 in her room, transferred her to a wheelchair and set her up with her breakfast at around 8:00 a.m. On 12/22/22 at around 9:22 a.m., she went to check on the resident and found her with her head tilted back and unresponsive. She quickly told the nurse who went to assess the resident. The nurse called a code blue. On 1/31/23 at approximately 3:30 p.m., the Director of Nursing said Resident #1 should have been observed during meals. On 2/1/23 at 2:17 p.m., Resident #1's brother who is the power of attorney said due her Parkinson's disease, Resident #1 had trouble with controlling her throat. She was supposed to always be supervised directly during eating or taken to a group dining room. But when he would come to visit her, she would be alone in her room with the food on her tray. He said there were several times that she had trouble getting her food down he would take the food from her mouth and remind her to eat slower. He said he told the staff when it occurred that she tried to put too much food in her mouth. 2. Resident #3 was admitted to the facility on [DATE] with diagnoses including cerebrovascular accident and dysphagia. Resident #3 received a pureed diet. The Speech Language Pathologist evaluation dated 1/16/23 noted Resident #3 required Speech Language Pathology services due to recent history of aspiration, and oropharyngeal dysphagia. Resident #3 completed a modified barium swallow (an imaging test that uses barium and X-rays to create images of the upper gastrointestinal tract) at the hospital resulting in recommendations for restorative exercises and compensatory strategies to improve safety and efficiency of swallowing function. The SLP noted during the clinical feeding evaluation of 1/16/23 Resident #3 completed small bites of pureed solids without overt signs and symptoms of aspiration. The SLP documented the resident was a known silent aspirator (food or liquid enters the airway and eventually the lungs without any outward signs of swallowing difficulty) and required cues to re-swallow. Penetration aspiration of 6 noted with straw sips of nectar thick. The assessment summary noted Resident #3 demonstrated coughing or choking during meals or when swallowing medications. The SLP documented the resident required supervision and assistance at mealtime due to swallowing safety 91 to 100% of the time. The admission Minimum Data Set (MDS) v1.17.1. assessment with an assessment reference date of 1/17/23 noted Resident #3 required extensive physical assistance of one person for eating. The assessment also noted Resident #3 did not display any signs or symptoms of possible swallowing disorder, including coughing or choking during meals or swallowing medications, despite the Speech Therapist's evaluation dated 1/16/23 which noted Resident #3 demonstrated coughing or choking during meals or when swallowing medications. The care plan initiated on 1/18/23 noted the resident had a potential for altered nutrition related to therapeutic/mechanically altered diet and multiple diagnoses. The care plan did not include provision to cue the resident to re-swallow as per the SLP's swallowing assessment to ensure swallow safety. Review of Resident #3's care plan developed on 2/2/23 showed Resident #3 has a swallowing problem related to difficulty with thin liquids, nectar thick liquids. The interventions listed included to keep the head of the bed elevated at 45 degrees during meals, not the 90 degrees recommended by the Speech Therapist. The care plan did not include the necessary one-to-one supervision when consuming food and liquids to cue the resident to swallow twice with each bite of food. The care plan did not have an intervention Resident #3 was not to use straws when drinking due to the potential for choking. On 2/3/23 at 1:30 p.m., the SLP said Resident #3 needed to be sitting at a 90 degree angle when eating and needed one-to-one supervision during meals to cue for second swallow with each bite of food. She verified the care plan was not individualized to meet the needs of the resident and ensure safe swallowing. 3. Resident #2 was initially admitted to the facility on [DATE] and diagnosed with dysphagia on 9/22/21. Resident #2's diet order dated 6/9/21 read, Dysphagia Advanced Diet texture [referring to the National Dysphagia Diet, Dysphagia-Advanced Level 3 (soft foods that require more chewing ability)], Nectar Thickened Fluids Consistency. Resident #2's care plan initiated on 10/19/2018 read, potential for ineffective airway clearance/aspiration . need for altered consistency diet and fluids with a history of Cerebral Vascular Accident. Interventions listed in Resident #2's care plan related to dysphagia included diet as ordered, observe during meals, Speech Therapy consult as ordered. On 1/30/23 at 12:50 p.m., observed a Styrofoam cup of thin water at Resident #2's bedside. Agency CNA, Staff B assigned to resident #2 verified the Styrofoam cup contained thin water. Staff B said no one reported to her Resident #2 was on thickened liquids. Staff B said there was no set process to pass on the information about meal supervision, assistance, and thickened liquid information. Staff B said the facility has a list of residents who need to go to the dining room for meals since the dining room is always supervised. On 2/3/23 at 11:55 a.m., Resident #2 was observed eating her lunch (rice, chicken, lima beans, cake, and ice cream) while lying in bed. The head of the bed was elevated approximately 40 degrees. The bed controller was observed at the foot of her bed and out of the resident's reach. Resident #2 was sliding down in the bed. There was no staff in the room assisting the resident. Resident #2 was not using utensils to eat. She was grabbing and bringing the food to her mouth with her right hand. On 2/3/23 12:58 p.m., Agency CNA, Staff C said she thought she had placed the head of the resident's bed at 90 degrees when she set up her tray. Staff C said she was not aware Resident #2 needed continued observation and assistance during meals. On 2/3/23 at 1:30 p.m., the Speech Therapist said on 2/2/23 she received a referral to assess Resident #2 for dysphagia. She said she was a graduate Speech Therapist and was still learning. She said she did not know how to ensure her recommendations for interventions to prevent choking could be a part of the resident's care plan. The Speech Therapist said Resident #2 should only be allowed to eat when she is awake, alert, and sitting upright at 90 degrees. The Speech Therapist said she would recommend periodic observations by staff during her meals. On 1/31/23 at approximately 3:30 p.m., the DON said staff should be observing Resident #2 during meals. The DON said Resident #2 shouldn't have had thin water at the bedside on 1/30/23. She said she was working with communication and documentation among all staff, but it was hard with so many agency staff being used by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview the facility administration failed to use its resources effectively to protect residents' rights to be free from neglect. The facility administration failed to ensure ongoing, accurate assessment, care planning, and adequate supervision of residents with dysphagia. Resident #1 who had dysphagia was not adequately assessed and did not have a care plan to meet her individualized needs for supervision during meals. On 12/22/22 Resident #1 did not receive the necessary supervision during meals. The resident was found unresponsive. Staff performed CPR (Cardiopulmonary resuscitation) and called Emergency Medical Services (EMS). EMS noted signs of foreign body airway obstruction and removed a golf ball size of oatmeal out of the resident's throat. Resident #1 was transferred to the hospital where she expired on 12/22/22. The failure of the facility's administration to prevent neglect and ensure ongoing, accurate assessment and provide necessary supervision of residents with dysphagia resulted in a determination of Immediate Jeopardy (IJ) at a scope and severity of isolated (J) starting on 12/22/22. The Administrator was notified of the Immediate Jeopardy on 2/6/23 at 3:15 p.m. and provided the IJ templates. The Immediate Jeopardy was ongoing. The findings included: Cross reference F600, F641, F684, and F689. Review of the Executive Director I (Administrator) job description showed the primary purpose of the Executive Director is to direct the day-to-day functions of the facility in accordance with current federal, state and local standards, guideline, and regulations that govern nursing facilities to ensure that the highest degree of quality care can be provided to our residents at all times . Job functions. Supervises Director of Clinical Services . Director of Rehabilitation Services . Duties and Responsibilities . Schedule regular meeting with direct report staff to provide supervision, ensure communication and to monitor facility operations. Maintain and guide the implementation of facility policies and procedures in compliance with corporate, state, federal, and other regulatory guidelines. Support and guide the facility's quality improvement process. Review of the Director of Clinical Services I (Director of Nursing) job description noted the purpose of the job position, . Entrusted with the responsibility of caring for our residents, families, co-workers, visitors, and all others . The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Executive Director to ensure that the highest degree of quality care is maintained at all times. Job Functions. As Director of Clinical Services I, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Responsible for planning, organizing, and directing the functions for the nursing department . Duties and Responsibilities . Recruit and hire a sufficient number of qualified nursing staff to deliver efficient resident care in accordance with established staffing plan . Actively participate in the quality improvement process for the facility . Schedule, direct and document regular meetings with nursing staff to assure effective communication. The facility policy, Abuse, Neglect, Exploitation & Misappropriation with a revision date of 11/16/22 noted, Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Failure to take precautionary measures to protect the health and safety of the residents. 1. Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Parkinson's disease (Long term degenerative disorder of the central nervous system). Review of the clinical record revealed a Speech Therapy (ST) evaluation dated 11/27/20 which noted Resident #1 was having more difficulty with mastication and swallowing, exhibiting coughing. The resident was now completely dependent on staff for feeding due to her Parkinson's. The Speech Therapist noted she witnessed Resident #1 gagging on food and coughing after the swallow at times. The ST documented a diagnosis of Dysphagia, oropharyngeal (Swallowing issues in the mouth and/or the throat) phase. Resident #1 received Speech Therapy and on 12/30/20 the Speech Therapist documented in a discharge summary, Patient education on . compensatory strategies to improve oral management of the bolus (mass of chewed food) and clear lingual residue. use of compensatory strategies and exercises for more effective and safe swallowing. Staff education on cueing and feeding strategies. The ST noted Resident #1 was controlling the bolus more effectively, the resident's Parkinson's disease was progressing, and she was no longer able to feed herself. Resident #1's care plan initiated on 6/3/20 and revised on 12/23/22 (one day after the resident expired) noted a diagnosis of Parkinson's disease. The interventions included to monitor, document, report to the physician as needed signs and symptoms of aspiration, or dysphagia, choking, coughing. Staff was to refer to Speech Therapy for any dysphagia problem. On 4/27/22 a Speech Therapist Evaluation showed Resident #1 was declining in her ability to communicate effectively. The Speech Therapist documented Resident #1 had a severe impairment with expressive language skills, and a severe impairment with oral motor and speech production. The Discharge Summary completed on 5/7/22 showed the patient was uncooperative and unable to be tested clinically due to, perseverative crying and agitated behavior. At discharge The Speech Therapist recommended supervision and anticipation of patient needs for optimal safety and quality of life at this time. There was no documentation the Speech Therapist assessed Resident #1's ability to swallow safely during the evaluation and treatment. The care plan as of 10/25/22 staff was to monitor, document, report PRN (as needed) any signs and symptoms of dysphagia including pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned at meals. Review of the Certified Nursing Assistants (CNAs) Activities of daily living tracking forms for November 2022 noted the CNAs were to answer Y (Yes) or N (No) to the question: Has the resident been coughing during meals, has the resident held food in mouth or cheeks or had resident food in mouth after meals? The form was blank for 50 of the 90 meals offered in November 2022. Six times the CNAs documented N/A meaning not applicable. On 11/21/22 for day and evening the CNA answered Y twice during the shift to the question Has the resident been coughing during meals. There was no documentation in the clinical record the CNA reported the episodes of coughing during meals as per the care plan instructions. CNA staff documented seven times during the month of 12/22 from 12/7/22 to 12/21/22 Resident #1 was dependent of staff for eating her meals. There was no documentation staff observed Resident #1 during meals from 12/7/22 to 12/22/22 for signs and symptoms of difficulty swallowing, aspiration, or dysphagia. On 12/22/22 at 9:24 a.m., Registered Nurse Staff C documented, CNA informed nurse that resident was unresponsive. Nurse called Code Blue., resident a full code per chart 0925 CPR started, crash cart in room, no v/s [vital signs] detected, 0930 911 called. Review of the EMS patient care record revealed they arrived onsite on 12/22/22 at 9:35 a.m. EMS noted what appeared to be signs of a foreign body airway obstruction. Patient had JVD (Jugular vein distention) and swelling in the throat. Patient also exhibited no chest rise and absent lung sounds during ventilations. EMS performed suction with no relief. EMS used a laryngoscope (tube with light to look at the voice box) and [NAME] forceps (angled forceps that can be used to remove foreign bodies) to open patient's airway. EMS was able to remove a golf ball size clump of oatmeal out of the patient's throat. EMS documentation noted Resident #1's cardiac arrest etiology (cause) was respiratory/asphyxia [a condition arising when the body is deprived of oxygen, causing unconsciousness or death]. Ventilation improved remarkably. Patient was transported to the local Emergency Room. Review of the local emergency room documentation dated 12/22/22 noted EMS found the resident unresponsive, pulseless, and apneic (not breathing) and took over CPR. EMS opened airway and noted airway obstruction; Large bolus removed from airway by EMS and airway secured. Review of the Emergency Department physician's documentation showed the primary encounter diagnosis documented was airway obstruction due to foreign body. Review of the facility's investigation dated 12/22/22 showed the agency CNA assigned to care for Resident #1 documented in a witness statement on 12/22/22 she provided care to Resident #1 in her room, transferred her to a wheelchair and set her up with her breakfast at around 8:00 a.m. On 12/22/22 at around 9:22 a.m., she went to check on the resident and found her with her head tilted back and unresponsive. She quickly told the nurse who went to assess the resident. The nurse called a code blue. The facility administration failed to conduct a thorough investigation of the incident. Review of the Nursing Home Federal Reporting submitted to the Florida Agency for Health Care Administration showed the facility did not substantiate the allegation of neglect for failure to provide the necessary supervision to Resident #1 on 12/22/22 when she was left unsupervised during meals. On 1/31/23 at approximately 3:30 p.m., the Director of Nursing said she did not know why the care plan said Resident #1 required supervision as needed. She said Resident #1 should have been observed during meals. On 2/2/23 at approximately 4:00 p.m., the Administrator said he thought Resident #1 expired due to cardiac arrest. He said on 1/18/23 he became aware of the allegation of neglect related to Resident #1 aspirating reported to him by adult protective services [Florida Department of Children and Families abuse investigator]. The Administrator provided a single sheet of paper signed and dated 2/1/23 by the Director of Nursing and Administrator listing the interventions implemented based on the incident involving Resident #1. The document read, Review in stand up meeting and it was decided by the team to restart the feeding program for resident at risk for dysphagia with emphasis on altered diet and fluids. PIP (Performance Improvement Project) was done in increase the number of residents attending dining room. Staff in serviced on documentation, checking [NAME] (gives overview of each resident's needs), huddle to emphasis on eating with supervision. Plan of care for residents with like diagnosis checked and ongoing. Referral to be sent to speech on any change in condition pertaining to eating. Review of the Education In-service Attendance record dated 1/19/23, 1/20/23, 1/24/23 and 1/25/23 showed education on Check [NAME] for assistance with eating and supervision was provided to nine of 20 Certified Nursing Assistants and four of 21 licensed nurses employed at the facility. There was no documentation the agency staff (Licensed Nurses and CNAs) were educated. There was no documented plan to ensure agency staff were educated prior to the start of their shift. The Administrator provided an ad hoc (unplanned) Quality Assurance and Performance Improvement meeting dated 1/3/23 to Increased in the number of residents attending the Main dining room for meals. The Administrator did not have documentation of a Performance Improvement Project with action steps and target date. The Administrator failed to provide documentation the facility administration discussed a process to ensure accurate evaluation , care planning, and the availability of staff to ensure residents with a diagnosis of dysphagia receive the necessary assistance and supervision during meals, or activities involving consumption of food and liquids. There was no audit to identify residents with dysphagia and ensure an accurate assessment and care plan was in place and implemented. 2. On 2/2/23 the facility provided a list of five residents with a diagnosis of dysphagia. Residents #2 and #3 were sampled for review. Resident #2 was initially admitted to the facility on [DATE] and diagnosed with dysphagia on 9/22/21. Resident #2's diet order dated 6/9/21 read, Dysphagia Advanced Diet texture, Nectar Thickened Fluids Consistency. Resident #2's care plan initiated on 10/19/2018 read, potential for ineffective airway clearance/aspiration . need for altered consistency diet and fluids with a history of Cerebral Vascular Accident. Interventions listed in Resident #2's care plan related to dysphagia included diet as ordered, observe during meals, Speech Therapy consult as ordered. On 1/30/23 at 12:50 p.m., observed a Styrofoam cup of thin water at Resident #2's bedside. Agency CNA, Staff B assigned to resident #2 verified the Styrofoam cup contained thin water. Staff B said no one reported to her Resident #2 was on thickened liquids. Staff B said there was no set process to pass on the information about meal supervision, assistance, and thickened liquid information. On 2/3/23 at 11:55 a.m., Resident #2 was observed eating her lunch (rice, chicken, lima beans, cake, and ice cream) while lying in bed. The head of the bed was elevated approximately 40 degrees. The bed controller was observed at the foot of her bed and out of the resident's reach. Resident #2 was sliding down in the bed. There was no staff in the room assisting the resident. Resident #2 was not using utensils to eat. She was grabbing and bringing the food to her mouth with her right hand. On 2/3/23 12:58 p.m., Agency CNA, Staff C said she was not aware Resident #2 needed continued observation and assistance during meals. On 2/3/23 at 1:30 p.m., the Speech Language Pathologist (SLP) said on 2/2/23 she received a referral to assess Resident #2 for dysphagia. She said she was a graduate Speech Therapist and was still learning. She said she did not know how to ensure her recommendations for interventions to prevent choking could be a part of the resident's care plan. 3. Resident #3 was admitted to the facility on [DATE] with diagnoses including cerebrovascular accident and dysphagia. Resident #3 received a pureed diet. The SLP noted during the clinical feeding evaluation of 1/16/23 Resident #3 was a known silent aspirator (food or liquid enters the airway and eventually the lungs, without any outward signs of swallowing difficulty) and required cues to re-swallow. The SLP documented the resident required supervision and assistance at mealtime due to swallowing safety 91 to 100% of the time. The care plan initiated on 1/18/23 did not include provision to cue the resident to re-swallow as per the Speech Therapy's swallowing assessment to ensure swallow safety. On 2/3/23 at 1:30 p.m., the SLP said Resident #3 needed to be sitting at a 90 degree angle when eating and needed one-to-one supervision during meals to cue for second swallow with each bite of food. She verified the care plan was not individualized to meet the needs of the resident and ensure safe swallowing. 4. Review of the Facility assessment dated [DATE] showed documentation the facility will staff according to the minimum staffing hours required of one hour of licensed nursing hours per person per day and two hours of certified nursing assist hours per person per day. The Facility assessments noted the facility will meet the minimum daily required ratios for staffing daily. The facility assessment did not include an evaluation of the residents' acuity level to ensure appropriate competent staffing, and equipment to meet each resident's individual needs. Review of the CMS Resident Census and Condition of Residents dated 1/30/23 showed the facility's census was 114. 23 residents were totally dependent on staff for eating, and toileting, and 49 residents required the assistance of at least one staff member for eating, and toileting. On 2/2/23 at 10:45 a.m., the Director of Nursing (DON) said the facility did not address the residents acuity when staffing the facility. She said due to the daily admissions she asks for extra assistance at least twice a week. The DON stated she did not have any role in completing the Facility Assessment, and administration did not include her in calculating staffing needs.