**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility and resident records, the facility's policy and procedure titled Abuse, Neglect, Exploitation, Mistreatment, Misappropriation of Property and Injury of Unknown Source Prevention (ANEMMI), and interviews with staff and outside medical professionals, the facility failed to protect Resident #1's right to be free from neglect, by failing to ensure adequate supervision and safeguards to prevent the resident, with a known history of pica (an eating disorder characterized by a compulsive and recurrent consumption of non-nutritive and non-food items), from consuming his incontinence pad, choking and dying. On June 20, 2025 at 1:49 PM, Resident #1 was found in his bed unresponsive with feces and bits of blue plastic resembling incontinence pad pieces in his mouth. Resuscitation efforts were initiated, and he was transported to the hospital by Emergency Medical Services (EMS), but resuscitation efforts failed. The Medical Examiner discovered during an autopsy that Resident #1 was full of foreign blue matter. The facility's failure to adequately supervise a resident with behavioral issues, resulting in his death, has the potential to negatively affect 52 other residents with behavioral care plans from a total of 173 residents residing in the facility. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 4:20 PM on July 1, 2025. On June 20, 2025 at 1:49 PM, Immediate Jeopardy (IJ) began. On July 2, 2025, at 6:30 PM, the Administrator was notified of the IJ determination, IJ templates were provided, and Immediate Jeopardy was ongoing as of the survey exit on July 2, 2025.The findings include:Cross reference F610, F835, and F867A review of a facility report authored by the Director of Nursing (DON) on 6/27/25, revealed that on 6/20/25 at 1:49 PM, Resident #1 was observed unresponsive in bed by a certified nursing assistant (CNA). The CNA called the Unit Manager (UM) immediately and upon entering the room, the UM observed brown stuff coming from Resident #1's mouth. A Code Blue (term used for a medical emergency involving respiratory or cardiac arrest) was paged overhead and chest compressions were initiated. Emergency Medical Services (EMS) was also called. EMS arrived at the facility and took over cardiopulmonary resuscitation (CPR). Resident #1 was taken to the emergency room but did not survive. An adult protective investigator (API) came to the facility, following a call she received from the sheriff's office, to investigate. The facility's report noted that Resident #1 was care planned for his behavior of eating his briefs/disposable incontinence pads. The report concluded that there was no diagnosis received from the emergency room (ER) and autopsy and toxicology reports were pending but normally took two months to receive. (Photographic evidence obtained)A review of the Adult Protective Investigator's (API's) 6/21/25 investigative report revealed that on 6/20/25, Resident #1 was pronounced deceased while in the care of the facility. He required 24-hour supervision, and the facility knew he liked to put things in his mouth. Resident #1 was left around those things and should have been supervised. He was able to put things in his mouth which possibly led to his death, but it was unknown if that was the cause. On 6/21/25, the API visited the facility and obtained interviews with staff involved. Supervisor A stated she was not in the building when the incident occurred but was aware that Resident #1 was hospitalized two or three months ago for placing inappropriate items in his mouth, including plastic forks, [disposable incontinence] pads, and adult diapers (briefs). According to Supervisor A, Resident #1's care plan should have included instructions for keeping these items out of his room. She also noted that this resident was not on one-on-one (1:1) supervision at the time. The report noted that CNA A stated 6/20/25 was her first day assigned to Resident #1 but no one informed her that he was not supposed to have incontinence pads in his room. CNA A also stated it was CNA B and CNA C who discovered Resident #1 with a disposable pad in his mouth, which had feces wrapped in it. When CNA A arrived at Resident #1's room, CNA B was attempting to remove the pad from the resident's mouth while the supervisor retrieved the emergency cart. CNA A reported she was informed by the UM at 3:00 PM that Resident #1 was not supposed to have disposable incontinence pads or briefs in his room due to his tendency to ingest them. CNA A stated she believed that Resident #1 should have been on one-on-one (1:1) supervision due to his behavior. During the API's interview, CNA A became emotional, began to cry and stated she had previously told the UM this resident needed one-on-one supervision. The staff dismissed her concerns saying she was trying to act like a supervisor. In the API's interview with Resident #1's family member, he explained that the facility contacted him and reported that Resident #1 was found eating his feces and an incontinence pad; behavior Resident #1 exhibited while living with family, which was part of the reason he was placed in a facility. (Photographic evidence obtained)An interview was conducted with CNA B on 7/1/25 at 10:36 AM. She reported recently finding Resident#1 unresponsive with several disposable incontinence pad pieces in his mouth. Feces were on the pad. She stated she could not say that was why he coded though. She picked up a hand full of leaves from the ground as an example of much material she found in his mouth (a small handful). She stated she removed pieces of the incontinence pad from the resident's mouth with her fingers, and when she did, he flinched. CNA B stated Resident #1 did not wear briefs or use disposable pads anymore. He had a brain injury and would chew on his socks, shirt, the pads and/or his briefs. She did not know how he got the pad she found in his mouth. The UM had recently advised the CNAs never to use the plastic pads, as the resident would chew on them. Resident #1's CNA that day was new to him and had only worked on the locked unit two or three times. CNA B did not know if the assigned CNA put the incontinence pad in the room, nor did she know where the rest of the pad (other than what she pulled from his mouth) was. She stated she felt terrible about the situation for three days. She was diligent in making sure Resident #1 was visible from the hall by making sure his window treatments and privacy curtains were pulled back, and he was placed so you could see his face from the hall. Resident #1 was not on one-on-one supervision.CNA C was interviewed on 7/1/25 at 11:13 AM. She stated she typically worked in the locked unit and usually had about 14 residents assigned to her, which kept her very busy. Residents were checked every two hours. On 6/20/25, she was across the hall and heard CNA B yelling for the nurse, so she ran into Resident #1's room. CNA B was trying to pull disposable incontinence pads out of the resident's mouth. There were strands of pads and feces in his mouth, and feces on his hand and leg. CNA B removed the pads, then she and CNA C laid him back down and started CPR (cardiopulmonary resuscitation). There was no plastic pad under Resident #1, and he was not wearing a brief, but he had been doing that, eating them. The CNAs reported it, and the UM was trying to figure out what to do and what to tell everyone to do. She thought the resident's physician knew about it. As far as she was aware, this behavior was new and had only been occurring for about four weeks. Resident #1 couldn't get up independently, so no one knew how he got an incontinence pad. He was taken to the hospital, and she found out that he didn't make it. He was gasping when she last saw him, so he was still breathing.CNA A was interviewed on 7/1/25 at 1:40 PM. She explained that she normally worked on another unit. The first time she worked in the locked unit, she saw Resident #1 eating his brief. This was about two weeks ago. She removed the brief and took it out of the room, but no one ever told her he could not have plastic briefs or pads. Later she saw him eating a cracker, and he was not supposed to have those because he could choke. She was assigned to Resident #1 on 6/20/25. When she first got to the locked unit, she was warned that Resident #1 would hit and kick, so CNA B volunteered to provide the resident's incontinence care that day. Since she had never worked with him before, CNA A agreed. She stated she was not used to those types of behaviors. She fed Resident #1 breakfast that morning and he sucked it down like a vacuum. He was not on one-on-one supervision, but she said he should have been. CNA A recalled that Resident #1 was not wearing brief, only shorts. There was no disposable pad. Later that day, CNA C said she had seen a pad on his bed but took it off. No one told her he couldn't be around briefs or pads. At about 2:00 PM, she was assisting a resident in another room, when she heard CNA B and someone else call out, [UM's name]! It's [Resident #1]! CNA A went to the room and when she went in, CNA B was pulling stuff out his mouth with a hanger, and a disposable pad this long (she used both hands to gesture the length of approximately 14 inches) came out. She stated the resident's jaw was locked and his tongue was sticking out. CNA B was trying to use the hanger to get the material out his mouth, but she was unsuccessful. CNA B started chest compressions, and the UM showed up and took over. Pieces of the incontinence pad were on the ground. CNA A stated she thought Resident #1's feces may have smelled like collard greens, which was what she fed him for lunch. He had asked for more greens after lunch. Maybe he ate the feces. There was no pad on the bed and Resident #1 could not move. When paramedics arrived and took over compressions, another piece of a pad came out of his rectum. He pooped the pads out. She stated she heard Resident #1 passed away on the way to the hospital. The next day (6/21/25) adult protective services came to the facility. Resident #1's entire chart was down/inaccessible, and when it became available again, a banner appeared on the chart. It was this whole huge warning about not providing incontinence pads or diapers. CNA A stated she told the UM two weeks prior to the incident that she saw Resident #1 eating his briefs. CNA A stated the UM said, We have it under control and accused the CNAs of breaking protocol. CNA A stated, We told [Licensed Practical Nurse (LPN) A] too but were told the residents on that unit always did that.The UM was interviewed on 7/1/25 at 2:38 PM. He stated there were a lot of resident behaviors on the locked dementia unit. No specific behavioral training was provided upon hire; they just used basic strategies. Any information related to medical history that came with a resident was put in the care plan on admission. When a behavior was reported or observed, it was documented and added to the care plan. CNAs could document on behaviors and a care warning could be placed on the electronic medical record (EMR) dashboard. The nurse would also notify the psychiatric nurse practitioner (PNP) or the physician. Resident #1 had a TBI (traumatic brain injury) with craniotomy (surgery to remove part of the skull to access the brain). He was combative with staff, cursed and bossed them around, kicked and punched at them. On the day of the event, the UM was at the nurses' station. The CNA called him to come to Resident #1's room. He went and could see Resident #1 was not exchanging air. The UM stated the CNA said it looked like the resident was choking on feces. He ate his feces and there were some blue particles he later realized were particles of an incontinence pad. Resident #1's mouth was open, and it looked like he was choking. The UM stated he ran, grabbed the crash cart, called Code Blue, and then called 911. CNA B started CPR. Resident #1 was in and out of consciousness and CPR continued until paramedics arrived. Resident #1 expired but the cause of death was not certain. The diagnosis of pica was not on his chart, but it was not a new behavior. The psychiatry service was aware. The UM stated he had seen Resident #1 picking at his brief and trying to eat his socks; he would eat anything. Resident #1 did not have one-on-one supervision, but the UM put documentation in his chart indicating no more briefs. This was on Friday the 13th (6/13/25). This was also put on the dashboard in the EMR. Resident #1 was care planned for no plastic, disposable pads, or anything like that. The facility investigated and got written statements from staff. Nothing unusual was reported and the CNAs who found the resident didn't say anything was different about him. They watched for disposable pads, but it may have been a brief too. He could not say where or when the resident obtained it. Resident #1 defecated a lot in the pads, so that was what he was eating, but there were no remnants of a pad anywhere in the room. The UM was asked if a KUB (abdominal x-ray) was ordered after discovering the resident was eating non-food items. He did not know. He stated Resident #1 had a history of this behavior according to CNA B, but that information was nowhere in the chart. The behavior resurfaced maybe a week before he put it in the resident's chart, and he advised CNA B to only use cloth pads. The UM stated he took the information to the Interdisciplinary Team and the Director of Nursing (DON) said, Ok, we will look into it. Eventually the environmental team provided the unit with cloth incontinence pads, but it took some time. Resident #1 had a fabric pad under him on 6/20/25. The UM stated he was unaware of the long strands of disposable incontinence pads on the floor. He said perhaps he didn't notice because they were covered with feces.The nurse practitioner (NP) was interviewed on 7/1/25 at 3:20 PM. She stated she came to the facility three times a week and Resident #1 was her resident. This was only the second time she had seen this resident, so she didn't know him that well. He had aggressive behaviors and would hit, kick, box, and once snarled at her. He was an eater. They called her to report he ate a sock one day, but she didn't know what to do about that. She was present on the day of the event (6/20/25) but had not been in the resident's room. When she got to him on 6/20/25, CPR had already been started. The UM had already suctioned out a lot of stuff but she did not know what it was. The UM used something like a Yankauer (a suction tip used for suctioning fluids and debris from a patient's airway) to get matter out. The NP used her hand to gesture a digging motion. It was really a Code [NAME] (a hospital code that generally refers to a hazardous spill that requires special handling). The NP stated Resident #1 would tear his sheets; he was an eater, like a toddler. His behavior was such that he was hard to work with. The disposable pad thing was addressed often. The UM made sure there were no plastic materials. The NP speculated that maybe it was an incontinence brief that they found in his mouth. She stated it was unfortunate but given the gravity of his issues, she did not know what more they could have done to prevent it. She asked herself if there was anything she could have done but felt that there was nothing more that could have done. When asked if additional supervision had been considered, she did not reply.A telephone interview was conducted with the Medical Examiner (ME) on 7/1/25 at 4:20 PM. He confirmed that he performed the autopsy on Resident #1. He reported the resident had a head injury, and there was a non-food items order on the resident's chart. When EMS arrived, Resident #1's oral cavity was filled with feces mixed in with small pieces of disposable incontinence pads; feces and plastic stuff. He stated he believed Resident #1 choked and that was how he died. When he opened the resident's cavity, it was full of the plastic material. The presence of feces in Resident #1's mouth indicated he was recycling it (defecating then eating the pad-tainted pieces). The ME found aspirated feces deep in the lungs and the resident's airway was stained with feces. Everything was contaminated. The ME stated he removed chunks of the material and digestive contents. He speculated it would take several days for the pad material to pass through the digestive system. The foreign matter extended past the resident's stomach; it was blue plastic with what looked like absorbent mesh. He stated he was surprised there was no obstruction or perforations, and he surgically removed a 6x6 centimeter square of white matter. At one point he just got tired of picking the material out piece-by-piece. The ME concluded by explaining that the material was not going to break down in the digestive tract, as the body did not produce enzymes to break down plastic.A telephone interview was conducted with the Adult Protective Investigator (API) on 7/2/25 at 7:30 AM. She verified the information in her report dated 6/21/25. She said she had a phone conversation with family who reported the facility was aware of Resident #1's behavior on admission. He was eating items and feces in the past while living at home. This was why he was admitted to the facility. She stated CNA B told her she had asked the nurses for one-on-one staffing but was told to stop acting like a supervisor; they already had it under control.During an interview with Licensed Practical Nurse (LPN) A on 7/2/25 at 9:54 AM, she said she worked on 6/20/25 but was not assigned to Resident #1. She was on break when he coded (cardiac/respiratory arrest). The UM advised her that the resident was in respiratory distress, had fecal matter all over him and coded. He said he had never seen anything like it. She gave Resident #1 his medications that morning. He was not on a disposable pad but was chewing his gown. She retrieved scissors and cut the tag off the gown. He would eat anything if you let him. Anything. The CNAs once reported he was trying to eat his brief. He would even tear his mattress and try to eat it. It was a new behavior every week. She did not know when the behavior started. The UM had written something, and the behavior was care planned, but he was not on one-on-one supervision. LPN A said she was familiar with pica behavior. All you must do is take items out of his reach. LPN A stated the new nurse practitioner (NP) came to the Code Blue. The psychiatric nurse practitioner (PNP) also worked with Resident #1, but medication did not always work. Resident #1 was polypharmacy (using multiple medications), but the PNP could not stop his aggressive behavior. LPN A stated psychotropic drugs (drugs that affect one's mental state) also make you eat a lot, so nothing worked in reducing Resident #1's desire to eat. She said, He was miserable and simply needed Jesus. At one point the PNP told her, I am maxed out (with meds); I don't know what more to do.An interview with the DON on 7/2/25 at 10:30 AM revealed that Resident #1 required total care and total assistance with transfers. He would try to eat everything around him, including his feces. The CNAs had to feed him so he could not get to the Styrofoam. Eating feces was kind of new but was not present on admission. Within a month or two, Resident #1 began pulling his briefs to shreds. Putting things in his mouth was also pretty new. The DON denied awareness of the 2024 incident when Resident #1 ingested a Styrofoam cup but reported that he would try to eat his socks. That had been happening for a while. He would tear his mattress, and everything would go to his mouth, so they removed everything they could. Staff kept Resident #1 in the TV room during the day to supervise him. These behaviors were discussed in our meetings. When asked what interventions were implemented to keep Resident #1 safe, The DON replied, Spoon-feeding and removing everything from his room. He said he thought Resident #1 had been care planned for his behavior from the start. He was followed by psychiatric services, was on medication, and the Medical Director (MD) knew of his behavior. The DON stated he was not present for the 6/20/25 event, but CNA A told him there were small pieces of blue incontinence pads in his mouth. The UM also reported this to him; that was why they did not use disposable pads for Resident #1. He was not sure how long the pads had been in his system, and speculated there were probably very long pieces present. He thought Resident #1 defecated and re-ingested them. There was a large amount of feces in the resident's mouth. The DON was unaware that during CPR, Resident #1 defecated pieces of blue plastic material.The MDS coordinator (MDSC) was interviewed on 7/2/25 at 11:45 AM. She explained that during morning meetings the team reviewed nursing and CNA notes about resident behaviors. They followed up with the psychiatric NP as needed. She knew Resident #1 but did not recall him chewing/eating incontinence pads or briefs. The MDSC reviewed Resident #1's care plan and confirmed it was not revised to include eating non-food items including briefs and incontinence pads until 6/20/25. She said she wished previous care plans had been more specific. The interdisciplinary team was responsible for developing care plan goals and interventions. She was not advised of Resident #1's behavior until the UM told her, and she was not sure what interventions were in place on the nursing unit. The MDSC knew about the dangers of pica behavior and took it very seriously.An electronic medical record (EMR) review for Resident #1 revealed he was admitted to the facility on [DATE], discharged on 9/4/24, and readmitted on [DATE]. The EMR landing page included a Special Instructions warning on the dashboard advising that Resident #1 should not be given, have within reach, or be left unattended if items were made from plastic, sponge, foam and/or paper. As a result, all following items are barred from use [disposable incontinence pads]/bed padding/under padding, brief/ [adult disposable incontinence briefs]/diaper and pull-ups, except for mattresses. Items made from fabric are ideal . (Photographic evidence obtained) Diagnoses included, but were not limited to, traumatic brain injury (TBI), hip fracture, unspecified protein -calorie malnutrition, muscle weakness, hemiplegia and hemiparesis (one sided weakness or paralysis) following cerebral infarction (stroke) affecting left non-dominant side, dysphagia oropharyngeal phase (difficulty initiating swallowing), cognitive communication deficit, need for assistance with personal care, anxiety, depression, restlessness and agitation.The quarterly minimum data set (MDS) assessment, with a reference date of 6/7/25, revealed that Resident #1's brief interview for mental status score was 7 out of a possible 15 points, indicating severe cognitive impairment. Inattention, disorganized thinking and altered level of consciousness fluctuated. Resident #1 used a wheelchair for mobility and was dependent on staff for activities of daily living including eating. He was frequently incontinent of bowel with no active toileting program. Resident #1 received routine antidepressant and anticonvulsant medications.Resident #1 was care planned on 6/2/24 for impaired or inappropriate behaviors related to his TBI. No specific description of inappropriate behavior was provided in the care plan. The goal was to be free from behavior through the next review. Interventions included medications as ordered, monitor for side effects and effectiveness; If reasonable, discuss resident's behavior. Explain why behavior is inappropriate or unacceptable to the resident. Provide a program of activities that accommodates the resident's status. Provide non-pharmacological interventions. Revisions were made on 6/10/24, 9/25/24, and 12/6/24; however, there were no changes to the interventions and no specific behaviors described until 6/20/25 to add, I.E. Resident removes his diapers, puts self on floor, slams leg against footrest/mattress, and eats briefs/[disposable pads]. (Photographic evidence obtained)A physician's order dated 6/13/25 instructed, [Resident #1] should not be given, have within reach or be left unattended if items are made from plastic, sponge, foam and paper. As a result, all following items are barred from use [disposable incontinence pads]/bed padding/under padding, brief/ [disposable incontinence briefs]/diaper and pull-ups, except for mattresses. Items made from fabric are ideal, therefore they are acceptable. There was no corresponding progress note to justify why this order was entered at this time.The physician's order for behavior monitoring, dated 1/22/25, instructed to monitor for: Itching, picking at skin, restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, foul language, elopement, stealing, delusions, hallucinations, psychosis, aggression, and refusal of care. There were no revisions or instructions to monitor Resident #1 for placing inedible objects and items into his mouth or eating them. (Photographic evidence obtained)A review of nursing progress notes revealed an entry dated 6/3/24 by the psychiatric nurse practitioner (PNP) reporting that a CNA advised him that Resident #1 was trying to eat his [incontinence pads]. (Photographic evidence obtained) A Nursing Alert progress note dated 6/17/24 advised that Resident #1 was found in bed eating a Styrofoam cup. He returned the remainder of the cup to the nurse but continued to chew and appeared to swallow the part of the cup that was in his mouth. The Nurse Practitioner (NP) was notified, and no new orders were given. (Photographic evidence obtained)Further review of the record found no orders for diagnostic tests or imaging after ingesting part of the Styrofoam cup.A review of additional progress notes found that contrary to staff interviews, no information about Resident #1 tearing and/or eating inedible items including briefs or incontinence pads was documented until 6/20/25 at 2:43 PM when the UM described the incident. The note said at approximately 1:49 PM, a CNA called the UM to [Resident #1's] room. Upon arrival, Resident #1 was found in bed, unresponsive and in respiratory distress. Both eyes were open, and two CNAs were at bedside. A brown substance was coming from the resident's mouth. He had no pulse, skin was warm to the touch, and he was very difficult to arouse with a sternal rub. Fecal matter was scattered over the bed, the resident's body, hands and face. His skin was pale and bilateral (both) lower extremities were bluish purple. Chest compressions were initiated, Code Blue was called, and Emergency Medical Services (EMS) was called for assistance. Resident #1 started responding as evidenced by chest rise, a weak carotid pulse, and slight improvement in skin color. Rescue arrived at approximately 2:07 PM. The resident was in and out of consciousness when EMS arrived and was transferred to the hospital at 2:25 PM. (Photographic evidence obtained)The NP's Discharge summary, dated [DATE], stated Resident #1 had a medical emergency, was transferred to the ER and was discharged . He had last been seen on 5/20/25 for a monthly visit. There was no mention of blue material or feces in Resident #1's mouth. (Photographic evidence obtained) Further review of the record found no notes by the NP, Psychiatric NP, Physician or Psychologist about Resident #1 ingesting inedible items.On 7/2/25 at 12:40 PM, the Administrator was asked about the 6/20/25 event. She stated she was on leave but was advised of the incident. She was told that Resident #1 had feces in his mouth. She did not know if Resident #1 aspirated or choked. When police arrived to investigate, they said they were trying to rule out homicide due to the presence of what appeared to be incontinence pads in the resident's mouth. She stated she had been told of the small pieces of what appeared to be pads in his mouth, but the resident had not had access to those items for a long time. The Administrator was advised, and acknowledged, the physician's order prohibiting access to those items was not obtained until 6/13/25; one week before the incident. When she was advised that the resident also defecated the blue material during CPR, she said she had not been told that.In a second interview with the Administrator on 7/2/25 at 1:26 PM, she explained that the UM told her Resident #1 had been picking at his plastic incontinence pads but also picked at cloth pads. On the day of the event, while suctioning Resident #1's mouth with a Yankauer suction device, the UM noticed feces and shreds of little blue pieces of plastic inside the resident's mouth. The matter was also coming from the resident's rectum, and he had feces in his hand. The psychiatric NP told the Administrator he had not noted any such behavior. He said with TBI, any type of behavior could occur. The Administrator stated she had not known of these behaviors as the only warning the nurses gave her was to watch out, he kicks. The Administrator said she did not understand why the CNAs were not telling the nurses about the resident's behavior. She was advised that the CNAs said they had notified nursing but were told to stand down. She confirmed that Resident #1 was never on increased supervision but said they would provide one-on-one staffing if needed. This was the first time she had ever been advised that Resident #1 was ingesting inedible items. Nothing had ever been in the 24-hour reports, which she reviewed daily.In an interview with the Medical Director (MD) on 7/2/25 at 1:19 PM, she said she had not been advised that Resident #1 was attempting to ingest inedible objects. She was in the building frequently and only knew of him kicking. She heard he was sent to the hospital but could not remember if staff told her about the plastic. The NP usually brought this type of information to her attention. Resident #1 was followed by the psychiatric NP. Had she been aware of the behavior, she would have referred to him so there were not two providers involved.A review of the facility's policy titled Abuse, Neglect, Exploitation, Mistreatment, Misappropriation of Property and Injury of Unknown Source Prevention (ANEMMI) (undated), revealed the purpose was to assure that the facility was doing all that was within its control to prevent occurrences of ANEMMI and protect its residents. The policy stated an alleged violation was a situation or occurrence that was observed or reported by staff, a resident, relative, visitor, another health care provider, or others, but had not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to . neglect. The policy defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish or emotional distress . The policy vowed residents would be protected from neglect by having structures and processes to provide needed care and services including identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. It stated the facility would analyze the supervision of staff on all shifts to identify inappropriate behaviors, including residents with self-injurious behavior. (Photographic evidence obtained)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility and resident records, facility's policy and procedure titled Abuse, Neglect, Exploitation, Mistreatment, Misappropriation of Property and Injury of Unknown Source Prevention (ANEMMI), and interviews with staff and outside medical professionals, the facility failed to conduct a thorough investigation to rule out abuse or neglect after one (Resident #1) of one resident with a known history of pica (an eating disorder characterized by a compulsive and recurrent consumption of non-nutritive and non-food items), who chewed and consumed incontinence briefs and disposable incontinence pads, was found unresponsive with feces and bits of blue plastic resembling incontinence pad pieces in his mouth. As a result of the incident, Resident #1 died. Despite direct observation of the event by CNAs A, B, C, the Unit Manager (UM) and Nurse Practitioner (NP), no interviews were obtained and there was no evidence verifying that a thorough record review was conducted. Only written statements, which omitted relevant information, were gathered for the investigation. Without a thorough analysis of adverse resident events, the facility was unable to identify causes and measures needed to ensure the safety and protection of other residents at risk. This failure had the potential to negatively impact all 52 residents in the facility who were care planned for behaviors. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 4:20 PM on July 1, 2025. On June 20, 2025 at 1:49 PM, Immediate Jeopardy (IJ) began. On July 2, 2025, at 6:30 PM, the Administrator was notified of the IJ determination, IJ templates were provided, and Immediate Jeopardy was ongoing as of the survey exit on July 2, 2025. The findings include:Cross Reference F600, F835, and F867An electronic medical record (EMR) review for Resident #1 revealed he was admitted to the facility on [DATE], discharged on 9/4/24, and readmitted on [DATE]. The EMR landing page included a Special Instructions warning on the dashboard advising that Resident #1 should not be given, have within reach, or be left unattended if items were made from plastic, sponge, foam and/or paper. As a result, all following items are barred from use [disposable incontinence pads]/bed padding/under padding, brief/ [adult disposable incontinence briefs]/diaper and pull-ups, except for mattresses. Items made from fabric are ideal . (Photographic evidence obtained) Diagnoses included, but were not limited to, traumatic brain injury (TBI), hip fracture, unspecified protein -calorie malnutrition, muscle weakness, hemiplegia and hemiparesis (one sided weakness or paralysis) following cerebral infarction (stroke) affecting left non-dominant side, dysphagia oropharyngeal phase (difficulty initiating swallowing), cognitive communication deficit, need for assistance with personal care, anxiety, depression, restlessness and agitation.The quarterly minimum data set (MDS) assessment, with a reference date of 6/7/25, revealed that Resident #1's brief interview for mental status score was 7 out of a possible 15 points, indicating severe cognitive impairment. He was frequently incontinent of bowel with no active toileting program. He was care planned on 6/2/24 for impaired or inappropriate behaviors related to his TBI (traumatic brain injury). On 6/20/25, the care plan was revised to add the following details: Resident removes his diapers, puts self on floor, slams leg against footrest/mattress, and eats briefs/[disposable pads]. Interventions did not address supervision or removal of such objects from his room. (Photographic evidence obtained)A review of the physician's order dated 6/13/25 prohibited exposure to plastic, sponge, foam and paper and barred disposable incontinence pads/bed padding/under padding, brief/disposable briefs/diaper and pull-ups, except for mattresses. There was no corresponding progress note to explain why this order was entered at this time.A progress note authored by the Unit Manager (UM) on 6/20/25 at 2:43 PM, revealed that at approximately 1:49 PM, a certified nursing assistant (CAN) called the UM to [Resident #1's] room. Resident #1 was found in bed, unresponsive, and in respiratory distress. Two CNAs were at bedside and a brown substance was coming from the resident's mouth. He had no pulse, was warm to the touch, and was difficult to arouse with a sternal rub. Fecal matter was scattered over the bed, the resident's body, hands and face. Chest compressions were initiated, Code Blue (term used for a medical emergency involving respiratory or cardiac arrest) was called, and Emergency Medical Services (EMS) was called for assistance. Rescue arrived at approximately 2:07 PM and the resident was transferred to the hospital at 2:25 p.m. (Photographic evidence obtained)A review of a facility report authored by the Director of Nursing (DON) on 6/27/25, revealed that on 6/20/25 at 1:45 PM, Resident #1 was observed unresponsive in bed by a certified nursing assistant (CNA). The CNA called the Unit Manager (UM) immediately and upon entering the room, the UM observed brown stuff coming from Resident #1's mouth. A Code Blue (term used for a medical emergency involving respiratory or cardiac arrest) was paged overhead and chest compressions were initiated. Emergency Medical Services (EMS) was also called. EMS arrived at the facility and took over cardiopulmonary resuscitation (CPR). Resident #1 was taken to the emergency room but did not survive. The facility's report noted that Resident #1's care plan indicated he had a behavior of eating his briefs/disposable incontinence pads. The report concluded that there was no diagnosis received from the emergency room (ER) and autopsy and toxicology reports were pending but normally took two months to receive. The report also noted that an Adult Protective Investigator (API) came to the facility to investigate following a call she received from the sheriff's office. (Photographic evidence obtained)A review of the Adult Protective Investigator's (API's) 6/21/25 investigative report revealed that on 6/20/25, Resident #1 was pronounced deceased while in the care of the facility. He required 24-hour supervision, and the facility knew he liked to put things in his mouth. Resident #1 was left around those things and should have been supervised. He was able to put things in his mouth which possibly led to his death, but it was unknown if that was the cause. On 6/21/25, the API visited the facility and obtained interviews with staff involved. Supervisor A stated she was not in the building when the incident occurred but was aware that Resident #1 was hospitalized two or three months ago for placing inappropriate items in his mouth, including plastic forks, [disposable incontinence] pads, and adult diapers (briefs). According to Supervisor A, Resident #1's care plan should have included instructions for keeping these items out of his room. She also noted that this resident was not on one-on-one (1:1) supervision at the time. The report noted that CNA A stated 6/20/25 was her first day assigned to Resident #1 but no one informed her that he was not supposed to have incontinence pads in his room. CNA A also stated it was CNA B and CNA C who discovered Resident #1 with a disposable pad in his mouth, which had feces wrapped in it. When CNA A arrived at Resident #1's room, CNA B was attempting to remove the pad from the resident's mouth while the supervisor retrieved the emergency cart. CNA A reported she was informed by the UM at 3:00 PM that Resident #1 was not supposed to have disposable incontinence pads or briefs in his room due to his tendency to ingest them. CNA A stated she believed that Resident #1 should have been on one-on-one (1:1) supervision due to his behavior. During the API's interview, CNA A became emotional, began to cry and stated she had previously told the UM this resident needed one-on-one supervision. The staff dismissed her concerns saying she was trying to act like a supervisor. In the API's interview with Resident #1's family member, he explained that the facility contacted him and reported that Resident #1 was found eating his feces and an incontinence pad; behavior Resident #1 exhibited while living with family, which was part of the reason he was placed in a facility. (Photographic evidence obtained)The facility's investigation file into the 6/20/25 incident was reviewed. The file consisted of written statements from multiple staff members who reported they had seen nothing unusual or nothing at all. The statement from the UM, dated 6/20/25, noted a brown substance in Resident #1's mouth, but said nothing about blue material. He wrote that EMS initially reported a possible homicide, thinking someone stuffed incontinence pads down the resident's mouth/throat. CNA B's report, dated 6/25/25, documented her observation of blue pads mixed with feces protruding from Resident #1's mouth during the event. (Photographic evidence obtained) CNA A's undated statement omitted all information of her direct witness to the blue material coming from the resident's mouth or rectum. There was no written statement by CNA C, who was in the room during the event. The investigation file was void of any staff interviews and was not reflective of a comprehensive record review in an effort to determine what happened or how blue foreign particles were discovered in Resident #1's feces.An interview was conducted with CNA B on 7/1/25 at 10:36 AM. She found Resident#1 unresponsive with several pieces of disposable incontinence pad pieces and feces in his mouth. She removed them with her fingers. Resident #1 had a brain injury and would chew on his socks, shirt and the incontinence pads or briefs. She did not know how he got the pad as he did not use disposable pads or briefs anymore because he would chew them. She was diligent in making sure Resident #1 was visible from the hall by making sure his window treatments and privacy curtains were pulled back, and the bed was placed so the resident's face could be seen from the hall. Resident #1 was not on one-on-one supervision. CNA B was not interviewed by any staff member after the event. She was only interviewed by the API.CNA C was interviewed on 7/1/25 at 11:13 AM. She stated she heard CNA B yelling for the nurse, so she ran to Resident #1's room. CNA B was trying to pull disposable pads out of the resident's mouth. There were strands of pads and feces in his mouth, and feces on his hand and leg. CNA B removed the pads, then she and CNA C laid him back down and started CPR (cardiopulmonary resuscitation). There was no plastic pad under the resident, and he was not wearing a brief, but he had been doing that, eating them. The CNAs reported it, and the UM was trying to figure out what to do and what to tell everyone to do. She thought the resident's physician knew about it. As far as she was aware, this behavior was new and had only been occurring for about four weeks. Resident #1 couldn't get up independently, so no one knew how he got an incontinence pad. No one from the facility interviewed her after the event, which she said she found strange since she was in the room at the time. CNA A was interviewed on 7/1/25 at 1:40 PM. She was assigned to Resident #1 for the first time on 6/20/25. She said she saw Resident #1 eating his brief about two weeks ago when she worked on the locked unit for the first time. She went to Resident #1's room around 2:00 PM after hearing calls for help. When she entered the room she saw CNA B was pulling stuff out of his mouth with a hanger, and a disposable pad this long (she used both hands to gesture the length of approximately 14 inches) came out. She stated the resident's jaw was locked, and his tongue was sticking out. CNA B was trying to use the hanger to get the material out his mouth, but she was unsuccessful. CNA B started chest compressions, and the UM showed up and took over. Pieces of the incontinence pad were on the ground. When paramedics arrived and took over compressions, another piece of a pad came out of his rectum. He pooped the pads out. The next day (6/21/25) adult protective services came to the facility. CNA A stated she told the UM two weeks prior to the incident that she saw Resident #1 eating his briefs. CNA A stated the UM said, We have it under control. and accused the CNAs of breaking protocol. CNA A stated, We told [Licensed Practical Nurse (LPN) A] too but were told the residents on that unit always did that. CNA A concluded by reporting that no one from the facility interviewed her as part of an investigation into the event.The UM was interviewed on 7/1/25 at 2:38 PM. He confirmed that he responded to calls for help on 6/20/25 and found Resident #1 was not exchanging air. The UM stated the CNA said it looked like the resident was choking on feces. Resident #1 ate his feces and there were some blue particles he later realized were particles of incontinence pads. Resident #1's mouth was open, and it looked like he was choking. CNA B started CPR, which continued until paramedics arrived. Resident #1 expired, but the cause of death was not certain. The UM had seen the resident picking at his brief and trying to eat his socks; he would eat anything. Resident #1 defecated on the incontinence pads a lot, so that was what he was eating, but there were no remnants of a pad anywhere in the room. The facility investigated and obtained written statements but nothing unusual was reported.A telephone interview was conducted with the Medical Examiner (ME) on 7/1/25 at 4:20 PM. He confirmed that he performed the autopsy on Resident #1. He reported the resident had a head injury, and there was a non-food items order on the resident's chart. When EMS arrived, Resident #1's oral cavity was filled with feces mixed in with small pieces of disposable incontinence pads; feces and plastic stuff. He stated he believed Resident #1 choked and that was how he died. When he opened the resident's cavity, it was full of the plastic material. The presence of feces in Resident #1's mouth indicated he was recycling it (defecating then eating the pad-tainted pieces). The ME stated at one point he just got tired of picking the material out piece-by-piece, as there was so much. He stated the body did not produce enzymes to break down plastic.A telephone interview was conducted with the Adult Protective Investigator (API) on 7/2/25 at 7:30 AM. She verified the accuracy of the interviews documented in her report dated 6/21/25. She said she had a phone conversation with a family member who reported that the facility was aware of Resident #1's behavior on admission; he was eating items and feces in the past while living at home. This was why he was admitted to the facility.On 7/2/25 at 12:40 PM, the Administrator was asked about the 6/20/25 event. She stated she was on leave but was advised of the incident. She was told that Resident #1 had feces in his mouth. She did not know if Resident #1 aspirated or choked. When police arrived to investigate, they said they were trying to rule out homicide due to the presence of what appeared to be incontinence pads in the resident's mouth. She stated she had been told of the small pieces of what appeared to be pads in his mouth, but the resident had not had access to those items for a long time. The Administrator acknowledged the physician's order prohibiting access to those items was not obtained until 6/13/25; one week before the incident. When advised the resident also defecated the blue material during the event, she said she had not been told that. She was asked if she investigated the incident. She said when she returned from leave, the investigation was already completed. The administrator was asked if she conducted any staff interviews as part of the investigation. She responded no and again insisted the investigation had been completed in her absence. She confirmed that only written statements were obtained. When asked if she realized how dangerous pica behavior/ingesting inedible objects was, she replied, I am not a nurse, so I don't know anything about pica. The Administrator acknowledged the presence of non-food items in Resident #1's mouth along with feces should have warranted a more thorough investigation and that interviews with staff involved would have likely revealed additional pertinent information. The Administrator was advised that the written statements failed to reflect details of what staff actually said they saw. She had no response. She returned to the conference room at 1:26 PM with scattered handwritten notes on a legal pad. She said she had been told by the UM that Resident #1 was picking at his plastic incontinence pads but would also pick at cloth ones. The UM had used a Yankauer device to suction the resident's mouth and noticed bits of feces and shreds of little blue plastic pieces in the feces. Pieces were coming from his mouth and rectum and were on his hands. She pointed to a handwritten note indicating that statements had been obtained but interviews were needed. There was also a question about the root cause. Another note was a reminder to identify other residents with behaviors. The Administrator said she heard Resident #1's jaws were locked so he could have had a seizure. She stated since he had never eaten feces prior to this, that was a question she also had. The Administrator had no awareness of pica behaviors observed during his initial admission in 2024; she was not here then. This writer advised her those notes were in the electronic medical record (EMR). She said she did not know why the CNAs weren't telling the nurses about the resident's behavior. She was advised that interviews were obtained to the contrary during the survey. Had she interviewed staff she may have had this information. A review of the facility's policy titled Abuse, Neglect, Exploitation, Mistreatment, Misappropriation of Property and Injury of Unknown Source Prevention (ANEMMI) (undated), revealed:Intent: The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences and protect its residents. Stated under section V. Investigation: The facility will investigate different types of violations, identify and interview all involved persons, including witnesses, and others who might have knowledge of the allegations. The investigation will focus on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and provide complete and thorough documentation of the investigation. (Photographic evidence obtained)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility and resident records, facility job descriptions, policies and procedures, and interviews with staff and medical professionals, the facility's Administration failed to provide oversight of the facility in a manner that ensured necessary interventions, including supervision, were in place for Resident #1's safety when he had a known history of pica (an eating disorder characterized by a compulsive and recurrent consumption of non-nutritive and non-food items), and consistently chewed/consumed his briefs and disposable incontinence pads. On June 20, 2025 at 1:49 PM, Resident #1 was found in his bed unresponsive with feces and bits of blue plastic resembling incontinence pad pieces in his mouth. Resuscitation efforts were initiated, and he was transported to the hospital by Emergency Medical Services (EMS), but resuscitation efforts failed, and the resident expired. Despite numerous staff members' awareness of the resident's behaviors, neither the Administrator nor the Medical Director had knowledge of the behaviors or risk factors for this resident's safety. Administration failed to exact immediate action following an event resulting Resident #1's death, failed to implement measures for resident safety, and failed to thoroughly investigate the incident to identify system failures and facility needs. This affected one (Resident #1) of three residents reviewed for behavioral issues, from a total of 52 residents with behavioral care plans. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 4:20 PM on July 1, 2025. On June 20, 2025 at 1:49 PM, Immediate Jeopardy (IJ) began. On July 2, 2025, at 6:30 PM, the Administrator was notified of the IJ determination, IJ templates were provided, and Immediate Jeopardy was ongoing as of the survey exit on July 2, 2025. The findings include:Cross reference F600, F610, and F867 A review of a facility report authored by the Director of Nursing (DON) on 6/27/25, revealed that on 6/20/25 at 1:49 PM, Resident #1 was observed unresponsive in bed by a certified nursing assistant (CNA). The Unit Manager (UM) responded and observed brown stuff coming from Resident #1's mouth. Code Blue (a term used for a medical emergency involving respiratory or cardiac arrest) was paged overhead, chest compressions were initiated, and Emergency Medical Services (EMS) was called. Upon arrival, EMS took over cardiopulmonary resuscitation (CPR). Resident #1 was transported to the emergency room but did not survive. An Adult Protective Investigator (API) came to the facility following a call she received from the sheriff's office. The facility's report noted that Resident #1 was care planned for his behavior of chewing/eating his briefs/disposable incontinence pads. The report concluded that there was no diagnosis received from the emergency room (ER) and autopsy and toxicology reports were pending. (Photographic evidence obtained)A review of the Adult Protective Investigator's (API's) 6/21/25 investigative report revealed that on 6/20/25, Resident #1 was pronounced deceased while in the care of the facility. He required 24-hour supervision, and the facility knew he liked to put things in his mouth. Resident #1 was left around those things and should have been supervised. During her visit to the facility on 6/21/25, the API interviewed Supervisor A, who reported Resident #1 was hospitalized two or three months ago for placing inappropriate items in his mouth, including plastic forks, [disposable incontinence] pads, and adult diapers/briefs. According to Supervisor A, Resident #1's care plan should have included instructions for keeping these items out of his room. The report noted that Certified Nursing Assistant (CAN) A was assigned to Resident #1 on 6/20/25, but no one informed her that he was not supposed to have incontinence pads in his room. CNA B and CNA C discovered Resident #1 with a disposable incontinence pad in his mouth, which had feces wrapped in it. CNA A saw CNA B attempting to remove the pads from the resident's mouth. At 3:00 PM that day, the UM told the API that Resident #1 was not supposed to have disposable pads or diapers in his room due to his tendency to ingest them. The API concluded by saying she believed Resident #1 should be on one-on-one supervision due to his behavior. CNA A became emotional, began to cry and stated she had previously told the UM this resident needed one-on-one supervision. The staff dismissed her concerns, saying she was trying to act like a supervisor. In the API's interview with Resident #1's family member, the family member explained that the facility contacted him and reported that the resident was found eating his feces and an incontinence pad; behavior Resident #1 exhibited while living with family, which was part of the reason he was placed in a facility. (Photographic evidence obtained)An interview was conducted with CNA B on 7/1/25 at 10:36 a.m. She reported recently finding (Resident#1) unresponsive with disposable incontinence pad pieces in his mouth. Feces were on the pad. She stated she could not say that was why he coded though. She picked up a hand full of leaves from the ground as an example of much material she found in his mouth (a small handful). She stated she removed pieces of the incontinence pad from the resident's mouth with her fingers, and when she did, he flinched. CNA B stated Resident #1 did not wear briefs or use disposable pads anymore. He had a brain injury and would chew on his socks, shirt, the pads and/or his briefs. She did not know how he got the pad she found in his mouth. The UM had recently advised the CNAs never to use the plastic pads, as the resident would chew on them. Resident #1's CNA that day was new to him and had only worked on the locked unit two or three times. CNA B did not know if the assigned CNA put the incontinence pad in the room, nor did she know where the rest of the pad (other than what she pulled from his mouth) was. She stated she felt terrible about the situation for three days. She was diligent in making sure Resident #1 was visible from the hall by making sure his window treatments and privacy curtains were pulled back, and he was placed so you could see his face from the hall. Resident #1 was not on one-on-one supervision.CNA C was interviewed on 7/1/25 at 11:13 AM. She stated she typically worked in the locked unit and usually had about 14 residents assigned to her, which kept her very busy. Residents were checked every two hours. On 6/20/25, she was across the hall and heard CNA B yelling for the nurse, so she ran into Resident #1's room. CNA B was trying to pull disposable incontinence pads out of the resident's mouth. There were strands of pads and feces in his mouth, and feces on his hand and leg. CNA B removed the pads, then she and CNA C laid him back down and started CPR (cardiopulmonary resuscitation). There was no plastic pad under Resident #1, and he was not wearing a brief, but he had been doing that, eating them. The CNAs reported it, and the UM was trying to figure out what to do and what to tell everyone to do. She thought the resident's physician knew about it. As far as she was aware, this behavior was new and had only been occurring for about four weeks. Resident #1 couldn't get up independently, so no one knew how he got an incontinence pad. He was taken to the hospital, and she found out that he didn't make it. He was gasping when she last saw him, so he was still breathing.CNA A was interviewed on 7/1/25 at 1:40 PM. She explained that she normally worked on another unit. The first time she worked in the locked unit, she saw Resident #1 eating his brief. This was about two weeks ago. She removed the brief and took it out of the room, but no one ever told her he could not have plastic briefs or pads. Later she saw him eating a cracker, and he was not supposed to have those because he could choke. She was assigned to Resident #1 on 6/20/25. When she first got to the locked unit, she was warned that Resident #1 would hit and kick, so CNA B volunteered to provide the resident's incontinence care that day. Since she had never worked with him before, CNA A agreed. She stated she was not used to those types of behaviors. She fed Resident #1 breakfast that morning and he sucked it down like a vacuum. He was not on one-on-one supervision, but she said he should have been. CNA A recalled that Resident #1 was not wearing brief, only shorts. There was no disposable pad. Later that day, CNA C said she had seen a pad on his bed but took it off. No one told her he couldn't be around briefs or pads. At about 2:00 PM, she was assisting a resident in another room, when she heard CNA B and someone else call out, [UM's name]! It's [Resident #1]! CNA A went to the room and when she went in, CNA B was pulling stuff out his mouth with a hanger, and a disposable pad this long (she used both hands to gesture the length of approximately 14 inches) came out. She stated the resident's jaw was locked and his tongue was sticking out. CNA B was trying to use the hanger to get the material out his mouth, but she was unsuccessful. CNA B started chest compressions, and the UM showed up and took over. Pieces of the incontinence pad were on the ground. CNA A stated she thought Resident #1's feces may have smelled like collard greens, which was what she fed him for lunch. He had asked for more greens after lunch. Maybe he ate the feces. There was no pad on the bed and Resident #1 could not move. When paramedics arrived and took over compressions, another piece of a pad came out of his rectum. He pooped the pads out. She stated she heard Resident #1 passed away on the way to the hospital. The next day (6/21/25) adult protective services came to the facility. Resident #1's entire chart was down/inaccessible, and when it became available again, a banner appeared on the chart. It was this whole huge warning about not providing incontinence pads or diapers. CNA A stated she told the UM two weeks prior to the incident that she saw Resident #1 eating his briefs. CNA A stated the UM said, We have it under control and accused the CNAs of breaking protocol. CNA A stated, We told [Licensed Practical Nurse (LPN) A] too but were told the residents on that unit always did that.The UM was interviewed on 7/1/25 at 2:38 PM. He stated there were a lot of resident behaviors on the locked dementia unit. No specific behavioral training was provided upon hire; they just used basic strategies. Any information related to medical history that came with a resident was put in the care plan on admission. When a behavior was reported or observed, it was documented and added to the care plan. CNAs could document on behaviors and a care warning could be placed on the electronic medical record (EMR) dashboard. The nurse would also notify the psychiatric nurse practitioner (PNP) or the physician. Resident #1 had a TBI (traumatic brain injury) with craniotomy (surgery to remove part of the skull to access the brain). He was combative with staff, cursed and bossed them around, kicked and punched at them. On the day of the event, the UM was at the nurses' station. The CNA called him to come to Resident #1's room. He went and could see Resident #1 was not exchanging air. The UM stated the CNA said it looked like the resident was choking on feces. He ate his feces and there were some blue particles he later realized were particles of an incontinence pad. Resident #1's mouth was open, and it looked like he was choking. The UM stated he ran, grabbed the crash cart, called Code Blue, and then called 911. CNA B started CPR. Resident #1 was in and out of consciousness and CPR continued until paramedics arrived. Resident #1 expired but the cause of death was not certain. The diagnosis of pica was not on his chart, but it was not a new behavior. The psychiatry service was aware. The UM stated he had seen Resident #1 picking at his brief and trying to eat his socks; he would eat anything. Resident #1 did not have one-on-one supervision, but the UM put documentation in his chart indicating no more briefs. This was on Friday the 13th (6/13/25). This was also put on the dashboard in the EMR. Resident #1 was care planned for no plastic, disposable pads, or anything like that. The facility investigated and got written statements from staff. Nothing unusual was reported and the CNAs who found the resident didn't say anything was different about him. They watched for disposable pads, but it may have been a brief too. He could not say where or when the resident obtained it. Resident #1 defecated a lot in the pads, so that was what he was eating, but there were no remnants of a pad anywhere in the room. The UM was asked if a KUB (abdominal x-ray) was ordered after discovering the resident was eating non-food items. He did not know. He stated Resident #1 had a history of this behavior according to CNA B, but that information was nowhere in the chart. The behavior resurfaced maybe a week before he put it in the resident's chart, and he advised CNA B to only use cloth pads. The UM stated he took the information to the Interdisciplinary Team and the Director of Nursing (DON) said, Ok, we will look into it. Eventually the environmental team provided the unit with cloth incontinence pads, but it took some time. Resident #1 had a fabric pad under him on 6/20/25. The UM stated he was unaware of the long strands of disposable incontinence pads on the floor. He said perhaps he didn't notice because they were covered with feces.The nurse practitioner (NP) was interviewed on 7/1/25 at 3:20 PM. She stated she came to the facility three times a week and Resident #1 was her resident. This was only the second time she had seen this resident, so she didn't know him that well. He had aggressive behaviors and would hit, kick, box, and once snarled at her. He was an eater. They called her to report he ate a sock one day, but she didn't know what to do about that. She was present on the day of the event (6/20/25) but had not been in the resident's room. When she got to him on 6/20/25, CPR had already started. The UM had already suctioned out a lot of stuff but she did not know what it was. The UM used something like a Yankauer (a suction tip used for suctioning fluids and debris from a patient's airway) to get matter out. The NP used her hand to gesture a digging motion. It was really a Code [NAME] (a hospital code that generally refers to a hazardous spill that requires special handling). The NP stated Resident #1 would tear his sheets; he was an eater, like a toddler. His behavior was such that he was hard to work with. The disposable pad thing was addressed often. The UM made sure there were no plastic materials. The NP speculated that maybe it was an incontinence brief that they found in his mouth. She stated it was unfortunate but given the gravity of his issues, she did not know what more they could have done to prevent it. She asked herself if there was anything she could have done but felt that there was nothing more that could have done. When asked if additional supervision had been considered, she did not reply.A telephone interview was conducted with the Medical Examiner (ME) on 7/1/25 at 4:20 PM. He confirmed that he performed the autopsy on Resident #1. He reported the resident had a head injury, and there was a non-food items order on the resident's chart. When EMS arrived, Resident #1's oral cavity was filled with feces mixed in with small pieces of disposable incontinence pads; feces and plastic stuff. He stated he believed Resident #1 choked and that was how he died. When he opened the resident's cavity, it was full of the plastic material. The presence of feces in Resident #1's mouth indicated he was recycling it (defecating then eating the pad-tainted pieces). The ME found aspirated feces deep in the lungs and the resident's airway was stained with feces. Everything was contaminated. The ME stated he removed chunks of the material and digestive contents. He speculated it would take several days for the pad material to pass through the digestive system. The foreign matter extended past the resident's stomach; it was blue plastic with what looked like absorbent mesh. He stated he was surprised there was no obstruction or perforations, and he surgically removed a 6x6 centimeter square of white matter. At one point he just got tired of picking the material out piece-by-piece. The ME concluded by explaining that the material was not going to break down in the digestive tract, as the body did not produce enzymes to break down plastic.A telephone interview was conducted with the Adult Protective Investigator (API) on 7/2/25 at 7:30 AM. She verified the information in her report dated 6/21/25. She said she had a phone conversation with family who reported the facility was aware of Resident #1's behavior on admission. He was eating items and feces in the past while living at home. This was why he was admitted to the facility. She stated CNA B told her she had asked the nurses for one-on-one staffing but was told to stop acting like a supervisor; they already had it under control.During an interview with Licensed Practical Nurse (LPN) A on 7/2/25 at 9:54 AM, she said she worked on 6/20/25 but was not assigned to Resident #1. She was on break when he coded (cardiac/respiratory arrest). The UM advised her that the resident was in respiratory distress, had fecal matter all over him and coded. He said he had never seen anything like it. She gave Resident #1 his medications that morning. He was not on a disposable pad but was chewing his gown. She retrieved scissors and cut the tag off the gown. He would eat anything if you let him. Anything. The CNAs once reported he was trying to eat his brief. He would even tear his mattress and try to eat it. It was a new behavior every week. She did not know when the behavior started. The UM had written something, and the behavior was care planned, but he was not on one-on-one supervision. LPN A said she was familiar with pica behavior. All you must do is take items out of his reach. LPN A stated the new nurse practitioner (NP) came to the Code Blue. The psychiatric nurse practitioner (PNP) also worked with Resident #1, but medication did not always work. Resident #1 was polypharmacy (using multiple medications), but the PNP could not stop his aggressive behavior. LPN A stated psychotropic drugs (drugs that affect one's mental state) also make you eat a lot, so nothing worked in reducing Resident #1's desire to eat. She said, He was miserable and simply needed Jesus. At one point the PNP told her, I am maxed out (with meds); I don't know what more to do.An interview with the DON on 7/2/25 at 10:30 AM revealed that Resident #1 required total care and total assistance with transfers. He would try to eat everything around him, including his feces. The CNAs had to feed him so he could not get to the Styrofoam. Eating feces was kind of new but was not present on admission. Within a month or two, Resident #1 began pulling his briefs to shreds. Putting things in his mouth was also pretty new. The DON denied awareness of the 2024 incident when Resident #1 ingested a Styrofoam cup but reported that he would try to eat his socks. That had been happening for a while. He would tear his mattress, and everything would go to his mouth, so they removed everything they could. Staff kept Resident #1 in the TV room during the day to supervise him. These behaviors were discussed in our meetings. When asked what interventions were implemented to keep Resident #1 safe, The DON replied, Spoon-feeding and removing everything from his room. He said he thought Resident #1 had been care planned for his behavior from the start. He was followed by psychiatric services, was on medication, and the Medical Director (MD) knew of his behavior. The DON stated he was not present for the 6/20/25 event, but CNA A told him there were small pieces of blue incontinence pads in his mouth. The UM also reported this to him; that was why they did not use disposable pads for Resident #1. He was not sure how long the pads had been in his system, and speculated there were probably very long pieces present. He thought Resident #1 defecated and re-ingested them. There was a large amount of feces in the resident's mouth. The DON was unaware that during CPR, Resident #1 defecated pieces of blue plastic material.The MDS coordinator (MDSC) was interviewed on 7/2/25 at 11:45 AM. She explained that during morning meetings the team reviewed nursing and CNA notes about resident behaviors. They followed up with the psychiatric NP as needed. She knew Resident #1 but did not recall him chewing/eating incontinence pads or briefs. The MDSC reviewed Resident #1's care plan and confirmed it was not revised to include eating non-food items including briefs and incontinence pads until 6/20/25. She said she wished previous care plans had been more specific. The interdisciplinary team was responsible for developing care plan goals and interventions. She was not advised of Resident #1's behavior until the UM told her, and she was not sure what interventions were in place on the nursing unit. The MDSC knew about the dangers of pica behavior and took it very seriously.An electronic medical record (EMR) review for Resident #1 revealed he was admitted to the facility on [DATE], discharged on 9/4/24, and readmitted on [DATE]. The EMR landing page included a Special Instructions warning on the dashboard advising that Resident #1 should not be given, have within reach, or be left unattended if items were made from plastic, sponge, foam and/or paper. As a result, all following items are barred from use [disposable incontinence pads]/bed padding/under padding, brief/ [adult disposable incontinence briefs]/diaper and pull-ups, except for mattresses. Items made from fabric are ideal . (Photographic evidence obtained) Diagnoses included, but were not limited to, traumatic brain injury (TBI), hip fracture, unspecified protein -calorie malnutrition, muscle weakness, hemiplegia and hemiparesis (one sided weakness or paralysis) following cerebral infarction (stroke) affecting left non-dominant side, dysphagia oropharyngeal phase (difficulty initiating swallowing), cognitive communication deficit, need for assistance with personal care, anxiety, depression, restlessness and agitation.The quarterly minimum data set (MDS) assessment, with a reference date of 6/7/25, revealed that Resident #1's brief interview for mental status score was 7 out of a possible 15 points, indicating severe cognitive impairment. Inattention, disorganized thinking and altered level of consciousness fluctuated. Resident #1 used a wheelchair for mobility and was dependent on staff for activities of daily living including eating. He was frequently incontinent of bowel with no active toileting program. Resident #1 received routine antidepressant and anticonvulsant medications.Resident #1 was care planned on 6/2/24 for impaired or inappropriate behaviors related to his TBI. No specific description of inappropriate behavior was provided in the care plan. The goal was to be free from behavior through the next review. Interventions included medications as ordered, monitor for side effects and effectiveness; If reasonable, discuss resident's behavior. Explain why behavior is inappropriate or unacceptable to the resident. Provide a program of activities that accommodates the resident's status. Provide non-pharmacological interventions. Revisions were made on 6/10/24, 9/25/24, and 12/6/24; however, there were no changes to the interventions and no specific behaviors described until 6/20/25 to add, I.E. Resident removes his diapers, puts self on floor, slams leg against footrest/mattress, and eats briefs/[disposable pads]. (Photographic evidence obtained)A physician's order dated 6/13/25 instructed, [Resident #1] should not be given, have within reach or be left unattended if items are made from plastic, sponge, foam and paper. As a result, all following items are barred from use [disposable incontinence pads]/bed padding/under padding, brief/ [disposable incontinence briefs]/diaper and pull-ups, except for mattresses. Items made from fabric are ideal, therefore they are acceptable. There was no corresponding progress note to justify why this order was entered at this time.The physician's order for behavior monitoring, dated 1/22/25, instructed to monitor for: Itching, picking at skin, restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, foul language, elopement, stealing, delusions, hallucinations, psychosis, aggression, and refusal of care. There were no revisions or instructions to monitor Resident #1 for placing inedible objects and items into his mouth or eating them. (Photographic evidence obtained)A review of nursing progress notes revealed an entry dated 6/3/24 by the psychiatric nurse practitioner (PNP) reporting that a CNA advised him that Resident #1 was trying to eat his [incontinence pads]. (Photographic evidence obtained) A Nursing Alert progress note dated 6/17/24 advised that Resident #1 was found in bed eating a Styrofoam cup. He returned the remainder of the cup to the nurse but continued to chew and appeared to swallow the part of the cup that was in his mouth. The Nurse Practitioner (NP) was notified, and no new orders were given. (Photographic evidence obtained)Further review of the record found no orders for diagnostic tests or imaging after ingesting part of the Styrofoam cup.A review of additional progress notes found that contrary to staff interviews, no information about Resident #1 tearing and/or eating inedible items including briefs or incontinence pads was documented until 6/20/25 at 2:43 PM when the UM described the incident. The note said at approximately 1:49 PM, a CNA called the UM to [Resident #1's] room. Upon arrival, Resident #1 was found in bed, unresponsive and in respiratory distress. Both eyes were open, and two CNAs were at bedside. A brown substance was coming from the resident's mouth. He had no pulse, skin was warm to the touch, and he was very difficult to arouse with a sternal rub. Fecal matter was scattered over the bed, the resident's body, hands and face. His skin was pale and bilateral (both) lower extremities were bluish purple. Chest compressions were initiated, Code Blue was called, and Emergency Medical Services (EMS) was called for assistance. Resident #1 started responding as evidenced by chest rise, a weak carotid pulse, and slight improvement in skin color. Rescue arrived at approximately 2:07 PM. The resident was in and out of consciousness when EMS arrived and was transferred to the hospital at 2:25 PM. (Photographic evidence obtained)The NP's Discharge summary, dated [DATE], stated Resident #1 had a medical emergency, was transferred to the ER and was discharged . He had last been seen on 5/20/25 for a monthly visit. There was no mention of blue material or feces in Resident #1's mouth. (Photographic evidence obtained) Further review of the record found no notes by the NP, Psychiatric NP, Physician or Psychologist about Resident #1 ingesting inedible items.On 7/2/25 at 12:40 p.m., the Administrator was asked about the 6/20/25 event and the results of her investigation. She stated she was on leave but was advised of the incident. She was told that Resident #1 had feces in his mouth. She did not know if Resident #1 aspirated or choked. When police arrived to investigate, they said they were trying to rule out homicide due to the presence of what appeared to be incontinence pads in the resident's mouth. The Administrator had been told of the small pieces of what appeared to be pads in his mouth, but he had not had access to those items for a long time. The Administrator was advised, and acknowledged, the physician's order prohibiting access to those items was not obtained until 6/13/25; one week before the incident. When she was advised that the resident also defecated the blue plastic material, she said she had not been told that. On 6/20/25, while not present in the facility, she instructed staff to conduct an Ad Hoc (impromptu) Quality Assessment and Performance Improvement (QAPI) meeting, which she participated in via telephone. She presented the meeting minutes at this time and explained the committee had not developed a Performance Improvement Plan (PIP) yet, because it would be a month or two before the medical examiner's reports were released. She was asked if she investigated the incident. She said when she returned from leave, the investigation was already completed. She was asked if she conducted any staff interviews as part of her investigation. She responded no, and again insisted the investigation was completed in her absence. Only written statements were obtained. When asked if she realized how dangerous pica behavior/ingesting inedible objects was, she replied, I am not a nurse, so don't know anything about pica. She acknowledged that the presence of non-food items in Resident #1's mouth along with feces should have warranted a more thorough investigation and that interviews with staff involved would likely have revealed additional information. The Administrator was advised that the written statements collected from staff failed to reflect details of what they said they actually saw. She had no response.The 6/20/25 Ad Hoc QAPI meeting minutes were reviewed. The meeting was chaired by the Director of Nursing (DON). The reason for the meeting: The resident was stuffing noted non-eatable [sic] products, sent out 911 for vomiting feces/coded. Opportunity for Improvement: Resident stuffing non-eatable [sic] products in their mouth (i.e. adult briefs, [disposable incontinence pads], etc. Data: Resident observed with [disposable pads] in mouth. Analysis: Resident is care planned for behavior of eating adult briefs and [disposable pads]. Plan: Not to have any briefs or [disposable pads] in patient's bed. Responsible Team: DON, Assistant DON, UMs and CNAs. A hand-written note on the form said the Regional Nurse, CEO (Chief Executive Officer) and CNO (Chief Nursing Officer) had been notified on 6/20/25 by the DON and the Administrator. There was no root cause analysis completed (A structured process to identify the contributing factors or underlying cause of an adverse patient outcome. Analysis addresses what happened, why it happened, and what could be done to prevent future occurrences). The Administrator was asked if the QAPI committee had identified a root cause analysis. She replied, Like I said, I just got back and am still investigating, so no. (Photographic evidence obtained)In an interview with the Medical Director (MD) on 7/2/25 at 1:19 PM, she said she had not been advised that Resident #1 was attempting to ingest inedible objects. She was in the building frequently and only knew of him kicking. She heard he was sent to the hospital but could not remember if staff told her about the plastic. She said the NP usually brought this type of information to her attention. Resident #1 was followed by the psychiatric nurse practitioner (PNP). Had she been aware of the resident's behavior, she would have referred to him so there were not two providers involved.In a second interview with the Administrator on 7/2/25 at 1:26 PM, she explained that the UM told her Resident #1 had been picking at his plastic incontinence pads but also picked at cloth pads. On the day of the event, while suctioning Resident #1's mouth with a Yankauer device, the UM noticed feces and shreds of little blue pieces inside the resident's mouth. The matter was also coming from the resident's rectum, and he had feces in his hand. The PNP told her he had not noted any such behaviors, and he said with a TBI (traumatic brain injury), any type of behavior could occur. She had not known of these behaviors, as the only warning the nurses gave her was to watch out, he kicks. The Administrator said she did not understand why the CNAs were not telling the nurses about the resident's behavior. She was advised that they said they had reported to nursing but were told to stand down. She confirmed that Resident #1 was never on increased supervision but said they would provide one-on-one staffing if [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility and resident records, staff interviews, and review of the Quality Assurance and Performance Improvement (QAPI) plan, the facility failed to have an effective QAPI process that used adverse event data to identify a Root Cause Analysis (RCA) and develop relevant performance improvement activities to prevent similar future events. Resident #1, with a known history of pica (an eating disorder characterized by a compulsive and recurrent consumption of non-nutritive and non-food items), who chewed and consumed briefs and disposable incontinence pads, was found unresponsive with feces and bits of blue plastic resembling incontinence pads in his mouth. As a result of the incident, Resident #1 died. Despite direct observation of the event by CNAs A, B, C, the unit manager (UM) and nurse practitioner (NP), the facility failed to thoroughly investigate in order to identify an RCA and develop measures needed to ensure the safety and protection of other residents at risk. This had the potential to affect 52 residents in the facility who were care planned for maladaptive behaviors. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 4:20 PM on July 1, 2025. On June 20, 2025 at 1:49 PM, Immediate Jeopardy (IJ) began. On July 2, 2025, at 6:30 PM, the Administrator was notified of the IJ determination, IJ templates were provided, and Immediate Jeopardy was ongoing as of the survey exit on July 2, 2025. The findings include:Cross Reference F600, F610 and F835A review of a facility report authored by the Director of Nursing (DON) on 6/27/25, revealed that on 6/20/25 at 1:49 PM, Resident #1 was observed unresponsive in bed by a certified nursing assistant (CNA). Upon entering the room, the Unit Manager (UM) observed brown stuff coming from Resident #1's mouth. Code Blue (a term used for a medical emergency involving respiratory or cardiac arrest) was paged and chest compressions were initiated. Emergency Medical Services (EMS) was also called. EMS arrived at the facility and took over cardiopulmonary resuscitation (CPR). Resident #1 was transported to the emergency room but did not survive. The report noted Resident #1's care plan indicated he had a behavior of eating his briefs/disposable incontinence pads. (Photographic evidence obtained)An interview was conducted with CNA B on 7/1/25 at 10:36 a.m. She reported finding (Resident#1) unresponsive with disposable incontinence pad pieces and feces in his mouth on 6/20/25. Resident #1 did not wear briefs or use disposable pads anymore. He had a brain injury and would chew on his socks, shirt and the incontinence pads or briefs. She stated she did not know how he got the incontinence pad.CNA C was interviewed on 7/1/25 at 11:13 AM. She worked on 6/20/25 and responded to a call for help in Resident #1's room. CNA B was trying to pull disposable incontinence pad pieces out of the resident's mouth. Strands of pads and feces were in his mouth, and feces was on his hand and leg.CNA A was interviewed on 7/1/25 at 1:40 PM. She was assigned to Resident #1 on 6/20/25 for the first time. At approximately 2:00 PM, she heard CNA B and someone else call for help. She responded to Resident #1's room and witnessed CNA B pulling stuff out his mouth with a hanger. A piece of a disposable pad this long (she used both hands to gesture the length of approximately 14 inches) came out. CNA B started chest compressions, and the Unit Manager (UM) arrived and took over. Pieces of the incontinence pad were on the floor. When paramedics arrived and took over compressions, another piece of a pad came out of his rectum. He pooped the pads out. She stated she heard Resident #1 passed away on the way to the hospital.The UM was interviewed on 7/1/25 at 2:38 PM. He stated Resident #1 had traumatic brain injury (TBI) with craniotomy (surgery to remove part of the skull to access the brain). On the day of the event, the UM was called to Resident #1's room. He entered the room and saw that Resident #1 was not exchanging air. The CNA said it looked like the resident was choking on feces, and there were some blue plastic particles mixed in that he later realized were pieces of the incontinence pad. CNA B started CPR. Resident #1 was in and out of consciousness and CPR continued until the paramedics arrived. Resident #1 expired, but the cause of death was not certain. The UM had seen him picking at his brief and trying to eat his socks in the past; he would eat anything.During a telephone interview with the Medical Examiner (ME) on 7/1/25 at 4:20 PM, he stated he performed the autopsy on Resident #1. When medics arrived at the facility, Resident #1's oral cavity was filled with feces mixed in with small pieces of disposable incontinence pad; feces and plastic stuff. He stated believed Resident #1 choked and that was how he died. When he opened the resident's cavity, it was full of the plastic material. The presence of feces in Resident #1's mouth indicated he was recycling it (defecating then eating the pad-tainted pieces).During an interview with Licensed Practical Nurse (LPN) A on 7/2/25 at 9:54 AM, she said Resident #1 was once reported trying to eat his incontinence brief. He would even tear his mattress and try to eat it. It was a new behavior every week.In an interview with the Director of Nursing (DON) on 7/2/25 at 10:30 AM, he said Resident #1 would try to eat everything around him, including his feces. The CNAs had to feed him so he could not get to the Styrofoam. Eating feces was kind of new but was not present on admission. Within a month or two, Resident #1 began pulling his briefs to shreds. Putting things in his mouth was also pretty new. He would try to eat his socks. That had been happening for a while. He would tear his mattress, and everything would go to his mouth so they removed everything they could.A review of Resident #1's record revealed he was admitted to the facility on [DATE], discharged [DATE] and readmitted [DATE]. The electronic medical record's (EMR's) landing page included a Special Instructions warning advising that Resident #1 should not be given, have within reach, or be left unattended if items were made from plastic, sponge, foam and paper. Disposable incontinence pads/bed padding/under padding, brief/ disposable incontinence briefs/diaper and pull-ups, except for mattresses, were barred. (Photographic evidence obtained) The resident's diagnoses included, but were not limited to, TBI (traumatic brain injury), hip fracture, unspecified protein-calorie malnutrition, muscle weakness, hemiplegia and hemiparesis (one sided weakness or paralysis) following cerebral infarction (stroke) affecting left non-dominant side, dysphagia oropharyngeal phase (difficulty initiating swallowing), cognitive communication deficit, need assistance with personal care, anxiety, depression, restlessness and agitation.The Quarterly Minimum Data Set (MDS) assessment, with a reference date 6/7/25, revealed that Resident #1 had severe cognitive impairment and was dependent on staff for activities of daily living including eating. He was frequently incontinent of bowel.A physician's order was obtained on 6/13/25 for no items made of plastic, sponge, foam and/or paper to be left within the resident's reach.A review of nursing progress notes revealed an entry dated 6/3/24 by the Psychiatric Nurse Practitioner (PNP) reporting that a CNA advised him Resident #1 was trying to eat his incontinence pads. (Photographic evidence obtained) A Nursing Alert progress note dated 6/17/24 advised that Resident #1 was found in bed eating a Styrofoam cup. He returned the remainder of the cup to the nurse but continued to chew and appeared to swallow the part of the cup that was in his mouth. The Nurse Practitioner (NP) was notified, and no new orders were given. (Photographic evidence obtained)Resident #1 was care planned on 6/2/24 for impaired or inappropriate behaviors related to his TBI. No specific description of inappropriate behavior was provided in the care plan after revisions were made on 6/10/24, 9/25/24, and 12/6/24. On 6/20/25, the care plan was revised to add, Resident removes his diapers, puts self on floor, slams leg against footrest/mattress, and eats briefs/[disposable pads]. (Photographic evidence obtained)The facility began an investigation on 6/20/25 and gathered written statements from multiple staff including the UM and CNAs A and B; all witnesses to the 6/20/25 event. CNA B's report, dated 6/25/25, noted the blue pieces of incontinence pads in the resident's mouth. (Photographic evidence obtained) No interviews were conducted as part of the investigation.On 7/2/25 at 12:40 PM, the Administrator was asked about the event and the results of her investigation. She said she was on leave but was advised of the incident. On 6/20/25, she instructed staff to conduct an Ad Hoc (impromptu) QAPI meeting, which she participated in via telephone. She presented the meeting minutes at this time and explained that the committee had not developed a performance improvement project (PIP) yet, because it would be a month or two before the medical examiner reports were released. The Administrator stated when she returned from leave, an investigation had already been completed. The Administrator was asked if she conducted any staff interviews as part of the investigation. She responded, no, only written statements were obtained.The Ad Hoc QAPI meeting minutes, dated 6/20/25, were reviewed. The reason for the meeting: The resident was stuffing noted non-eatable [sic] products, sent out 911 for vomiting feces/coded. Opportunity for Improvement: Resident stuffing non-eatable [sic] products in their mouth (i.e. adult briefs, [disposable incontinence pads], etc.). Data: Resident observed with [disposable pads] in mouth. Analysis: Resident is care planned for behavior of eating adult briefs and [disposable pads]. Plan: Not to have any briefs or [disposable pads] in patient's bed. Responsible Team: DON, Assistant DON, UMs and CNAs. A hand-written note on the form revealed that the Regional Nurse, CEO (Chief Executive Officer) and CNO (Chief Nursing Officer) had been notified on 6/20/25 by the DON and the Administrator. There was no root cause analysis completed (A structured process to identify the contributing factors or underlying cause of an adverse patient outcome. Analysis addresses what happened, why it happened, and what could be done to prevent future occurrences). The Administrator was asked if the QAPI committee had identified a root cause analysis. She replied, Like I said, I just got back and am still investigating, so no. (Photographic evidence obtained) A review of the facility's Quality Assurance Performance Improvement (QAPI) plan, dated 12/20/24, revealed that the purpose of the plan was to provide guidance for the overall quality improvement program. The guidelines drive the decision making as the Center always strives to exceed expectations and achieve quality outcomes. Decisions will be made to promote excellence and focus areas will include systems that affect quality of care and services. Each area of care and services should have a representative on the committee, and activities will cross service areas to address all concerns. Under the Responsibility and Accountability section the plan notes that the Administrator has responsibility and is accountable to the Risk Management, QAA (Quality Assessment and Assurance) Committee and Corporation to ensure QAPI is implemented throughout the Center. Under the Framework for QAPI section the policy states the committee will prioritize opportunities for improvement and determine which PIPs (Performance Improvement Plans) will be initiated. When an issue or problem is identified that is not systemic and does not require a PIP, the QAA committee will decide how to correct the issue or problem. These corrections may include an easy decision, corrective action plan, or rapid improvement cycle. The policy further stated factors that are considered high-risk will drive how potential PIPs will be identified. The final section, which described how the team would conduct the PIP, states the team will follow steps and processes needed for any quality improvement process. The team will use root cause analysis to ensure the root cause and contributing factors are identified. (Photographic evidence obtained)