**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement their policy and procedure and honor the resident's documented advance directives, including Do Not Resuscitate status for 1 (Resident #1) of 3 residents reviewed. On [DATE] at approximately 11:40 a.m., Resident #1 was found without a pulse or respiration. Staff did not verify Resident #1's advance directives for code status and administered cardiopulmonary resuscitation (CPR) against the resident's documented wishes to withhold CPR in the event of cardiac or respiratory arrest. Applying the reasonable person concept, the failure to honor the resident's wishes for a natural, dignified death created a likelihood for serious psychosocial harm. This failure placed other residents with established advance directives at a likelihood to be resuscitated against their wishes and resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of isolated (J) starting on [DATE]. On [DATE] at 4:49 p.m., the Administrator was notified of the determination of Immediate Jeopardy and provided the IJ templates. The findings of Immediate Jeopardy were determined to be corrected on [DATE]. The findings included: The facility's policy titled, Advanced Directives Code Status issued 1/2024 noted, It is the policy of the facility to honor Advanced Directives, Code status and Do Not Resuscitate Orders in accordance with state and federal regulations . Do Not Resuscitate (DNR) - A DNR code status would indicate that the person would not want CPR performed and would be allowed to die naturally if their heart stops beating and/or they stop breathing . Review of the clinical record for Resident #1 revealed an admission date of [DATE]. The admission Minimum Data Set (MDS) assessment with a target date of [DATE]. The MDS noted the resident's cognition was intact with a Brief Interview for Mental Status score of 15. On [DATE] the Social Worker documented in a progress note Resident #1 was [AGE] years old and said she did not think she would be, better off dead but would accept her time when it comes. The clinical record contained a yellow State of Florida Do Not Resuscitate Order form signed and dated by Resident #1 on [DATE] and signed by the physician on [DATE] directing that CPR be withheld or withdrawn. On [DATE] at 5:16 p.m., Registered Nurse (RN) Staff A documented in a progress note upon rounds at 11:40 a.m., Resident #1 was identified unresponsive, without pulse, no spontaneous respirations noted. Code blue called. The nurse went to retrieve the crash cart. CPR initiated. Emergency Medical Services were called. The resident was then noted to be a DNR and CPR was terminated. Resident #1 did not regain pulse or respirations. Review of the facility's investigation showed that on [DATE] at approximately 11:40 a.m., Resident #1 was found without pulse or respiration. RN Staff A did not verify Resident #1's advance directives for code status and administered cardiopulmonary resuscitation (CPR) against the resident's documented wishes to withhold CPR in the event of cardiac or respiratory arrest. After approximately four minutes of CPR being administered, the Director of Nursing (DON) realized Resident #1 was DNR and permission was received from Resident #1's daughter to cease CPR. Resident #1 expired. During an interview on [DATE] at 11:47 a.m., Licensed Practical Nurse (LPN) Staff B said she was upstairs and heard the code blue. When she got to the resident's room, the first thing she did was to ask if the resident was a full code or DNRO. She said she was told she was a full code. When she walked in the room she saw CPR being performed. Certified Nursing Assistant (CNA) Staff C was doing the compressions. The Weekend Supervisor was next to him and they were rotating. They had Staff B do the ambu bag (medical tool to force air into lungs) and give her the two breaths. Somebody came in and said to stop doing CPR as the resident was a DNR. During an interview on [DATE] at 1:13 p.m., LPN Staff D said she heard the code blue. She was downstairs and came up. She went to grab the crash cart, but it was gone. She went to the resident's room. The weekend supervisor was doing CPR. The CNAs were standing in the room and trying to assemble the ambu bag. After that, one CNA took over the CPR compressions, and the other nurse. LPN Staff B grabbed the ambu bag. The Weekend Supervisor left the room to make calls. CPR was still going and someone in hall said the resident was a DNR. Everything stopped. Emergency Medical Services (EMS) stopped coming off the elevator when they heard she was DNR and left back down elevator. The resident's daughter eventually came. During an interview on [DATE] at 1:58 p.m., CNA staff C said he heard the code blue. The Weekend Supervisor said the resident was a full code, then she did CPR. When she stopped she asked CNA Staff C to take over. He said he had CPR training and he took over the compressions. CNA Staff C said it was the first time he was doing CPR on anyone. He said the crash cart was there. He said he did not know how long CPR lasted but between two to five minutes. Then he heard someone say to stop doing CPR she's passed away. The Weekend Supervisor said to stop. Afterward, he heard the weekend supervisor spoke to the family. The DON asked him (Staff C) for his CPR certification and made a copy of it. He said when he checked the facility's electronic medical record, it showed the resident was a DNR. On [DATE] at 2:08 p.m., in an interview the DON said facility policy is to follow the Residents' Advanced Directive wishes. The DON explained the proper process if found unresponsive would be to go to the hall and yell code blue for assistance. At that time, all staff respond and check Electronic Health Record to confirm code status so they know what to do next. If a person is identified as DNR they do not start compressions. If the Resident was not DNR status they would start compressions. The DON confirmed RN Staff A did not follow facility's policy by failing to verify Resident #1's Advance Directives and initiated CPR against the resident's wishes. She said RN Staff A was no longer employed at the facility. During an interview on [DATE] at 2:30 p.m., CNA Staff E said she was working and Resident #1 was her patient. She said the Weekend Supervisor found Resident #1 unresponsive. When the code blue was called she went to the room. Her CPR certification had expired, she helped move everything in the room to make room for the crash cart and EMS. She said the Weekend Supervisor started CPR until the DON found the resident was a DNR, then CPR was stopped. The immediate actions implemented by the facility and verified by the survey team on [DATE] included: As of [DATE], Resident #1 no longer resides in the facility. On [DATE] an investigation was initiated that included obtaining statements from staff involved and placing staff involved on suspension by the Director of Nursing and Administrator. On [DATE], the surveyor reviewed and verified the investigation was complete. On [DATE] staff members involved were given 1:1 (one on one) education on the advance directive process by the Director of Nursing. On [DATE], the surveyors verified all nurses completed the training on [DATE]. On [DATE] five of five nurses interviewed verified receipt of the training and able to verbalize process to verify advance directives. On [DATE] a root cause analysis was conducted by the DON, Risk Manager, RNC (Registered Nurse Consultant) and NHA (Nursing Home Administrator). On [DATE], the survey reviewed and verified the root cause analysis was complete. On [DATE] current residents had their advance directives audited to ensure accuracy by the Social Services Director. No new concerns were identified. On [DATE], the Social Services Director was interviewed and explained that every Morning Meeting the IDT team discuss each new admission from the prior day and verify when they have obtained the code status. She further explained that each Monday morning she or her back-up brings the code book to Morning Meeting and all new admissions from the prior week are reviewed for code status and verified the status is in the book. On [DATE], the surveyor verified the advanced directives were accurate through record review and reviewed Morning Meeting minutes to verify Code Status is discussed. On [DATE] a timeline was completed by the Director of Nursing. On [DATE] the surveyor verified the timeline and interviewed the Director of Nurses. On [DATE] through [DATE] current licensed nurses were educated on the advanced directive process with an emphasis on ensuring FL Yellow DNR form for those who wish for CPR to be withheld completed and in electronic medical record, orders accurately reflect current resident's code status in the electronic medical record, code status binder process and accuracy of care plans reflect individualized code status wishes, abuse/neglect, and resident's rights education by the Director of Nursing. On [DATE] the surveyors verified the nurses were trained and the code status book were complete and accurate. Code status books observed on the first and the second floor at the nurse's station and on the crash carts. 15 Total licensed nurses including one contracted nurse. On [DATE] 9 out of 15 nurses completed the education, 60% of nurses. On [DATE] the surveyors verified the nurses were trained through record review. On [DATE] 6 out of 15 nurses completed the education, 40% of nurses for a total of 100% of nurses educated. On [DATE] the surveyors verified through record review the nurses, including the contracted nurse were trained. Any contracted nurses who are placed at the facility on assignment will receive the above education prior to starting their shift through an agency orientation packet. On [DATE] the surveyors interviewed the Director of nurses and reviewed the Agency Nurses training packet. Ad Hoc (unplanned) QAPI (Quality Assurance and Performance Improvement) on [DATE] completed with Medical Director, Administrator, Director of Nursing and remaining IDT members on the advance directive process including following policy and procedures in accordance with advance directives and a review of the root cause analysis. A Palm Vista Specific Code Process was developed. On [DATE] the surveyors interviewed the Director of nurses and verified the QAPI committee had reviewed all audits. On [DATE], the Registered Nurse (who did not verify the code status) was terminated and reported to the Board of Nursing. On [DATE], the surveyor verified through record review the Registered Nurse was terminated and reviewed the referral to the Board of Nursing. As part of the ongoing QAA (Quality Assessment and Assurance) process, an ad hoc QAPI was conducted on [DATE] that included the Medical Director, Administrator, Director of Nursing and remaining IDT (Interdisciplinary Team) members to review the plan viability on the advance directives process, code process, code status binder process and results of ongoing audits from [DATE] until [DATE]. No discrepancies or concerns were noted from the reviewed information and no changes to the plan were made. On [DATE] the surveyors verified through interview with the Director of nursing and verified the QAPI committee had reviewed all audits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to implement their policies and procedures by failing to verify code status and administering cardiopulmonary resuscitation (CPR) to 1 (Resident #1) of 2 sampled residents found without pulse or respiration, against the resident's documented wishes and physician's order for DNR (Do not resuscitate). On [DATE] at approximately 11:40 a.m., Resident #1 was found without a pulse or respiration. Staff did not verify Resident #1's code status and administered cardiopulmonary resuscitation (CPR) against the resident's documented wishes, and the physician's orders to withhold CPR in the event of cardiac or respiratory arrest. The failure to follow the facility's CPR policies and procedures placed residents who had established advance directives at a likelihood that they would be resuscitated against their wishes and resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of isolated (J) starting on [DATE]. CPR may result in major physical trauma including broken ribs, lungs bruising, damage to the airway and internal organs, and internal bleeding. On [DATE] at 4:49 p.m., the Administrator was notified of the determination of Immediate Jeopardy and provided the IJ templates. The findings of Immediate Jeopardy were determined to be corrected on [DATE]. The findings included: The facility's policy and procedure titled, Advanced Directives Code Status issued 01/2024 noted, Do Not Resuscitate (DNR)- A DNR code status would indicate that the person would not want CPR performed and would be allowed to die naturally if their heart stops beating and/or they stop breathing . Review of the clinical record for Resident #1 revealed an admission date of [DATE]. The admission Minimum Data Set (MDS) assessment with a target date of [DATE]. The MDS noted the resident's cognition was intact with a Brief Interview for Mental Status score of 15. Review of the State of Florida Do Not Resuscitate Order form showed a patient statement signed and dated by Resident #1 on [DATE] noting to withhold or withdraw CPR based upon informed consent. On [DATE] the physician signed the form directing the withholding or withdrawing of cardiopulmonary resuscitation from Resident #1 in case of cardiac or respiratory arrest. On [DATE] at 5:16 p.m., Registered Nurse (RN) Staff A documented in a progress note upon rounds at 11:40 a.m., Resident #1 was identified unresponsive, without pulse, no spontaneous respirations noted. Code blue called. The nurse went to retrieve the crash cart. CPR initiated. Emergency Medical Services were called. The resident was then noted to be a DNR and CPR was terminated. Resident #1 did not regain pulse or respirations. Review of the facility's investigation showed that on [DATE] at approximately 11:00 a.m., Resident #1 was found without pulse or respiration. Staff A Registered Nurse (RN) did not verify Resident #1's advance directives for code status and administered cardiopulmonary resuscitation (CPR) against the resident's documented wishes to withhold CPR in the event of cardiac or respiratory arrest. After approximately four minutes of CPR being administered, the Director of Nursing (DON) discovered Resident #1 was DNR and permission was received from Resident #1's daughter to cease CPR and resident expired. During an interview on [DATE] at 11:47 a.m., Licensed Practical Nurse (LPN) Staff B said she was upstairs and heard the code blue. When she got to the resident's room, the first thing she did was to ask if the resident was a full code or DNRO. She said she was told she was a full code. When she walked in the room she saw CPR being performed. Certified Nursing Assistant (CNA) Staff C was doing the compressions. The Weekend Supervisor was next to him and they were rotating. They had Staff B do the ambu bag (medical tool to force air into lungs) and give her the two breaths. Somebody came in and said to stop doing CPR as the resident was a DNR. During an interview on [DATE] at 1:13 p.m., LPN Staff D said she heard the code blue. She was downstairs and came up. She went to grab the crash cart, but it was gone. She went to the resident's room. The weekend supervisor was doing CPR. The CNAs were standing in the room and trying to assemble the Ambu bag. After that, one CNA took over the CPR compressions, and the other nurse. LPN Staff B grabbed the Ambu bag. The Weekend Supervisor left the room to make calls. CPR was still going and someone in hall said the resident was a DNR. Everything stopped. Emergency Medical Services (EMS) stopped coming off the elevator when they heard she was DNR and left back down elevator. The resident's daughter eventually came. During an interview on [DATE] at 1:58 p.m., CNA staff C said he heard the code blue. The Weekend Supervisor said the resident was a full code, then she did CPR. When she stopped she asked him (CNA Staff C) to take over. He said he had CPR training and he took over the compressions. CNA Staff C said it was the first time he was doing CPR on anyone. He said the crash cart was there. He said he did not know how long CPR lasted but between two to five minutes. Then he heard someone say to stop doing CPR she's passed away. The Weekend Supervisor said to stop. Afterward, he heard the weekend supervisor spoke to the family. The DON asked him (Staff C) for his CPR certification and made a copy of it. He said when he checked the facility's electronic medical record, it showed the resident was a DNR. On [DATE] at 2:08 p.m., in an interview the DON said on the day of the event, she was in the dining room, heard the code blue called, and went to the room. She said Staff A (RN) was actively doing CPR. The DON said Staff A asked her to get paperwork to prepare for transfer. When she went to the nurse's station, the DON saw the DNR order on the Electronic Health Record. She said at that time Staff A had switched out compressions with another staff member and was coming up the hall. The DON said she told Staff A that Resident #1 was DNR at which time Staff A opened Resident #1's chart and saw the yellow DNR form. RN Staff A was on the phone with Resident #1's daughter who advised to stop CPR. The DON said facility policy is to follow the Residents Advanced Directive wishes. DON explained the proper process if found unresponsive would be to go to the hall and yell code blue for assistance. At that time, all staff respond and check the Electronic Health Record to confirm code status in order to determine what to do next. If a person is identified as DNR, they do not start compressions. If the Resident does not have a DNR status, they would start compressions. the DON said Staff A (RN) did not follow facility policy and was no longer employed at the facility. During an interview on [DATE] at 2:30 p.m., CNA Staff E said she was working and Resident #1 was her patient. She said the Weekend Supervisor found Resident #1 unresponsive. When the code blue was called she went to the room. Her CPR certification had expired, she helped move everything in the room to make room for the crash cart and EMS. She said the Weekend Supervisor started CPR until the DON found the resident was a DNR, then CPR was stopped. The immediate actions implemented by the facility and verified by the survey team on [DATE] included: As of [DATE], Resident #1 no longer resides in the facility. On [DATE] an investigation was initiated that included obtaining statements from staff involved and placing staff involved on suspension by the Director of Nursing and Administrator. On [DATE], the surveyors reviewed and verified the investigation was complete. On [DATE] The Director of Nursing and the Nursing Home Administrator were educated by the Regional Nurse Consultant on the procedure for performing cardio-pulmonary resuscitation and double validation process of code status. On [DATE], the surveyors verified the training of Director of Nursing and Nursing Home Administrator. On [DATE] staff members involved were given 1:1 (one on one) education on regarding providing basic life support, including CPR, related to physician's orders and the resident's advanced directives by the Director of Nursing. On [DATE], the surveyors verified the training of all nurses was completed on [DATE] and interviewed five of five nurses present. On [DATE] a root cause analysis was conducted by the DON, Risk Manager, RNC (Registered Nurse Consultant and NHA (Nursing Home Administrator). On [DATE], the surveyors reviewed and verified the root cause analysis was complete. On [DATE] the Human Resources Director completed an audit of licensed nurse's CPR certification to ensure they were up to date including staff involved. On [DATE], the surveyor verified CPR was current for all nursing staff. On [DATE] a timeline was completed by the Director of Nursing. On [DATE] the surveyor verified the timeline through record review and interview with the Director of Nursing. The surveyors also verified the audit for nurses' CPR certification. On [DATE] through [DATE] current licensed nurses were educated on providing basic life support, including CPR, related to physician's orders, code blue process, verifying code status, the resident's advance directives, abuse/neglect, and resident's rights education by the Director of Nursing. 15 Total licensed nurses including one contracted nurse received education. On [DATE] 9 out of 15 nurses completed the education, 60% of nurses. On [DATE] 6 out of 15 nurses completed the education, 40% of nurses for a total of 100% of nurses educated. On [DATE] the surveyors verified through record review the nurses were trained and the code status book were complete and accurate. One contracted licensed nurse is on staff. On [DATE] the surveyors verified the contracted nurse was trained through record review and interview with the contracted nurse. Any contracted nurses who are placed at the facility on assignment will receive the above education prior to starting their shift through an agency orientation packet. On [DATE] the surveyors verified through interview with the Director of nursing and review of the Agency Nurses training packet. On [DATE] current residents had their advance directives audited to ensure accuracy by the Social Services Director. No new concerns were identified. On [DATE], the Social Services Director was interviewed and explained that every Morning Meeting the IDT team discuss each new admission from the prior day and verify when they have obtained the code status. She further explained that each Monday morning she or her back-up brings the code book to Morning Meeting and all new admissions from the prior week are reviewed for code status and verified the status is in the book. On [DATE], the surveyor verified the advanced directives were accurate through record review and reviewed Morning Meeting minutes to verify Code Status is discussed. On [DATE] mock code drills including verification of resident code status were conducted with nursing staff by the Director of Nursing/Designee daily through [DATE] and then additional drills for a total of 10 mock code drills. Director of Nursing/Designee conducted five drills on day shift and five drills on night shift with a variety of DNR and Full Code scenarios addressed. On [DATE] six out of 15 nurses completed a mock code drill, 40% of nurses. On [DATE] seven out of 15 nurses completed a mock code drill, 47% of nurses. On [DATE] eight out of 15 nurses completed a mock code drill, 53% of nurses. On [DATE] 12 out of 15 nurses completed a mock code drill, 80% of nurses. Two licensed nurses to participate in a mock code drill prior to the next shift work. One total contracted licensed nurse is on staff. This was completed by [DATE] when they returned from leave to make 100% of licensed nurses participated in the mock code drill. On [DATE] the surveyor verified through review of the drills that all licensed nurses, including the contracted nurse participated in at least one mock drill by [DATE]. Ad Hoc (unplanned) QAPI on [DATE] completed with Medical Director, Administrator, Director of Nursing and remaining IDT (Interdisciplinary Team) members on the Advance Directives process including verifying code status prior to providing CPR related to the resident's wishes, code blue process, code status binder and a review of the root cause analysis. A Palm Vista Specific Code Process was developed. On [DATE] the surveyors verified through record review the nurses were trained, the code status book were complete and accurate and the policy covered the procedure. On [DATE] the surveyors verified the nurses were trained and the code status book were complete and accurate. Code status books observed on the first and the second floor at the nurse's station and on the crash carts. On [DATE], RN Staff A was terminated and reported to the Florida Board of Nursing. On [DATE], the surveyor verified the nurse was terminated and reviewed the referral to the Board of Nursing. As part of the ongoing QAA (Quality Assessment and Assurance) process, an ad hoc QAPI was conducted on [DATE] that included the Medical Director, Administrator, Director of Nursing and remaining IDT members to review the plan viability on the advance directives process, code process, code status binder process and results of ongoing audits including mock code drills conducted from [DATE] until [DATE]. No discrepancies or concerns were noted from the reviewed information and no changes to the plan were made. On [DATE] the surveyors interviewed the Director of nurses and verified the QAPI committee had reviewed all audits.

Based on record review, review of the facility's policies and procedures, and staff interviews, the facility failed to protect residents from neglect when they failed to ensure residents received food in the appropriate texture to prevent accidental choking for 2 (Residents #1, and #4) of 4 sampled residents. The facility's failure to provide the services necessary to prevent neglect placed other residents with similar conditions at a likelihood of serious illness and/or death and resulted in the determination of Immediate Jeopardy. Resident #1 had a diagnosis of Dysphagia (impaired Swallowing) and had been downgraded to a pureed diet (all food has been ground, pressed, and/or strained to a soft, smooth consistency, like a pudding) with nectar thickened liquids on 10/06/23. On 10/7/23 the resident was served a mechanical soft meal with chopped chicken, which resulted in the resident choking on the food and requiring transfer to an acute care facility, where he was diagnosed with acute aspiration pneumonia (food or liquid breathed into the lungs) and acute hypoxemic (low oxygen in the blood) respiratory failure. On 10/25/23 at 9:30 a.m., the Administrator was informed of the determination of Immediate Jeopardy and provided the IJ templates. The Immediate Jeopardy started on 10/6/23 when the facility failed to implement the pureed diet for Resident #1. The Immediate Jeopardy was removed on 10/25/23 after verification of immediate actions implemented by the facility through observation, record reviews and interviews. The scope and severity were decreased to E, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The findings included: Cross reference F692. The facility's policy titled, Abuse, Neglect and Exploitation, no revision date stated: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The policy noted neglect means failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the clinical record revealed Resident #1 had an admission date of 12/28/2019. Current diagnoses included Dysphagia (difficulty swallowing food or liquids). The physician's diet orders dated 12/30/22 were for a Dysphagia Advanced Mechanical texture (soft food that require more chewing ability), and regular, thin consistency liquids. The Quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 9/29/23 noted Resident #1 experienced loss of liquids/solids from mouth when eating or drinking, coughing, or choking during meals or when swallowing medications, complained of difficulty or pain with swallowing. The nursing progress note dated 10/06/23 at 2:58 p.m., note revealed documentation, Resident had excessive coughing during lunch from eating soup. Diet was downgraded to puree from mechanical soft. Therapy referral completed and submitted. Updated diet slip submitted. MD (physician) made aware. On 10/07/23 in a progress note the Licensed Practical Nurse documented the Certified Nursing Assistant (CNA) called her to resident's room. Resident #1 was actively choking on his meal. The suction machine was needed to clear secretions and food particles from the resident's mouth. Resident #1 continued to cough after airway was cleared. The resident began to talk and said he was fine, had no complaint of pain or discomfort to the chest area. On 10/7/23 at approximately 5:30 p.m., Resident #1 had a delayed response in following commands, persistent excessive coughing, and a drop in oxygen to 88%. On 10/7/23 at 6:35 p.m., the Licensed Practical Nurse documented Resident #1 was sent to the emergency room for delayed response in following command, persistent excessive coughing spell, and a drop in oxygen status. On 10/10/23 a nursing progress note documented Resident #1 was readmitted to the facility. The diagnosis listed was, Choked and aspiration PNA (Pneumonia). On 10/11/23 the physician documented Resident was sent to the emergency room (ER), with concerns for aspiration after choking at lunchtime. Patient was examined in the ER with relevant labs run and then admitted for Aspiration Pneumonia and respiratory failure. Patient readmitted in stable condition, will complete antibiotic therapy, will have therapy availed to him to assist with regaining his baseline status before this event . Review of the facility's investigative findings included reviewing the resident's diet order which stated puree, nectar thickened liquids. Resident #1 received a Mechanical Soft Tray on 10/07/23 at lunch of chopped chicken. The Dietary Manager verified the diet order was entered correctly in the tray ticket system. The new tray tickets were not printed or filed. The Dietary Manager's assistant who was responsible to make the diet change in the system was also responsible to print and file the new tray tickets but failed to do so. On 10/6/23 at dinner and on 10/7/23 for breakfast and lunch Resident #1 continued to receive a mechanical soft diet instead of the pureed diet. On 10/23/23 at 11:45 a.m., the Registered Dietitian (RD) said she started going around at lunch to look at every mechanical/puree tray to make sure they were correct. She said today (10/23/23) was her third day auditing. She said on 10/20/23 during her audit, she found one resident (Resident #4) on a mechanical diet received a regular tray. She said the kitchen made the wrong tray, but the floor staff also delivered the wrong consistency tray to the resident. She said the facility was in the process of implementing different color tickets for the different diets. She said they will finalize the colored ticket today (10/23/23) and they will go into effect tomorrow (10/24/23). On 10/23/23 at 1:05 p.m., the Dietary Manager said an update for Resident #1's diet came through as he was leaving on Friday afternoon. He gave it to his assistant and told her it was important. He explained the normal process is to update the computer, print the new meal ticket with the new diet on it, remove the old meal ticket from the tray line folder and replace it with the new ticket. He said the assistant updated the computer system but must have gotten distracted. She didn't replace the ticket in the tray line folder. He said the change to puree didn't show on the tray line ticket and Resident #1 received a mechanical diet for dinner on 10/6/23, and for breakfast and lunch on 10/7/23. On 10/23/23 at 1:47 p.m., the Speech Therapist said, It was a Friday, the nurse came to me and said he (Resident #1) was having problems with the mechanical soft texture. We downgraded to puree and nectar thick. I agreed it was appropriate. The nurse completed the requisition form, one form came to therapy, and one went to kitchen to alert about the downgrade. Something happened in kitchen that it didn't go through. He (Resident #1) got the mechanical and that caused him to choke. On 10/23/23 at 2:11 p.m., the Assistant Dietary Manager said the Dietary Manager asked her to put the new order for Resident #1 into the system. She said she entered the new order into the computer system and must have gotten sidetracked. She didn't print the new meal ticket and did not put it into the folder for tray line. She said Resident #1's mechanical soft diet was downgraded to puree, but the mechanical soft diet ticket was still in the tray line file. She said she was supposed to take the old one out and replace it with the new one. On 10/24/23 at 1:13 p.m., the Administrator said the Assistant Dietary Manager forgot to file the ticket and as a consequence the wrong consistency was served. He said they put a Performance Improvement Plan in place and started audits of the tray line, consistency/diet, dietary and clinical computer systems to ensure diets match. They held in-services including topics on proper meals and service, trays, and proper diet. On 10/24/24 at 12:54 p.m. the RD said on 10/20/23 while auditing room trays, she found Resident #4 who was on a mechanical soft diet received a regular consistency meal tray, consisting of a Peanut Butter and Jelly (PBJ) sandwich, breaded fish, potatoes, and some sort of vegetable. She said Resident #4 had the PBJ sandwich in his hand and had broken the bread apart with his hands. She took the tray and brought him a mechanical soft diet. She brought the issue to the Administrator. She said that was when she decided to do audits each day and that it was an ongoing process. She said she found the mechanical veggies to be cut a little big and she would be re-educating what size needs to be for mechanical veggies. On 10/25/23 at 9:30 a.m., the Administrator said since the incident with Resident #1 all staff were in serviced on Abuse, Neglect and Exploitation. The Administrator said he personally gave the in-service on 10/15/23 on the topics of proper meals and service, trays, and proper diet. He said they discussed the incident with Resident #1 and nursing staff was advised to check resident's meal ticket against the meal when delivered to the resident. He verified after this in-service and auditing, somehow, a tray got through both the dietary tray line and the clinical staff, resulting in Resident #4 being served the wrong consistency diet on 10/20/23. He said room to room auditing of trays had not been in their original Performance Plan and they will continue working on improving the plan. The Administrator provided documentation on 10/24/23, the facility held an ad hoc (impromptu) meeting to discuss the 10/20/23 incident when Resident #4 received the wrong consistency diet. The root cause documented was, the wrong consistency was placed on the tray by the dietary aide and the CNA (Certified Nursing Assistant) failed to distinguish it was the wrong consistency. The facility provided documentation on 10/24/23 the facility educated the nursing, and activity staff on recognizing diet textures and liquid consistency. On 10/26/23 the Immediate Jeopardy was removed as of 10/25/23 after verification of implementation of the immediate actions which included: Beginning 10/07/23, current Licensed Nurses were educated by the Director of Clinical Services related to the components of the regulation with emphasis on ensuring residents receive the appropriate diet and initiating emergency response if indicated to include a respiratory assessment. The surveyor verified through review of the education and random staff interviews. On 10/08/23 the Performance Improvement Plan was developed and initiated based on root cause analysis. The surveyor verified through review of the Performance Improvement Plan and interview with the Administrator, The Nursing Home Administrator (NHA), Assistant NHA, and Director of Clinical Services educated by the Chief Risk Officer and Regional Nurse Consultant regarding F600, components of this regulation with emphasis on ensuring incidents are investigated, incident report is completed wit reporting to the Agency for Health Care Administration as indicated, and a system for monitoring that its employees or service providers provide goods or services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The surveyor verified through review of the education and interview with the Director of Nursing and the Administrator. The current rate of education compliance for current Licensed Nurses, Certified Nursing Assistants, and Dietary staff as of 10/20/23 was 100% completed. The surveyor verified through record review and random staff interviews. Seventeen residents have a diagnosis of Dysphagia and had the potential to be affected by the deficient practice and potentially suffer serious harm, serious injury, serious impairment, or death. The surveyor verified through record review of residents' ordered diet. On 10/8/23, a root cause analysis was conducted and revealed that the dietary assistant failed to complete the process for the diet order change. She completed the order change in the tray card system but failed to print and file the new tray ticket. The surveyor verified through review of facility's investigation and interview with the Administrator and Director of Nursing. 10/8/23, Performance Improvement Plan was developed and initiated based upon Root Cause Analysis. The surveyor verified through record review of the Performance Improvement Plan. 10/09/23, Nursing staff reeducation initiated on timely reporting of incidents and emergency responses. The surveyor verified through record review and random staff interview of Licensed Nurses and Certified Nursing Assistants. 10/11/23, Quality Assurance and Performance Improvement (QAPI) meeting conducted to review the root cause of the incident and to approve the improvement plan. In attendance were the Administrator, Medical Director, Assistant Administrator, Director of Clinical Services. The surveyor verified through record review. 10/11/23, weekly audits initiated and will continue by Registered Dietitian to verify the electronic medical record (EMR) diet order matches the tray ticket in the dietary electronic system. No discrepancies noted. The surveyor verified through review of the audits. 10/12/23 through 10/16/23, Speech Language Pathologist with assistance of Director of Rehabilitation conducted screens of current residents to ensure proper diet texture. The surveyor verified through review of the audits, and interview with the Speech Language Pathologist. 10/14/23, Director of Nursing initiated education for Licensed Nurses including Physical assessment, proper use of the suction machine, procedure guideline for performing oropharyngeal suction, procedure guideline for taking aspiration precautions and aspiration and dysphagia. Education completed 10/19/23. The surveyor verified through review of the education and random Licensed Nurses interviews, including agency nurses. 10/15/23 through 10/20/23, all department staff were educated on Abuse, Neglect, Exploitation and Reporting. The surveyor verified through record review of the education and random staff interviews. 10/16/23, a quality review was conducted by Human Resources/Business Office Manager to verify all Licensed Nurses have up to date CPR (Cardiopulmonary Resuscitation) certifications. All Licensed Nurses have a valid CPR license. The surveyor verified through review of CPR certification. On 10/17/23, a QAPI meeting was conducted with the following members: NHA, Medical Director, DON (Director of Nursing), DOR (Director of Rehab), Dietary Manager, Social Service Director, staffing Development Coordinator, Nurse Practitioner, Activity Director, Registered Dietitian, and the Speech Language Pathologists. The QAPI committee determined that a revision of the improvement plan be implemented consisting of a diet order binder and a diet order change log. The surveyor verified through review of the QAPI meeting and interview with the Administrator. 10/17/23, the Director of Nursing created Diet Binders containing residents' diet orders and are located at each nursing stating and the main dining room. Binders will be maintained by the Registered Dietitian. The surveyor verified through observation of the binders at each nursing station and the main dining room. 10/17/23, NHA conducted an audit of random trays for accuracy of food and fluid texture and consistencies. No discrepancies noted. The surveyor verified through review of the audit. 10/18/23, DON conducted an audit of 5 random trays for accuracy of food and fluid texture and consistencies. No discrepancies noted. The surveyor verified through review of the audit. 10/18/23, RD conducted an audit of five random trays for accuracy of food and fluid texture and consistencies. No discrepancies noted. The surveyor verified through review of the audit. 10/18/23, RD conducted an audit comparing the EMR physician diet order to the dietary electronic tray ticket system. No discrepancies noted. The surveyor verified through review of the audit. 10/20/23, RD conducted an audit on altered diet or liquids. One discrepancy noted. The tray ticket was correct. The food plated was an uncut peanut butter sandwich. The RD immediately removed the tray without a bite being taken. A correct tray was made and given to the resident. Re-education and disciplinary action was given to the dietary aide who prepared the tray. Re-education and disciplinary action was given to the CNA who delivered the tray. The surveyor verified through review of the audit, and interview with the RD. 10/25/23, an Ad hoc QAPI meeting was conducted with the following members: NHA, Medical Director, DON, and Assistant Administrator. The QAPI committee reviewed the audits and effectiveness for the current plan in conjunction with survey findings. The surveyor verified through review of the QAPI meeting. Newly hired staff will receive education in orientation. Education will include agency and contract staff members. The surveyor verified through interview with the Administrator and Director of Nursing. The Quality Improvement Performance Committee will continue to hold weekly and as needed meetings to review and discuss the results of the ongoing quality monitoring along with staff and resident interviews. The findings of these quality reviews/interviews to be reported to the Quality Assurance/performance Improvement Committee weekly. Quality review schedule modified based on the findings. The surveyor verified through interview with the Administrator and Director of Nursing.

Based on record review, review of policies and procedures, resident and staff interviews, the facility failed to consistently ensure the therapeutic mechanically altered diet was followed for 2 (Residents #1 and #4) of 4 sampled residents on mechanically altered diet. Resident #1 had a diagnosis of Dysphagia (impaired swallowing). On 10/6/23 Resident #1's diet texture was downgraded to a pureed consistency with nectar thickened liquids. The facility failed to provide Resident #1 with the appropriate consistency diet for three meals. On 10/7/23 Resident #1 did not receive a pureed diet for lunch and choked on the food. Staff suctioned food particles from the resident's mouth. On 10/7/23 at approximately 5:30 p.m., Resident #1 was transported to the emergency room for delayed response in following command, persistent excessive coughing spell, and a drop in oxygen status. Resident #1 was diagnosed with acute aspiration pneumonia (food or liquid breathed into the airways) and acute hypoxemic (low oxygen in the blood) respiratory failure. The facility's failure to ensure residents receive food in the appropriate consistency placed residents with similar conditions a risk of accidental choking which could result in serious illness or death and resulted in the determination of Immediate Jeopardy. On 10/25/23 at 9:30 a.m., the Administrator was informed of the determination of Immediate Jeopardy (IJ) and provided the IJ templates. The Immediate Jeopardy started on 10/6/23 when the facility failed to implement the new diet order for Resident #1. The Immediate Jeopardy was removed on 10/25/23 after verification of immediate actions implemented by the facility through observation, record review and interviews. The scope and severity were decreased to E, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The findings included: Cross reference F600. Review of the facility's policy titled, Therapeutic Diet Orders with a revised date of 3/2023 noted a mechanically altered diet is one in which the texture or consistency of food is altered to facilitate oral intake. Examples include soft solids, pureed food, ground meat, and thickened liquids. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed. Review of the clinical record revealed Resident #1 was a long term resident at the facility since 12/2019. The Quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 9/29/23 noted Resident #1 exhibited sings and symptoms of possible swallowing disorder, including complaints of difficulty or pain with swallowing, coughing, or choking during meals or when swallowing medications. Resident #1's cognitive pattern was moderately impaired with a Brief Interview for Mental Status score of 12. Review of the physician's orders revealed on 12/30/22 Resident #1's was on a Dysphagia Advanced Mechanical texture with regular, thin consistency liquids. According to the National Institute of Health, People with dysphagia have difficulty swallowing and may even experience pain while swallowing . Food pieces that are too large for swallowing may enter the throat and block the passage of air. In addition, when foods or liquids enter the airway of someone who has dysphagia, coughing or throat clearing sometimes cannot remove it. Food or liquid that stays in the airway may enter the lungs and allow harmful bacteria to grow, resulting in a lung infection called aspiration pneumonia . (https://www.nidcd.nih.gov/sites/default/files/Documents/health/voice/NIDCD-Dysphagia.pdf) The nursing progress note dated 10/06/23 at 2:58 p.m., note revealed documentation, Resident had excessive coughing during lunch from eating soup. Diet was downgraded to puree from mechanical soft. Therapy referral completed and submitted. Updated diet slip submitted. MD (physician) made aware. On 10/07/23 in a progress note the Licensed Practical Nurse documented the Certified Nursing Assistant (CNA) called her to resident's room. Resident #1 was actively choking on his meal. The suction machine was needed to clear secretions and food particles from the resident's mouth. Resident #1 continued to cough after airway was cleared. The resident began to talk and said he was fine, had no complaint of pain or discomfort to the chest area. The facility provided documentation from the International Dysphagia Diet Standardization Initiative (IDDSI) noting pureed foods do not require chewing, have a smooth texture with no lumps. Per the facility's investigation, Resident #1's lunch meal on 10/7/23 consisted of a mechanical soft diet, including chopped chicken. On 10/7/23 at approximately 5:30 p.m., Resident #1 had a delayed response in following commands, persistent excessive coughing, and a drop in oxygen to 88%. He was sent out to the emergency room and was subsequently admitted to the hospital for three days. On 10/10/23 Resident #1 returned to the facility with a diagnosis of acute aspiration pneumonia and acute hypoxemic respiratory failure. On 10/11/23 the physician documented Resident was sent to the emergency room (ER), with concerns for aspiration after choking at lunchtime. Patient was examined in the ER with relevant labs run and then admitted for Aspiration Pneumonia and respiratory failure. Patient readmitted in stable condition, will complete antibiotic therapy, will have therapy availed to him to assist with regaining his baseline status before this event . On 10/23/23 at 9:55 a.m., in an interview Resident #1 said on 10/7/23 the diet texture had just been changed and he did not really notice the diet was the wrong consistency. On 10/23/23 at 1:05 p.m., in an interview the Dietary Manager said an update for Resident #1's diet came through as he was leaving on Friday afternoon (10/6/23). He said he gave it to his assistant and told her it was important. He explained the normal process is to update the computer, then print the new meal ticket, remove, and replace the old meal ticket from the tray line folder with the new meal ticket. He said the assistant updated the computer system but must have gotten distracted and didn't print or replace the old meal ticket in the tray line folder. Resident #1 received a mechanical texture diet for dinner on 10/6/23 and for breakfast and lunch on 10/7/23. On 10/23/23 at 2:11 p.m., in an interview the Assistant Dietary Manager said on 10/6/23, the Dietary Manager asked her to put the new puree diet order for Resident #1 into the system. She entered it into the computer system, got sidetracked, did not print the new meal ticket, or replace the old meal ticket with the new diet order in the folder for tray line. The meal ticket from the previous mechanical texture diet was still in the tray line folder. On 10/24/23 at 1:13 p.m., in an interview the Administrator said the facility completed a thorough investigation and verified the Assistant Dietary Manager did not print and file the new tray ticket for the pureed diet in the tray line folder. This resulted in Resident #1 receiving the wrong consistency diet. He said they had put a Performance Improvement Plan in place and had started audits of the tray line, consistency/diet audits, auditing the dietary and clinical computer systems to ensure diets match, and had held in-services including topics on proper meals and service, trays, and proper diet. Review of the Performance Improvement Plan dated 10/8/23 showed the following action steps: Education for dietary staff on workflow of tray tickets, completed on 10/20/23. Staff education conducted with focus on facility process for serving meals and utilizing meal ticket to ensure proper diet, completed on 10/15/23. On 10/23/23 at 11:45 a.m., the Registered Dietitian said she started going around at lunch to look at every mechanical/puree tray to make sure they were correct. She said today (10/23/23) was her third day auditing. She said on 10/20/23 during her audit, she found one resident (Resident #4) on a mechanical diet received a regular tray. She said the kitchen made the wrong tray, but the floor staff also delivered the wrong consistency tray to the resident. She said the facility was in the process of implementing different color tickets for the different diets. She said they will finalize the colored ticket today (10/23/23) and they will go into effect tomorrow (10/24/23). On 10/24/24 at 12:54 p.m., in an interview the Registered Dietitian said on 10/20/23 Resident #4 received a regular diet instead of the ordered mechanical soft diet. The resident received a Peanut Butter and Jelly (PBJ) sandwich, breaded fish, potatoes, and some sort of vegetable. She said Resident #4 had the PBJ sandwich in his hand and had broken the bread apart with his hands. She said she took the tray and brought him a mechanical soft diet and brought the issue to the Administrator. The Registered Dietitian also said she found the mechanical veggies to be cut a little big and she would be re-educating what size needs to be for mechanical veggies. The facility provided a Quality Assessment and Performance Improvement (QAPI) Plan dated 10/24/23 with a problem statement indicating a resident received the wrong diet at lunch which was caught during audit. The wrong consistency diet was placed on the tray by the Dietary Aide during tray line. The Certified Nursing Assistant failed to distinguish it was the wrong consistency. On 10/24/23 the facility educated the nursing staff on the different diet consistencies and implemented a process to ensure a Licensed Nurse checked each tray coming out of the kitchen for the proper consistency diet. On 10/25/23 at 9:30 a.m., in an interview the Administrator said he personally had given the in-service on 10/15/23 on the topics of proper meals and service, trays, and proper diet. He said they had discussed the incident with Resident #1 and staff was advised to check resident ticket against the meal when delivered to the resident. He verified after this in-service and auditing, somehow, a tray got through both the dietary tray line and the clinical staff passed the incorrect tray to Resident #4 on 10/20/23. He said room to room auditing of trays had not been in their original Performance Plan and they will continue working on improving the plan. On 10/26/23 the Immediate Jeopardy was removed as of 10/25/23 after verification of implementation of the immediate actions which included: Beginning 10/7/23, current Licensed Nurses were educated by the Director of Nursing related to the components of the regulation with emphasis on ensuring residents receive the appropriate diet and initiating emergency response if indicated to include a respiratory assessment. The surveyor verified through review of the education and random Licensed Nurses interviews. On 10/8/23, the Performance Improvement Plan was developed and initiated based on root cause analysis. The surveyor verified through review of the Performance Improvement Plan, and Administrator interview. The Nursing Home Administrator (NHA), Assistant NHA, and Director of Nursing educated by the Chief Risk Officer and Regional Nurse Consultant regarding F692 and the components of the regulation with emphasis on ensuring incidents are investigated, incident report is completed with reporting to the Agency for Health Care Administration as indicated and a system for monitoring that nursing staff were competent and appropriately trained to provide the necessary care to the residents to include oversight, monitoring and auditing of training completion or competency by nursing management to prevent a resident from suffering serious harm. The surveyor verified by review of training and random nursing staff interviews, including agency Licensed Nurses. The current rate of education compliance for current Licensed Nurse staff as of 10/20/23 was 100%. The surveyor verified through review of education and random staff interviews. 10/7/23 at 8:00 p.m., the Dietary Manager verbally educated evening dietary staff on proper workflow when creating, reading, printing, and filing of resident meal tickets. They were educated on the importance of providing the proper diet meals and consistencies for the residents. New tickets were printed for the resident involved and filed in the weekend meal tickets. The surveyor verified through interview of the dietary staff. 10/8/23, the Dietary Manager educated the morning dietary staff on proper workflow when creating, reading, printing, and filing of resident meal tickets. Dietary staff were educated on the importance of providing the proper diet meals and consistencies for the residents. The surveyor verified through random interviews of dietary staff. On 10/8/23, a root cause analysis was conducted and revealed the Dietary Assistant failed to complete the process of the diet order change. She completed the order change in the tray card system but failed to print and file the new tray ticket. The surveyor verified through review of the facility's investigation and interview with the Dietary Assistant. On 10/8/23, Performance Improvement Plan was developed and initiated based upon the root cause analysis. The surveyor verified through review of the Performance Improvement Plan and interview with the Administrator. 10/9/23, Nursing staff reeducation initiated on timely reporting of incidents and emergency responses. The surveyor verified through review of the education and random interview with Licensed Nurses and Certified Nursing Assistants. 10/10/23, NHA (Nursing Home Administrator) conducted an audit of random trays for accuracy of food and fluid texture and consistencies. No discrepancies noted. The surveyor verified through review of the audits and interview with the NHA. 10/11/23, QAPI meeting conducted to review the root cause of the incident and to approve the Improvement plan. In attendance were the Administrator, the Medical Director, Assistant Administrator, Director of Nursing. The surveyor verified through review of the QAPI meeting and attendance log. 10/11/23, weekly audits initiated and will continue by Registered Dietitian to verify the electronic computer system diet order matches the tray ticket in the Dietary computer system. No discrepancies noted. The surveyor verified through review of the audits. 10/11/23, written counseling was provided to the Dietary Assistant by the Administrator and Dietary Manager. The surveyor verified through review of counseling and interview with the Dietary Assistant. 10/11/23, the DON conducted an audit of current resident's diet orders to verify the correct tray tickets were in place. No discrepancies noted. The surveyor verified through review of the audits. 10/11/23, Weekly Audits initiated and will continue by Registered Dietitian to verify electronic computer system diet order matches the tray ticket in the dietary computer system. No discrepancies noted. The surveyor verified through review of the audits. 10/11/23, Written counseling was provided to the Dietary Assistant by the Administrator and Dietary Manager. The surveyor verified through interview with the Dietary Assistant. 10/12/23 through 10/16/23, Speech Language Pathologist with assistance of Director of Rehabilitation conducted screens of current residents to ensure proper diet texture. The surveyor verified through review of the audits. 10/12/23, Weekly Audits initiated and continued by the Dietary Manager or Registered Dietician to verify tray accuracy. The surveyor verified through review of the audits. 10/13/23, Dietary Manager was educated via phone by [NAME] President of Operations regarding duties and best practices of Dietary Manager role and duties. The surveyor verified through review of the education and interview with the Dietary Manager. 10-12-2023, 10-13-2023 and 10-16-2023 [NAME] 1 was educated by the Dietary Manager on dietary computer tray card system to be able to input new diet orders and print meal tickets. A return demonstration of the process was performed. 10/18/23, [NAME] 2 was educated by the Dietary Manager on the dietary computer tray card system to be able to input new diet orders and print meal tickets. A return demonstration of the process was performed. The surveyor verified through review of the education and random interviews with dietary staff. 10/14/23, Director of Nursing initiated education for licensed Nurses including Physical assessment, Proper use of the suction machine, Procedure Guideline for Performing Oropharyngeal Suction, Procedure Guideline for Taking Aspiration Precautions and Aspiration and Dysphagia. Education completed 10/19/23. The surveyor verified through review of the education and random interviews with Licensed Nurses. 10/15/23 through 10/20/23, all Department Staff were educated on Abuse, Neglect, Exploitation and Reporting. The surveyor verified through review of the education and random staff interviews. 10/16/23, a quality review was conducted by Human Resources/Business Office Manager to verify all Licensed Nurses have up to date CPR certifications. All Licensed Nurses have a valid CPR license. The surveyor verified through review of the audits. On 10/17/23, a QAPI meeting was conducted with the following members: NHA, Medical director, DON, DOR, Dietary manager, social service director, staffing development coordinator, Nurse practitioner, activity director, registered dietician, and the speech language pathologists. The QAPI committee determined that a revision of the improvement plan be implemented consisting of a diet order binder and a diet order change log. The surveyor verified through review of the QAPI meeting and interview with the Administrator. 10/17/23, Facility Implemented a new Diet Order Change Log Sheet to track daily diet order changes. The surveyor verified through review of the Diet Order Change Log Sheet. 10/17/23, Dietary staff were educated on the Diet Order Change Log by facility Administrator and Dietary Manager. The surveyor verified through review of the education and interview with the Dietary Manager. 10/17/23, Director of Nursing created Diet Binders containing resident's diet orders and are located at each Nursing Station and the Main Dining Room. Binders will be maintained by the Registered Dietitian. The surveyor verified through observation of the binders at each nursing station, the main dining room and interview with the Registered Dietitian. On 10/17/23, NHA conducted an audit of random trays for accuracy of food and fluid texture and consistencies. No discrepancies noted. The surveyor verified through review of the audits. On 10/18/23, DON conducted an audit of 5 random trays for accuracy of food and fluid texture and consistencies. No discrepancies noted. The surveyor verified through review of the audits. On 10/18/23, RD conducted an audit comparing the electronic computer system physician order to the dietary computer tray ticket system. No discrepancies noted. The surveyor verified through review of the audits. On 10/20/23, RD conducted an audit on altered diets or liquids. One discrepancy noted. The tray ticket was correct. The food plated was an uncut peanut butter sandwich. The RD immediately removed the tray without a bite taken. A correct tray was made and given to the resident. Re-education and disciplinary action was given to the dietary aide who prepared the tray. Re-education and disciplinary action was given to the CNA who delivered the tray. The surveyor verified through review of the audits and interview with the RD. On 10/23/23, DON conducted an audit of altered diets. No discrepancies noted. The surveyor verified through review of the audits. On 10/24/23, RD conducted an audit of altered diet or fluid textures and found no discrepancies. The surveyor verified through review of the audits. On 10/24/23 and 10/25/23, RD conducted an audit verifying PCC physician orders to the IMPAC tray ticket system. No discrepancies noted. The surveyor verified through review of the audits. On 10/24/23, RD conducted a tray accuracy audit and found no discrepancies. The surveyor verified through review of the audits. On 10/24/23, an ad hoc QAPI meeting was conducted due to the wrong diet was noted on a tray during the audit conducted on 10-20-23. The root cause analysis showed that the wrong consistency was placed on the tray by the dietary aide and the CNA failed to distinguish it was the wrong consistency. In attendance were the Administrator, medical director, DON, assistant administrator, Director of Maintenance, Activity director, Dietary Manager, Housekeeping supervisor, Director of rehab, Registered dietitian, Unit manager, Licensed Practical Nurse, and Human Resources Director. Initiated a kitchen runner. Increased audit frequency to daily with varying locations and implemented that a nurse verifies the tray is accurate according to the tray ticket when the carts are delivered to the floor prior to delivery to the resident. A nurse in the dining room will verify the tray is accurate according to the tray ticket prior to delivery to the resident. Additional education for CNAs, Nurses, Activities and Dietary was conducted regarding accurately identifying diet and fluid texture types. DON educated CNAs and nurses, Assistant administrator educated Activities staff (one staff member in Italy remains uneducated and will be educated prior to beginning her next shift). Dietary staff were educated by the dietary manager. The surveyor verified through review of the QAPI meeting and interview with the Administrator, and observation of two meals. On 10/25/23, a QAPI meeting was conducted with the following members: NHA, Medical Director, DON, and Assistant Administrator. The QAPI committee reviewed the audits and effectiveness of current plan in conjunction with surveyor findings. The surveyor verified through review of the QAPI meeting. On 10/25/23, RD conducted an audit of diet texture and fluid. No discrepancies noted. The surveyor verified through review of the audit. Newly hired staff will receive education in orientation. Education will include agency and contract staff members. The surveyor verified through review of the Performance Improvement Plan and interview with the Administrator. The Quality Improvement Performance Committee will continue to hold weekly and as needed meetings to review and discuss the results of the ongoing quality monitoring along with staff and resident interviews. The findings of these quality reviews/interviews to be reported to the Quality Assurance/Performance Improvement Committee weekly. Quality Review schedule modified based on findings. The surveyor verified through review of the Performance Improvement Plan and interview with the Administrator.