**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff interviews, and a review of the facility's policy titled Care Plan Policy, the facility failed to implement the care plan for one of 26 sampled residents (R) (R165) related to nutrition. Specifically, the facility provided R165 a sandwich which resulted in him being sent out to the local emergency room (ER) and admitted to a hospice facility where he expired on 8/31/2024. On 3/13/2025 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) for F656, F684, and F835 on 3/13/2025 at 12:48 pm. The noncompliance related to the IJ was identified to have existed on 7/23/2024. An Acceptable IJ Removal Plan was received on 3/14/2025 related to Comprehensive Care Plans, C.F.R. 483.21; Quality of Care, C.F.R. 483.25; and Administration, C.F.R. 483.70. Findings included: A review of the policy titled Care Plan Policy with the last revised date of 2/4/2025 stated each resident will have a person-centered plan of care to identify problems, needs, and strengths that will identify how the facility staff will provide service to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. A review of the Electronic Medical Record (EMR) revealed that R165 was admitted to the facility on [DATE] with diagnoses including, but not limited to, dysphagia following cerebral infraction, dysphagia, oropharyngeal phase, cerebrovascular disease affecting the right dominant side, adult failure to thrive, seizures, and other symptoms and signs involving cognitive functions following unspecified cerebrovascular disease. A review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that R165 presented with a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment and that R165 required supervision/touching while eating. A review of the care plan initiated on 11/3/2022 and updated on 3/5/2024 revealed that R165 has the potential for nutritional deficit problems related to receiving a mechanically altered diet. Interventions indicate NAS (no added salt) pureed /dysphagia puree texture, thin liquids consistency diet as ordered 6/6/2024. A review of the physician orders for R165 dated 6/6/2024 revealed R165 had an order for NAS diet pureed/dysphagia puree texture with thin liquids consistency. A review of the nursing note written by the Licensed Practical Nurse (LPN) OO revealed that R165 was sitting in a wheelchair at the nursing station when she noted that the resident choking on undigested food. It was documented that Food was falling out of his mouth, and he was choking for air. The Heimlich maneuver was started, and a mouth sweep was done but was unsuccessful. She documented that Cardiopulmonary Resuscitation (CPR) started and at that 911 was called; R165 started breathing again; the Medical Doctor (MD) was called; and R165's family member was called, informed of the resident choking, and that he was sent out by 911 to closet hospital. At 3:45 pm, R165 departed the facility breathing on his own with Emergency Medical Services (EMS). An interview on 3/11/2025 at 9:30 am with the facility Administrator revealed that Certified Nursing Assistant (CNA) AA was viewed on facility camera handing R165 a sandwich prior to the event. She revealed that she expected R165 to return to the facility but when the facility contacted the local hospital, R165 was discharged from the hospital and sent to a local hospice on 8/5/2025 and expired on 8/31/2025. An interview was conducted on 3/14/2025 at 8:43 am with MDS Coordinator PP and MDS Coordinator QQ revealed they are responsible for putting information into the care plan. They stated diets were entered into the care plan by reviewing the physician's orders and that staff members and residents were interviewed to obtain interventions for nutrition for their abilities to eat. The facility implemented the following corrective action in response to the deficient practice which occurred on 7/30/2024: 1. The facility's Modified Texture of Food Policy, Care Plan Policy, and Resident Food Preferences Policy were reviewed on 7/24/2024; staff in-service education was initiated on 7/24/2024. As of 7/29/2024, all policies were reviewed with 100% staff with the exception of those on Leave of Absence (LOA) and Family Medical Leave Act (FMLA). On 7/23/2024, R165's care plan was reviewed to reflect the appropriate diet; no changes were made. As of 7/29/2024, the facility census was 107. A review of the facility's policy titled, Modified Textures of Foods, revealed a revision date of August 2024. A review of the facility's policy titled, Resident Food Preferences, revealed a revision date of May 2024. A review of the facility's policy titled Care Plan Policy, revealed a revision date of 2/4/2025. An interview with the Administrator on 3/18/2025 at 1:28 pm revealed that they do not add a new reviewed date unless there are changes to be made. A review of R165's care plan revealed a focus related to his mechanically altered diet. 2. On 7/25/2024, an Ad Hoc QAPI meeting was held with the Medical Director, Corporate Operations Consultant, Administrator, DON, Social Services Director, Staff Development Coordinator, Food Services Director, MDS staff, and Nurse Managers to review the IJ Removal Plan. The Care Plan policy was reviewed with no changes. The Daily Diet Verification Audit was performed for 100% of current residents and was completed on 7/24/2024, by the DON. The audit concluded that 100% of the meal tray cards matched 100% of the residents' diet orders, [NAME], and care plans. See the attached audit of the Daily Diet Verification Audit. The specific number of staff that received the in-service included: Administrative nine out of nine; Registered Nurses (RNs) six out of six; LPNs 15 out of 15; Certified Medication Aides (CMAs) 10 out of 10; CNAs 44 out of 44; Housekeeping/Laundry 14 out of 14; Maintenance two out of two; Dietary nine out of nine; and Activities two of two. Interviews were conducted on 3/19/2025 and all staff were found to be knowledgeable and able to verbalize the information shared during the education. LPN UUU at 1:59 pm; LPN EE at 1:28 pm; CMA RR at 1:50 pm; CNA PPP at 1:31 pm; CNA QQQ at 1:35 pm; CNA RRR at 1:40 pm; CNA LL at 1:47 pm; CNA BBB at 1:52 pm; CNA VVV at 2:06 pm; Laundry Aide (LA) AAA at 1:53 pm; LA XXX at 2:11 pm; Director of Housekeeping at 2:18 pm; Maintenance Director interviewed at 2:20 pm; Physical Therapy Assistant (PTA) TTT at 1:56 pm; Housekeeping WWW at 2:09 pm; Floor Tech YYY at 2:26 pm; CNA YY at 1:28 pm; CNA CCC at 1:32 pm; CMA SS at 1:55 pm; LPN AAA at 1:26 pm; Dietary Aide (DA) LLL 1:44 pm; DA MMM at 1:48 pm; DA NNN at 1:50 pm; DA OOO at 1:52 pm; ADON ZZ at 1:30 pm; LPN AA at 1:35 pm; CNA YY at 1:25 pm; CMA MM at 1:29 pm; CNA JJJ at 2:10 pm; Dietary Manager VV at 1:46; DA KK at 1:48 pm; DA HHH at 1:50 pm; DA TT at 1:53 pm; MDS PP at 2:00 pm, Rehab Director III at 2:05 pm; CMA FFFF at 3:27 pm; CNA GGGG3:32 pm; RN Supervisor HHHH at 3:35 pm; LA IIII at 3:40 pm; CMA/CNA JJJJ at 3:49 pm; CNA KKKK at 3:52 pm; and LPN DDDD at 3:55 pm. 3. No staff worked until they had completed the in-service education. There were 14 staff that were part-time; 15 staff PRN (as needed); and 12 staff contracted. These staff will be in-serviced and educated on the Modified Texture of Food Policy, Care Plan Policy, and Resident Food Preferences Policy by the DON or Staff Development Coordinator before being allowed to work. The target date for completion of all education was 7/29/2024. A review of the agency training binder revealed one undated in-service log titled, Care Plan Policy. Signatures of eight agency staff documented attendance dated 2/19/2025, 2/20/2025, 2/27/2025, 2/26/2025, 3/12/2025, and 3/14/2025. A review of the agency in-services titled, Plan of Correction, Dietary Trays, Snack, Care Plan, dated 7/25/2024, 8/30/2024, 9/3/2024, 9/4/2024, 9/20/2024, 9/22/2024, 10/9/2024, 10/11/2024, 11/1/2024, 11/12/2024, and 2/19/2025 revealed documented in-service of agency care staff who have worked in the facility since 7/29/2024. An interview with the Staff Development Coordinator on 3/17/2025 at 12:37 pm revealed that she documents training for the agency in a separate binder and housekeeping in a separate binder. She stated that her process on how she educates agency staff involves putting the in-service in the book, and then they read the book and sign an acknowledgment of understanding. 4. Effective 7/29/2024, all newly hired staff will be in-serviced on their first day of hire by the Staff Development Coordinator, DON, or Nursing Administration. She will be providing the in-service/training during orientation upon hire, annually, and quarterly. Individuals will not work until they have received this in-service/training. A total of 107 out of 107 residents were identified as having correct diet orders. All residents' care plans were reviewed and updated to reflect appropriate diet orders. A review of the Plan of Correction revealed that the following would be discussed: Process of passing out snacks to the residents, Different types of meals given, Where to locate the snacks and what snacks can be given to the residents, Passing trays and checking the Diet Sheet to ensure that the resident gets the correct meal, and what to do if dietary send an incorrect meal. A review of the General Orientation Record revealed new hires received the education in orientation. The staff was re-educated related to the Dietary, Verifying snacks, Correct Diet, Heimlich maneuver, and tray verification. A review of 107 residents' diet orders and care plans, all were updated and correct. A review of the newly hired orientation and in-service training related to the Plan of Correction revealed they were completed. During an interview on 2/18/2025 at 11:12 am, the Administrator stated depending on the staff start date, they would have training before going on the floor training or at orientation. The orientation agenda was revamped to gear towards the IJ. The DON is responsible for letting Human Resources (HR) know if an employee is no longer active. For the new employees, there is an agenda that is presented for the IJ Plan of Correction. There is a summary for Passing Tray and Snacks. It is a general orientation when they have something going on, it is specifically for training that is included in the orientation process. There is an addendum to the orientation regarding policy, summary, and orientation list attached to the sign-in sheets. 5. The facility implemented interventions on 7/29/2024, to minimize the environmental risks and hazards. Interventions include: A Daily Diet Verification Audit was performed for 100% of current residents and was completed on 7/24/2024 by the DON to ensure 100% of residents' meal trays matched 100% of residents' diet orders, [NAME], and care plans. A Snack Distribution Audit was performed for 100% of current residents and was completed on 7/26/2024 by the DON and Nursing Administration to ensure that all residents received an accurate diet including snacks. A Meal Tray Observation Audit was performed for 100% of current residents and was completed on 7/26/2024 by the DON and Nurse Managers to ensure that all residents received their appropriate meal trays. Provided education to all staff regarding Modified Texture of Food Policy, Care Plan Policy, and Resident Food Preferences Policy to include reporting any unmatched meal trays and diet orders to the Food Services Director and Director of Nursing. The initial incident was reported to the state on 7/24/2024. The facility reported all audit findings to the Quality Assurance Process Improvement (QAPI) Committee and conducted an Ad Hoc QAPI meeting on 7/25/2024. A review on 7/24/2025 revealed that the Daily Diet Verification Audit was completed at 100% for resident diet orders, [NAME], and care plans. A review on 7/26/2024 revealed that the Meal Tray Observation Aduit was completed at 100% for all residents who received appropriate meal trays. A review on 7/26/2024 revealed that the Snack Distribution Aduit was completed at 100% for all residents who received appropriate meal trays. A review of the all-staff education documented Modified Texture of Food Policy, Care Plan Policy, and Resident Food Preferences Policy were reviewed and completed by the Food Service Director and Director of Nursing. A review of the QAPI Committee minutes revealed all audit findings were discussed and in place. A review of the sign-in sheet revealed that the Ad Hoc QAPI meeting was held on 7/25 2024. 6. New interventions will be monitored by the DON daily for six months for effectiveness using the audit tools Daily Diet Verification Audit, and Snack Distribution Audit to ensure this deficient practice does not reoccur. If a problem is identified, it will be addressed by the Food Service Director, Administrator, DON, and Medical Director. All parties including the resident, the resident's responsible party, the Medical Director, the Administrator, the DON, and the Food Service Director will meet to discuss the policy's violation. If there is a problem and all parties cannot agree, there will be an Ad Hoc QAPI meeting with the Consultant Operations Consultant and possible corrective action. An interview was conducted on 3/18/2025 at 1:15 pm with the administrator revealed the DON is responsible for overseeing the daily audits. Interview on 3/18/2025 at 2:53 pm with DON, she stated there were no errors. She said no one received the incorrect tray during the audits. 7. All dates of corrective action for staff will be completed on 7/29/2024. The facility alleged that the IJ was removed on 7/30/2024. All dates of corrective actions were completed on 7/29/2024. The facility's IJ was determined to be Past Noncompliance, removed on 7/30/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, staff interviews, and review of the facility's policies Modified Texture of Food and Resident Food Preferences, the facility failed to provide a pureed snack to one of 26 sampled residents (R) (R165) ordered to receive a mechanically altered diet. Specifically, the facility provided R165 a sandwich which resulted in him being sent out to the local emergency room (ER) and admitted to a hospice facility where he expired on 8/31/2024. On 3/13/2025 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) for F656, F684, and F835 on 3/13/2025 at 12:48 pm. The noncompliance related to the IJ was identified to have existed on 7/23/2024. An Acceptable IJ Removal Plan was received on 3/14/2025 related to Comprehensive Care Plans, C.F.R. 483.21; Quality of Care, C.F.R. 483.25; and Administration, C.F.R. 483.70. Findings included: A review of the Facility policy titled Modified Texture of Food Policy revealed that the facility offers Puree diets. The considerations were to read each tray card carefully to ensure all food textures were served to the residents accurately. Failure to do so may place the resident in a harmful situation. A review of the facility policy titled Resident Food Preferences revealed the Physician and Dietician will communicate the risks and benefits of specialized therapeutic versus liberalized diets. A review of the Electronic Medical Record (EMR) revealed that R165 was admitted to the facility on [DATE] with diagnoses including, but not limited to, dysphagia following cerebral infraction, dysphagia, oropharyngeal phase, cerebrovascular disease affecting the right dominant side, adult failure to thrive, seizures, and signs involving cognitive functions following unspecified cerebrovascular disease. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R165 presented with a Brief Interview for Mental Status (BIMS) score of three, which indicates severe cognitive impairment. Further review revealed that R165 required supervision or touching assistance with eating and was ordered a mechanically altered diet. A review of the care plan initiated on 11/3/2022 and updated on 3/5/2024 revealed that R165 has the potential for nutritional deficit problems related to receiving a mechanically altered diet. Further interventions indicate NAS (No added salt) pureed /dysphagia puree texture, thin liquids consistency diet as ordered (6/6/2024). A review of the Physician Orders for R165 dated 6/6/2024 revealed an order NAS (No Added Salt) diet, pureed / dysphagia puree texture, and thin liquids consistency. A review of a facility document dated 7/31/2024 revealed that the Director of Nursing (DON) found that the allegation of neglect was substantiated and that the Certified Nursing Assistant (CNA) AA had been terminated. It was noted that the camera footage obtained on 7/24/2024 revealed R165 pointing to the snack tray behind the nurse's station and CNA AA then proceeded to walk behind the nurse's station. Footage then showed CNA AA walking over to R165 and handing him an item that appeared to be a sandwich. A review of the nurse note dated 7/23/2024 at (3:35 pm) by a Licensed Practical Nurse (LPN) OO documented that R165 was sitting in a wheelchair at the nursing station when he was noted the resident choking on undigested food. The nurse documented, Food was falling out of his mouth, and he was choking for air. The Heimlich maneuver was started, and a mouth sweep was done, but was unsuccessful. Cardiopulmonary Resuscitation (CPR) started the emergency services number was called. It was documented that R165 started breathing, the Medical Doctor called, and R165's family member was called and informed of the resident choking. He was sent out to an acute care hospital, and he was breathing on his own when he left the facility with emergency medical transport (EMT) personnel. During an interview on 3/14/2025 at 8:38 am, CNA KK stated that she was present on 7/23/2024 and witnessed the event related to R165. She stated she was sitting at the desk when another resident told her that he thought R165 was choking. She stated she observed LPN OO go to the resident and begin to pat him on the back. CNA KK stated that LPN OO took R165 to his room. She stated that she notified the DON and witnessed the DON enter R165's room. CNA KK stated she then called the emergency services number. During an interview on 3/14/2025 at 8:52 am with Certified Medication Technician (CMT) RR she stated she was present on 7/23/2024 and witnessed the event related to R165. She stated that she had started talking to R165 and she realized something was wrong. She stated that she took him to his room. She stated she thought LPN OO was present. CMT RR stated that she tried getting R165 out of the wheelchair to perform the Heimlich Maneuver, but he required a Hoyer Lift for transfer, and she was not able to get him up. She stated that the DON came into the room and went out to ensure that the emergency services number was called. She further stated that she and LPN OO got R165 out of the chair and onto the floor and performed a finger sweep in R165's mouth and removed what appeared to her to be a bread-like substance. She stated that CPR was started until the EMT service personnel arrived, took over CPR, and transported R165 to the local ER. During an interview on 3/11/2025 at 9:30 am, the facility Administrator revealed employee CNA AA was viewed on the facility camera handing R165 a sandwich before the event. During an interview conducted on 3/11/2025 at 3:25 pm, the Administrator revealed she expected the resident to return but when the facility checked with the local hospital and was informed that R165 had been transferred out to a hospice facility on 8/5/2025 and that he expired on 8/31/2025. An attempt was made but CNA AA was unavailable for an interview. The facility implemented the following corrective action in response to the deficient practice which occurred on 7/30/2024: 1. The facility's Modified Texture of Food Policy, Care Plan Policy, and Resident Food Preferences Policy were reviewed on 7/24/2024; staff in-service education was initiated on 7/24/2024. As of 7/29/2024, all policies were reviewed with 100 percent (%) staff except for those on Leave of Absence (LOA) and Family Medical Leave Act (FMLA). On 7/23/2024, R165's care plan was reviewed to reflect the appropriate diet; no changes were made. As of 7/29/2024, our census was 107. A review of the facility's policies titled Modified Textures of Foods, Resident Food Preferences, and Care Plan Policy were reviewed with no concerns. An interview with the Administrator on 3/18/2025 at 1:28 pm stated that these policy reviews are mentioned in the QAPI meetings. A review of in-services in the removal plan binder revealed training specific to the Modified Texture of Food Policy, Care Plan Policy, and Resident Food Preferences Policy initiated on 7/24/2024. 2. On 7/25/2024, an AdHoc Quality Assurance Process Improvement (QAPI) meeting was held with the Medical Director (MD), Corporate Operations Consultant (COC), Administrator, DON, Social Services Director (SSD), Staff Development Coordinator (SDC), Food Services Director (FSD), MDS staff, and Nurse Managers to review the self-imposed IJ Removal Plan. The Care Plan policy was reviewed with no changes. The Daily Diet Verification Audit was performed for 100% of current residents and was completed on 7/24/2024 by the DON. The audit concluded that 100% of meal tray cards matched 100% of the residents' diet orders, [NAME], and care plans. See the attached audit of the Daily Diet Verification Audit. The specific number of staff that received the in-service included: nine of nine Administrative Staff; six of six Registered Nurses (RNs);15 of 15 LPNs; 10 of 10 CMAs; 44 of 44 CNAs; 14 of 14 Housekeeping and Laundry staff; two of two Maintenance staff; nine of nine Dietary staff; and two of two Activities staff. A review on 3/17/2025 of the Plan of Correction (PoC) Binder revealed that a QAPI meeting was held on 7/25/2024 and revealed a copy of the Care Plan policy. A review on 3/17/2025 of PoC Binder revealed the Daily Diet Verification Audit was performed for 100% of current residents and completed on 7/24/2024. The audit concluded that 100% of the meal tray cards matched 100% of the residents' diet orders, [NAME], and care plans. Interviews were conducted on 3/19/2025 and all staff were found to be knowledgeable and able to verbalize the information shared during the education. LPN UUU at 1:59 pm; LPN EE at 1:28 pm; CMA RR at 1:50 pm; CNA PPP at 1:31 pm; CNA QQQ at 1:35 pm; CNA RRR at 1:40 pm; CNA LL at 1:47 pm; CNA BBB at 1:52 pm; CNA VVV at 2:06 pm; Laundry Aide (LA) AAA at 1:53 pm; LA XXX at 2:11 pm; Director of Housekeeping at 2:18 pm; Maintenance Director interviewed at 2:20 pm; Physical Therapy Assistant (PTA) TTT at 1:56 pm; Housekeeping WWW at 2:09 pm; Floor Tech YYY at 2:26 pm; CNA YY at 1:28 pm; CNA CCC at 1:32 pm; CMA SS at 1:55 pm; LPN AAA at 1:26 pm; Dietary Aide (DA) LLL 1:44 pm; DA MMM at 1:48 pm; DA NNN at 1:50 pm; DA OOO at 1:52 pm; ADON ZZ at 1:30 pm; LPN AA at 1:35 pm; CNA YY at 1:25 pm; CMA MM at 1:29 pm; CNA JJJ at 2:10 pm; Dietary Manager VV at 1:46; DA KK at 1:48 pm; DA HHH at 1:50 pm; DA TT at 1:53 pm; MDS PP at 2:00 pm, Rehab Director III at 2:05 pm; CMA FFFF at 3:27 pm; CNA GGGG3:32 pm; RN Supervisor HHHH at 3:35 pm; LA IIII at 3:40 pm; CMA/CNA JJJJ at 3:49 pm; CNA KKKK at 3:52 pm; and LPN DDDD at 3:55 pm. 3. No staff shall work until they have completed the in-service education. There are 14 staff that are part-time, 15 staff that are PRN (as needed), and 12 staff that are contracted. These staff will be in-serviced and educated on the Modified Texture of Food Policy, Care Plan Policy, and Resident Food Preferences Policy by DON or Nursing Administration before being allowed to work. The target date for completion of all education is 7/29/2024. A review of the agency training binder revealed one undated in-service log titled, Care Plan Policy. Signatures of eight agency staff documented attendance dated 2/19/2025, 2/20/2025, 2/27/2025, 2/26/2025, 3/12/2025, and 3/14/2025. A review of the agency in-services titled, Plan of Correction, Dietary Trays, Snack, Care Plan, dated 7/25/2024, 8/30/2024, 9/3/2024, 9/4/2024, 9/20/2024, 9/22/2024, 10/9/2024, 10/11/2024, 11/1/2024, 11/12/2024, and 2/19/2025 revealed 40 names of agency care staff have documented in-service attendance since 7/29/2024. An interview with the SDC on 3/17/2025 at 12:37 pm revealed that she documents training for the agency staff in a binder and housekeeping in a separate binder. She stated that her process on how she educates agency staff involves putting the in-service in the book and then they are required to read the in-service and sign for understanding. 4. Effective 7/29/2024, all newly hired staff will be in-serviced on their first day of hire by the SDC or Infection Preventionist (IP) Nurse. They will be providing the in-service/training during orientation upon hire, annually, and quarterly. Individuals will not work until they have received this in-service/training. A total of 107 out of 107 residents were identified as having correct diet orders. All residents' care plans were reviewed and updated to reflect appropriate diet orders. A review of the PoC stated the following will be discussed (1) Resident Food Preference Policy, (2) Frequency of Meals Policy, (3) Process of passing out snacks to the residents, (4) Different types of meals given at (the facility), (5) Where to locate the snacks and what snacks can be given to the residents, (6) Passing trays and checking the Diet Sheet to ensuring that the resident get the correct meal, (7) What to do if dietary send an incorrect meal, (8) Offering the resident an alternative meal if they dislike the meal, and (9) Hand hygiene. A review of the General Orientation Record revealed new hires received orientation accordingly. Dietary (PoC) Verifying snacks, Correct Diet, Heimlich maneuver, and Abuse all verified. * A review of 107 of 107 residents' diet orders and care plans were updated and all correct. * A review of the new hire orientation and in-service training related to the PoC revealed they were completed. During an interview on 2/18/2025 at 11:12 am, the Administrator stated depending on the staff start date, they would have training before going on the floor training or at orientation. The orientation agenda was revamped to gear towards the IJ. The DON was responsible for letting Human Resources know if an employee was no longer active. For the new employee, there is an agenda that is presented for the IJ PoC. There was a summary for Passing Tray and Snacks. It was a general orientation when they have something going on, it is specifically for training that is included in the orientation process. There is an addendum to the orientation regarding policy, summary, orientation list, and sign-in sheets. The in-service sheets dated 7/24/2024 through 7/29/2024 were reviewed and verified that staff were re-educated. The [NAME] was updated. 5. The facility implemented interventions on 7/29/2024 to minimize environmental risks and hazards. Interventions include: * A Daily Diet Verification Audit was performed for 100% of current residents and was completed on 7/24/2024, by the Director of Nursing to ensure 100% of residents' meal trays matched 100% of residents' diet orders, [NAME], and care plans. * A Snack Distribution Audit was performed for 100% of current residents and was completed on 7/26/2024 by the DON to ensure that all residents received the accurate diet including snacks. * A Meal Tray Observation Audit was performed for 100% of current residents and was completed on 7/26/2024 by the DON and Nurse Managers to ensure that all residents received their appropriate meal trays. * Provided education to all staff regarding Modified Texture of Food Policy, Care Plan Policy, and Resident Food Preferences Policy including reporting any unmatched meal trays and diet orders to the FSD and DON. It was verified that the initial incident was reported to the state on 7/24/2024. The facility reported all audit findings to the QAPI Committee. Conducted an Ad Hoc QAPI meeting on 7/25/2024. * A review on 7/24/2025 revealed the Daily Diet Verification Audit was completed at 100% for resident diet orders, [NAME], and care plans. * A review on 7/26/2024 revealed the Meal Tray Observation Aduit was completed at 100% for all residents who received appropriate meal trays. * A review on 7/26/2024 revealed the Snack Distribution Aduit was completed at 100% for all residents who received appropriate meal trays. A review of the all-staff education documented Modified Texture of Food Policy, Care Plan Policy, and Resident Food Preferences Policy were reviewed and completed by the FSD and DON. A review of the QAPI Committee minutes revealed all audit findings were discussed and in place. The Ad Hoc QAPI meeting was determined to be held on 7/25/2024. 6. New interventions were monitored by the DON for effectiveness using the audit tools Daily Diet Verification Audit, Snack Distribution Audit, and Meal Tray Observation Audit to ensure the deficient practice did not reoccur. If a problem is identified, it will be addressed by the FSD, Administrator, DON, and Medical Director. All parties including the resident, the resident's responsible party, the Medical Director, the Administrator, the DON, and the FSD will meet to discuss the policy's violation. If there is a problem and all parties cannot agree, there will be an Ad Hoc QAPI meeting with the COC and possible corrective action. A review of the audits dated October 2024, November 2024, and December 2024 revealed the Food Service Director Audit and Meal Tray Observation Aduit were completed. During an interview on 3/18/2025 at 2:42 pm, DON stated they have a meeting every day related to diets, and all the issues found were discussed in the QAPI meeting. She stated the audits were discussed at QAPI. 7. All dates of corrective action for staff were alleged by the facility to be completed on 7/29/2024. The facility alleged that the IJ was removed on 7/30/2024. All dates of corrective actions were validated as completed on 7/29/2024. The facility's IJ was determined to be Past Noncompliance, removed on 7/30/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and a review of the documents Administrator and Director of Nursing, the Administration failed to effectively and efficiently manage facility compliance with federal regulatory requirements related to Quality of Care for one of 26 sampled residents (R) (R165) receiving an altered diet. Specifically, the facility provided R165 a sandwich, which resulted in him being sent out to the local emergency room (ER) and admitted to a hospice facility where he expired on 8/31/2024. On 3/13/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) for F656, F684, and F835 on 3/13/2025 at 12:48 pm. The noncompliance related to the IJ was identified to have existed on 7/23/2024. An Acceptable IJ Removal Plan was received on 3/14/2025 related to Comprehensive Care Plans, C.F.R. 483.21; Quality of Care, C.F.R. 483.25; and Administration, C.F.R. 483.70. Findings included: A review of the document titled Administrator Job Description revealed under Duties and Responsibilities: Assume the administrative authority, responsibility, and accountability for all programs in the facility. The document is noted to be signed by the Administrator and dated 9/18/2023. A review of the document titled Director of Nursing revealed the primary purpose of this position is to plan, organize, develop, and direct the overall operation of the nursing services department in accordance with current federal, state, and local standards, guidelines and regulations that govern the facility and as directed by the Administrator and the Medical Director to ensure the highest degree of quality care is always maintained. * The facility failed to implement the care plan for R165 related to nutrition. * The facility failed to provide a pureed snack to R165, ordered to receive a mechanically altered diet. An interview on 3/11/2024 at 9:30 am with the Administrator revealed she was aware of the incident on 7/24/2024 related to R165. She stated that she viewed the facility camera and saw Certified Nursing Assistant (CNA) AA hand R165 a sandwich. The Administrator revealed that she expected R165 to return to the facility after being sent out to the local hospital, but when the facility checked with the local hospital, she found out that R165 had been transferred out to a hospice facility on 8/5/2024 and expired on 8/31/2025. The facility implemented the following corrective action in response to the deficient practice, which occurred on 7/30/2024: 1. On 7/25/2024 at 1:00 pm, an Ad Hoc Quality Performance Improvement (QAPI) meeting was held with the Administrator, Social Services Director (SSD), the DON, Corporate Operations Consultant (COC), and Food Service Director (FSD) to identify the root cause of failure to follow R165's care plan. The facility's Modified Texture of Food Policy, Care Plan Policy, and Resident Food Preferences Policy were reviewed; no changes were made. A review of the AD-Hoc QAPI meeting dated 7/25/2024 reviewed the following policies, and no changes were required: Modified texture and Food policy, Care Plan policy, Resident food preferences policy, Heimlich maneuver, Choking policy, and Abuse and Neglect policy. A review of the identified root cause of failure for the R165 care plan was completed. 2. On 7/24/2024, the Administrator's job description was reviewed with the Administrator, FSD, SSD, and DON by the COC. No revisions were made. A review of the Administrator Job description: duties and responsibilities, committee functions, personnel functions, staff development functions, safety and sanitation functions, equipment and supply functions, budget and planning functions, working conditions, education, experience, specific requirements, physical and sensory requirements, job position analysis information, were acknowledge and signed off by the Administrator and COC on 7/24/2024. 3. On 7/24/2024, the COC in-serviced the Administrator, DON, FSD, and SSD on how to implement a process on how to verify diet orders before distributing resident meal trays, how to track and trend to determine a root cause analysis, and communication among departments on reviewing and updating resident care plans timely. The facility's QAPI policy was reviewed specifically regarding how to determine root cause analysis (RCA). A review of facility QAPI meeting minutes dated 7/24/2024 revealed Chief Operating Officer (COO) conducted a one-hour meeting on What is QAPI, When should QAPI be conducted, Who should attend QAPI, What is an RCA, all signatures confirmed. A review of the Attendance Record revealed COO completed in-service on the subject Implementation of a process to verify diet orders, tracking and trending of root cause of incident, updating care plans, policy review. During an interview with the DON, it was confirmed that she attended. 4. On 7/24/2024, the COC reviewed and approved the facility's audit forms and Plan of Correction (PoC) for any further areas of concern. Name of Audits- Daily Diet Verification Audit and Snack Distribution Audit. Residents' diets and care plans were discussed with the Administrator, DON, and FSD. Interventions were put into place, such as removing accessible snacks from the nurse stations; snacks were placed inside the pantry and available upon request. A snack diet reference sheet was initiated and placed inside the pantry. An observation was conducted on 3/11/2025 at 2:43 pm, residents were seen eating pudding and sandwiches, and one CNA was seen with a tray of snacks that contained fig [NAME] bars, vanilla pudding, peanut butter and jelly sandwiches, and fruit cups. When asked how she knew what type of snacks residents could eat, she went to the binder where it had residents' names and the type of diet types. 5. On 7/24/2024, the Corporate Nurse Consultant (CNC) and DON audited the resident's diet orders and meal tray cards from July 2024 through the current. The audits are named Daily Diet Verification Audit and Snack Distribution Audit. The Administrator, DON, and FSD will discuss all diet order changes in the morning and the clinical meeting to ensure all care plans are updated and accurate. Documentation will be monitored through the Abuse Performance Improvement Plan (PIP) and reported during QAPI by the DON and Administrator. The SSA reviewed and compared Diet Master from the Dietary Department and the Facility's Diet Type Report for all residents in the facility on 3/17/2025 was completed no discrepancies were found. 6. The COC met with the Administrator and DON to review the process of providing direct oversight of the following correct processes in the building as it relates to following care plans for resident diet orders. There is ongoing educational training for all members of the facility through the company's online courses. The Administrator was also in-service on how to conduct a QAPI meeting and how to identify and complete an RCA by the COC on 7/24/2024. The SSA reviewed in-service education related to the QAPI meeting and RCA dated 7/24/2024 with no concerns. 7. The corrective actions were completed on 7/29/2024, and the facility alleges that the immediate jeopardy was removed on 7/30/2024. All dates of corrective actions were completed on 7/29/2024. The facility's IJ was determined to be Past Noncompliance, removed on 7/30/2024.