**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement a comprehensive care plan for one of 45 residents (R200) related to a diagnosis of dysphagia (difficulty swallowing) and supervision with meals, resulting in R200's death by choking on a sandwich. On 2/3/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had 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) on 2/3/2025, at 10:25 am. The noncompliance related to the IJ was identified to have existed on 8/6/2024. An Acceptable Removal Plan was received on 2/5/2025. Based on observation, record review, a review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice were removed on 2/5/2025. The facility remained out of compliance while the facility continued management-level staff oversight as well as continuing to develop and implement a Plan of Correction (POC). This oversight process includes an analysis of the facility staff's conformance with the facility's policies and procedures governing providing Activities of Daily Living (ADL) care and supervision with meals. Finding included: A facility policy titled, Care Plans, Comprehensive Person-Centered updated December 2022 indicated, 9. Areas of concern that are identified during the resident assessment will be evaluated for interventions are added to the care plan. 10. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, or the endpoint of an interdisciplinary process . 13. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. An admission Record revealed R200 was a [AGE] year-old male admitted to the facility on [DATE] with a medical history of gastroesophageal reflux disease without esophagitis, urinary tract infection, site not specified, cerebral palsy, congenital malformation syndromes predominantly involving limbs, functional quadriplegia, asthma, seizures, malaise, mood disorder. A Speech Therapy Transitional Evaluation and Plan of Treatment Record revealed that R200 had poor visual acuity (right eye retinal detachment) and was non-verbal. An initial Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/8/2024, revealed R200 had a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident is severely impaired. The resident requires total dependence on all ADL care. Speech Therapy Transitional Evaluation and Plan of Treatment, dated 8/1/2024 performed treatment for dysphagia, oropharyngeal phase by the facility Speech and Language Pathologist (SLP) revealed R200 prior level of function (PLOF) (before onset), Patient was previously consuming 75 - 100% of low residue diet (LRD) of regular texture solids with thin liquids, in a home environment with caregiver supervision, with history of one episode of choking on a chicken bone, per caregiver report. Baseline (8/1/2024), Patient currently demonstrating oral/pharyngeal swallowing ability within functional limits for consumption of regular texture diet with thin liquids; however, patient demonstrates risk of choking/aspiration due to decreased visual acuity and per os (PO) (by mouth) efficiency. The assessment indicated Precautions/Contraindications are as follows: nonverbal, falls, left foot wound, communicate via vocalizations/gestures/facial expressions; poor visual acuity; follow aspiration/choking precautions - upright during PO intake, set up and orient resident to items on meal tray, supervision during meals. The most recent MDS dated [DATE] indicated in section GG the resident required Setup or clean-up assistance with eating. Section K Swallowing Disorder indicated in C. Coughing or choking during meals or when swallowing medications. No. Swallow Therapy (ST) notes outlined that R200 received Daily ST with a start date of 7/3/2024 through 8/6/2024. A review of R200's 'ST Daily Treatment Note', dated 7/8/2024 revealed R200 was unable to self-feed today's noon meal. Physical Therapy Review of Therapy notes dated 7/29/2024 revealed: PT required one-to-one assistance with feeding today due to the nature of the breakfast meal. A review of the physician orders with the last review date of 8/3/2024 revealed that R200 was full code, and had special instructions of up 90 degrees to eat sit up 30 minutes after eating alternate liquids and solids slowly . The Physician orders further included: Rehab ST orders: skilled therapy for 5 times a week x 12 weeks for dysphagia (start date 7/2/2024 end date 9/24/2024. Aspiration Precautions Maintained: Up 90 degrees to eat sit up 30 minutes after eating alternate liquids and solids slowly every shift with the start date of 6/15/2024. Regular diet regular texture and regular consistency with a start date of 6/15/2024. On 8/6/2024, R200's assigned feeding assistant Certified Nursing Assistant (CNA) EE received the late dinner trays for his assigned hall at approximately 6:40 pm, approximately 20 minutes before his shift ended. CNA EE notified the nurse that he would not have time to feed R200, but he could drop off R200's tray in his room before his time to clock out by 7:00 pm. Surveillance footage provided by PPP shows CNA EE entering R200's room with his food tray at 6:43 pm. The feeding assistants assignment was reassigned to CNA FF at 6:45 pm. Surveillance footage shows CNA FF initially entering R200's room at 7:15 pm and exiting at 7:21 pm with R200's food tray. CNA FF reported at approximately 7:15 pm that R200 was found to be unresponsive. The facility provided R200 a sandwich to consume for 32 minutes without the required one-to-one supervision when eating or drinking on 8/6/2024. R200 had a banner alert in his electronic medical records (EMR) chart with orders/special instructions for the following, UP 90 DEGREES TO EAT SIT UP 30 MINUTES AFTER EATING ALTERNATE LIQUIDS AND SOLIDS SLOWLY. A record review of R200's Care Plan revealed the facility failed to customize R200's care plan to include one-to-one assistance while eating and drinking as an intervention for complication risks of dysphagia. A record review of the Medical Examiner's report and photos of the scene (a half-eaten slice of bread on R200's pillow and a half-eaten slice of bread on the floor next to the resident's bed) revealed the cause of death was R200 choked on a sandwich. In an interview and record review with the facility DON on 1/29/2025 at 9:30 am she did not understand why the MDS nurse did not include the dysphagia diagnosis in the R200's chart and care plan. When asked about who is responsible for auditing the MDS and care plans for accuracy, the DON stated the facility has had many transfers of ownership and leadership in the last year and audit processes are not perfect right now, but they are working on it. In an interview and record review on 1/29/2025 at 12:05 pm with the facility SLP, Director of Rehabilitation, she remembered prescribing R200 one-on-one assistance while he was eating to make sure that he was eating at a proper pace and not eating too fast or drinking. In an interview and record review on 1/29/2025 at 12:19 pm with MDS Nurse, Registered Nurse (RN) NNN she stated that they do not always enter therapy diagnosis with the medical diagnosis. She stated that the doctor could have changed it. When shown the medical records list a diagnosis of oral pharyngeal impairment, which is dysphagia, and the resident required a specialized diet and close supervision to prevent an incident of aspiration. She replied, I don't remember it's been too long ago but if the doctor saw the person when they got here. He didn't include it. It may have been that he didn't feel they had dysphasia anymore. The RN NNN was reminded that the evaluation was concluded the day before the R200 admission to the facility. She stated, I don't know. I don't remember. I mean it's been so long ago, and we just do hundreds and hundreds of assessments. A review of the facility's dysphagia care plan audit compared with the residents currently assigned feeding assistance during meals revealed 30 of 45 residents diagnosed with dysphagia who require assistance with meals care plans had not been reviewed/customized/ or revised for this individualized intervention for complication risks of dysphagia. Record review revealed that the facility updated the 30 dysphagia residents' care plans on 2/5/2025 and assigned caregivers and in-serviced all active nursing staff of their responsibilities and expectations of their duties when providing the various levels of feeding assistance. The facility implemented the following actions to remove the IJ: R200 expired at the center on 8/6/2024. On 2/3/2025, the policy for comprehensive care plans was reviewed and/or revised by the Administrator and Regional Director of Clinical Operations without a recommendation for revisions. On 3/4/2025, the MDS Nurse reviewed care plans for 45 of 45 in-house residents identified with a diagnosis of dysphagia. Thirty care plans were updated to include a diagnosis of dysphagia current and active care plans for dysphagia and appropriate levels of meal supervision. On 2/4/2025, the DON in-serviced the MDS team and licensed nurses on the Center's Comprehensive Care Plan policy and development/implementation and adherence of care plans. (RNs nine of nine equaling 100%; LPNs 42 of 43 equaling 97.7%; OVERALL 98%). Employees on leave of absence, vacation, agency staff, or new hires will be re-educated by the Staff Development Coordinator, DON, or Nursing Supervisor prior to returning to duty, and will not be given an assignment until they are given additional on-site education. On 2/4/2025, the DON and Regional Director of Clinical Operations reviewed residents in the past thirty (30) days with a new diagnosis of dysphagia to ensure that care plans were updated as appropriate. Two (2) residents were identified with a new diagnosis of dysphagia for this review period. The Administrator reviewed the results of the audits and shared the findings with the Ad Hoc Quality Assurance Performance Improvement Committee on 2/4/2025. All corrective actions were completed on 2/4/2025 and the IJ was removed on 2/5/2025. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: A review of the facility census list revealed that the facility stopped billing R200 on 8/6/2024 with an action code of DE - deceased Date (Facility). A review of the Care Plans and Comprehensive Person-Centered policy statement updated in December 2022 and signed by the Administrator, DON, Regional Director of Clinical Operations, Regional Director of Operations, and Medical Director via phone on 2/2/2025 without revisions. Review of the diagnosis report after the facility audited the residents diagnosed with dysphagia on 2/4/2025 they discovered that 30 of 45 needed updates to their care plan interventions for feeding assistance. There were 23 residents assigned meal supervision on 2/4/2025, the assignments were revised on 2/5/2025 to 45 residents assigned meal supervision as an intervention for their individualized risk. On 2/4/2025 at 9:08 pm, the facility provided via email a revised list of in-serviced staff due to recent terminations, suspensions, and agency staffing. This consisted of 43 LPNs and nine RNs. There were two new diagnoses of dysphagia identified in the last 30-day review of the diagnosis report after the facility audited the residents diagnosed with dysphagia on 2/4/2025 and updates to their care plans were updated as appropriate. Dated (1/23/2025 and 1/28/2025) An Ad hoc meeting was held on 2/4/2025 to address the concerns described in the IJ called on 2/3/2025 during the annual recertification survey that began on 1/13/2025. Topics reviewed F677 - ADL Care Provided for Dependent Residents, F656 - Develop/Implement Comprehensive Care Plan, and F835 - Administration. The POCs and related performance improvement plans were initiated for abatement. The root causes and contributing factors were discussed. A review of the sign-in sheet for QAPI revealed that the Medical Director attended via phone. All corrective actions were determined to be completed on 2/4/2025 and the IJ was removed on 2/5/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and the review of the facility policies titled Activities of Daily Living (ADL) and Assistance with Meals, the facility failed to provide supervision and assistance with Activities of Daily Living (ADL) care during meals for one of 45 residents (R) (R200) related to a diagnosis of dysphagia (difficulty swallowing). On 8/6/2024, this failure resulted in R200's death by choking on a sandwich. On 2/3/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had 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) on 2/3/2025, at 10:25 am. The noncompliance related to the IJ was identified to have existed on 8/6/2024. An Acceptable Removal Plan was received on 2/5/2025. Based on observation, record review, a review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice were removed on 2/5/2025. The facility remained out of compliance while the facility continued management-level staff oversight as well as continuing to develop and implement a Plan of Correction (POC). This oversight process includes an analysis of the facility staff's conformance with the facility's policies and procedures governing providing Activities of Daily Living (ADL) care and supervision with meals. Finding included: A facility policy titled, Activities of Daily Living (ADL) updated December 2024 indicated, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 4. Eating to include meals and snacks . A review of the facility policy titled Assistance with Meals issued in April 2024, revealed that Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. 3. Residents Requiring Full Assistance: Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity . Keeping interactions with other staff to a minimum while assisting residents with meals. A review of the admission Record in the Electronic Medical Record (EMR) revealed R200 was a [AGE] year-old male admitted to the facility on [DATE] with a medical history of gastroesophageal reflux disease without esophagitis, urinary tract infection, cerebral palsy, congenital malformation syndromes predominantly involving limbs, functional quadriplegia, asthma, seizures, malaise, and mood disorder. A Speech Therapy Transitional Evaluation and Plan of Treatment Record revealed that R200 had poor visual acuity (right eye retinal detachment) and was non-verbal. A review of the admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 7/8/2024, revealed R200 had a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was severely impaired and required total dependence with ADL care. A review of the Speech Therapy Transitional Evaluation and Plan of Treatment dated 8/1/2024 revealed that R200 received treatment for dysphagia and oropharyngeal phase by the facility Speech and Language Pathologist (SLP). It was revealed that R200's prior level of function (PLOF) (prior to onset), Patient was previously consuming 75 - 100% of low residue diet (LRD) of regular texture solids with thin liquids, in a home environment with caregiver supervision, with history of one episode of choking on a chicken bone, per caregiver report. Baseline (8/1/2024), Patient currently demonstrating oral/pharyngeal swallowing ability within functional limits for consumption of regular texture diet with thin liquids; however, the patient demonstrates the risk of choking/aspiration due to decreased visual acuity and per os (PO) (by mouth) efficiency. The assessment indicated precautions/ contraindications are as follows: nonverbal, falls, left foot wound, communicate via vocalizations/gestures/facial expressions; poor visual acuity; follow aspiration/choking precautions - upright during PO intake, set up and orient resident to items on meal tray, supervision during meals. The most recent MDS assessment dated [DATE] indicated that the resident required Setup or clean-up assistance with eating. Section K Swallowing Disorder indicated in C. Coughing or choking during meals or when swallowing medications. No. Speech Therapy (ST) notes outlined that R200 received Daily ST with a start date of 7/3/2024 through 8/6/2024. A review of R200's 'ST Daily Treatment Note', dated 7/8/2024 revealed R200 was unable to self-feed today's noon meal. The Physical Therapy review notes dated 7/29/2024 revealed: PT required one-on-one assistance with feeding today due to the nature of the breakfast meal. A review of the physician orders with the last review date of 8/3/2024 revealed that R200 was full-code, and had special instructions of up 90 degrees to eat sit up 30 minutes after eating alternate liquids and solids slowly . The Physician orders further included: Rehab ST orders: skilled therapy for five times a week x 12 weeks for dysphagia (start date 7/2/2024 end date 9/24/2024). Aspiration Precautions Maintained: Up 90 degrees to eat sit up 30 minutes after eating alternate liquids and solids slowly every shift with the start date of 6/15/2024. Regular diet regular texture and regular consistency with a start date of 6/15/2024. During an interview on 1/30/2025 at 7:49 pm, Certified Nursing Assistant (CNA) EE stated he was assigned to feed R200 during the 7:00 am to 7:00 pm shift on 8/6/2024. CNA EE stated he fed R200 breakfast around 8:00 am. He stated that lunch arrived late, and he fed R200 after 1:00 pm. CNA EE stated the dinner service was running late as well that evening. The dinner trays came to his hall between 6:40 pm and 7:00 pm. He stated as an Agency CNA, they were not paid for working past the scheduled time. CNA EE stated, R200 can't feed himself because of his condition. It's like he cannot grip a spoon to feed himself with it, so he needed to be fed by staff. CNA EE stated a female CNA (Couldn't remember her name) would help him with positioning R200 to 90 degrees for feeding. CNA EE stated, You have to be patient feeding him and watch him . make sure he swallows before giving the resident the next bite. I would give R200 a bite and intermittently give him fluids to drink in between bites. CNA EE stated he notified the night nurse that he would not have time to feed R200 after distributing trays to other residents on the floor, but he could drop off R200's tray in his room before his clock-out time of 7:00 pm. CNA EE left the facility in the resident's room at 7:05 pm. A review of posted dining times for meals delivered to R200's hall revealed that breakfast was served at 7:40 am, lunch was served at 11:40 am, and dinner was served at 4:40 pm. A review of the timesheet for 8/6/2024 revealed that CNA HH clocked in at 6:45 pm for her 7:00 pm through 7:00 am shift. During an interview on 1/30/2025 at 8:25 pm, CNA HH reported that she was assigned to care for R200 via assignment sheet and was assigned to feed R200 at the shift change meeting. A review of the video surveillance footage and documentation of the video footage the facility provided dated 8/6/2024 revealed CNA EE entered R200's room with his food tray at 6:43 pm. The feeding assistance assignment was reassigned to CNA FF at 6:45 pm. Surveillance footage revealed that CNA FF entered R200's room at 7:15 pm and exited at 7:21 pm with R200's food tray. CNA FF reported that at approximately 7:15 pm, R200 was found to be unresponsive. A review of the EMR revealed that R200 had a banner alert in his chart with orders/special instructions for the following: UP 90 DEGREES TO EAT; SIT UP 30 MINUTES AFTER EATING; ALTERNATE LIQUIDS AND SOLIDS SLOWLY. It was revealed that R200 was provided with a meal, including a sandwich, to consume independently for 32 minutes without the required one-on-one supervision when eating or drinking on 8/6/2024. A review of R200's Care Plan revealed his care plan was not updated to include one-on-one assistance while eating and drinking as an intervention for complication risks of dysphagia. A review of the Medical Examiner's report and photos of the scene revealed a half-eaten slice of bread on R200's pillow and a half-eaten slice of bread on the floor next to the resident's bed. It was documented that the cause of death was R200 choked on a sandwich on 8/6/2024. During an interview on 1/29/2025 at 9:30 am, the DON stated that she did not understand why the MDS nurse failed to include the dysphagia diagnosis on the care plan. The DON stated that the facility has had many transfers of ownership and leadership in the last year and that audit processes are not perfect right now in relation to the MDS assessments and care plans. During an interview on 1/29/2025 at 12:05 p.m., the SLP, who is the Director of Rehabilitation, stated that s/he remembered prescribing R200 one-on-one assistance during meals to ensure that R200 was eating at a proper pace and not eating or drinking too fast. During an interview on 1/29/2025 at 12:19 pm, the MDS Nurse, Registered Nurse (RN) NNN, stated that they do not always enter therapy diagnosis with the medical diagnosis. She confirmed that R200's medical record listed a diagnosis of oral pharyngeal impairment (dysphagia) and that R200 required a specialized diet and close supervision to prevent an incident of aspiration. She stated that she did not remember the specifics because it had been too long ago. She stated, If the doctor saw the person when they got here and he didn't include it in the diagnosis list, it may have been that he didn't feel they had dysphasia anymore. The facility implemented the following actions to remove the IJ: R200 expired at the center on 8/62024. The Regional Director of Operations (RDO) and the Administrator reviewed the dining assistance policies to ensure alliance with CMS/State regulation, on 2/3/2025, without recommendation for changes/revisions. On 2/4/2025, the Administrator, DON, and the Regional Director of Clinical Operation (RDCO) conducted mandatory retraining for nurses on supervision of ADL care including feeding/dining assistance assignments: nine of nine RNs; 42 of 43 LPNs; and 64 of 64 CNAs). Employees on leave of absence, vacation, agency staff, and/or new hires will be re-educated by the Staff Development Coordinator (SDC), DON, or Nursing Supervisor prior to returning to duty and will not be given an assignment until they are given additional on-site education. On 2/3/2025, the DON and/or Administrator retrained nursing staff that ADL care/meal assistance must continue uninterrupted and cannot be halted or delayed due to a shift change. On 2/32025, the Administrator and DON assessed staffing levels during meal service to ensure adequate assistance. On 2/4/2025, an emergency Quality Assurance and Performance Improvement (QAPI) Ad Hoc meeting was conducted with the Administrator, DON, RDO, RDCO, and Medical Director to review the removal plan and root cause analysis. All corrective actions were alleged to be completed on 2/4/2025 and the lJ was alleged to be removed on 2/5/2025. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: A review of the facility's census list revealed that R200 expired at the facility with an effective stop billing date of 8/6/2024 at 8:00 pm. A review of the facility policy titled Assistance with Meals dated April 2024, revealed that the following individuals reviewed the policy for accuracy: The administrator signed on 2/3/2035; RDO signed on 2/3/2025; RDCO signed on 2/3/2025; the DON signed on 2/3/2025; and the Medical Director was documented as attending via the phone on 2/3/2025. A review of the facility's education/in-service record revealed the following: The presenters of in-service were the clinical leadership that was composed of the DON, Unit Manager (UM), and RDCO. The date of the education was 2/3/2025. The subject matter of the education was Nursing education-IJ POC and related policies. The overview of the education included a review of the comprehensive care plan policy (including development/implementation and adherence) and the ADL policy (including supervision of dependent residents during meal assistance, ADL care, and meal assistance). A review of the facility's active employee list below was the breakdown of direct care staff (CNAs) and Nurses (LPNs and RNs). During an interview on 2/4/2025 at 2:49 pm, the count for the active employees matched the number provided by the administrator. Per the RDCO, there were several employees who were crossed off the list, and they were terminated. Additionally, there was an in-service with staff names on the list with an R next to their name indicating they had refused in-service. On 2/4/2025 at 3:19 pm, the Administrator was asked to provide an active list of employees and include an updated list of staff that received the in-serving. On 2/4/2025 at 9:08 pm, the Director of Regulatory Compliance (DRC) provided an updated Active Employee list. During an interview on 2/5/2025 at 7:55 am, the Administrator revealed the list that was provided by the DRC was on the active employee list and reflected on all the staff that were interviewed. This list included both active employees and staff that were reeducated/in-serviced. Some CNAs do work multiple shifts; UMs primarily work 7:00 am through 3:00 pm with one-weekend day shift per month. The following staff were interviewed on 2/5/2025 to 2/6/2025 to certify the education/in-services: 2/5/2025 at 7:42 am (CNA JJ); 2/5/2025 at 7:45 am (CNA KK); 2/5/2025 at 10:53 am (CNA LL); 2/5/2025 at 11:02 am (LPN MM); 2/5/2025 at 11:15 am (LPN NN); 2/5/2025 at 11:23 am (CNA OO); 2/5/2025 at 11:23 am (CNA PP); 2/5/2025 at 11:41 am (UM/LPN QQ); 2/5/2025 at 11:51 am (CNA RR); 2/5/2025 at 12:01 pm (CNA SS); 2/5/2025 at 12:09 pm (UM/LPN TT); 2/5/2025 at 12:18 pm (CNA UU); 2/5/2025 at 12:23 pm (CNA VV); 2/5/2025 at 12:34 pm (CNA WW); 2/6/2025 at 5:45 am (RN YY); 2/6/2025 at 5:58 am (CNA ZZ); 2/6/2025 at 6:13 am (CNA AAA); 2/6/2025 at 6:30 am (RN BBB); 2/6/2025 at 6:50 am (LPN CCC); 2/6/2025 at 7:07 am (LPN DDD); 2/6/2025 at 7:15 am (CNA EEE); and 2/6/2025 at 7:21 am (CNA FFF). A review of the facility's education/in-service record revealed the following: The presenters of the in-service were the Clinical leadership that was composed of the (DON, UM, and RDCO). The date of the education was 2/3/2025. The subject matter of the education was Nursing education-IJ POC and related policies. The overview of the education included: Comprehensive care plan policy (including development/implementation and adherence); ADL policy including supervision of dependent residents during meal assistance; reeducation related to meal assistance must continue uninterrupted until individual service is complete; assistance with meals policy; assignment of assisted diners (ensure orders match tray card and care plan/[NAME]). Interviews were conducted on 2/5/2025 from 7:42 am through 2/6/2025 with no concerns. Several interviews were conducted with nursing staff (CNAs and nurses) to determine what happens when food is delivered late. Staff confirmed that they are to finish feeding/providing assistance to residents even if that means they will be staying past their scheduled time. During an interview on 2/5/2025 at 11:23 am, CNA OO revealed they must stay and complete feeding a resident even if meals are served late due to kitchen staff shortage. During an interview on 2/5/2025 at 12:09 pm, UM/LPN TT stated that staff must have the resident's meal tray when they leave the rooms. They enter the room with the tray and exit the room with the tray in hand. During an interview on 2/5/2025 at 12:34 pm, CNA WW stated one of the re-educations was to ensure the proper meal tray delivery processes. The Administrator and the DON completed a review of staffing levels to ensure adequate assistance availability during mealtimes. They had no concerns identified. A daily assignment sheet will be used to identify residents who require assistance with ADL dining to ensure staff assistance is available. The Administrator and DON reviewed the assignments sheets daily to monitor compliance. Both the Administrator and DON signed off on the acknowledgment. A review of the facility's daily assignment sheets included the following: The staff who are scheduled, residents who are identified as 'need to feed' residents identified as NPO, and snack times. Residents were identified by room and bed numbers that needed to be fed. The monthly QAPI meeting was conducted on 2/3/2025. The presenter/facilitator was the facility Administrator. The duration of the meeting was 30 minutes. The team members included DON, Medical Director, UM, Assistant DON, Scheduler, RDO, VP of Clinical Services, Social Service Directors, MDS, Maintenance Director, Activities Director, Business Office Manager, and the RDCO. Per the attendance sign-in sheet, the following individuals were in attendance: The administrator, RDO, RDCO, Assistant DON, DON, Director of Regulatory Compliance (RDC), Staffing Coordinator, three Unit Managers, Infection Control Preventionist, Social Services, Dietary Manager, Registered Dietician, Director of Therapy, Central Supply, Medical Records, Maintenance Director, MDS, Business Office Manager/Human Resources, Director of Housekeeping, Staff Development Coordinator, and Assistant Administrator. The meeting overview was to review the IJ concerns. A brief narrative description of the QAPI meeting was documented. An updated get-up list for nursing was created. Each root cause had its corresponding corrective action, responsible individual(s) have been identified with a timeline determined to be ongoing, All corrective actions were completed on 2/4/2025 and the lJ was removed on 2/5/2025.

Based on interviews and record review, the facility's Administration failed to provide protective oversight of the facility ensuring that staff followed appropriate policies and procedures to prevent accidents and hazards resulting in Immediate Jeopardy for resident (R) R200 and Harm for R46, R206, and R204. On 2/3/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had 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) on 2/3/2025 at 10:25 am. The noncompliance related to the IJ was identified to have existed on 8/6/2024. An Acceptable Removal Plan was received on 2/5/2025. Based on observation, record review, a review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice were removed on 2/5/2025. The facility remained out of compliance while the facility continued management-level staff oversight as well as continuing to develop and implement a Plan of Correction (POC). This oversight process includes an analysis of the facility staff's conformance with the facility's policies and procedures governing providing Activities of Daily Living (ADL) care and supervision with meals. Findings included: 1. On 8/6/2024, R200 was found unresponsive in his bed after a Certified Nursing Assistant (CNA) EE dropped off the resident's food tray, leaving R200 unsupervised with food for 30 minutes. R200 expired in the facility, with the cause of death documented as choking. Cross Refer F677 2. The facility failed to develop a comprehensive care plan for R200 related to a diagnosis of dysphagia and supervision with meals. Cross Refer F656 3. Harm was identified on 9/25/2023 when R46 sustained a fall resulting in a right femur fracture with possible patella fracture; on 6/4/2023, R206 sustained a second-degree burn to bilateral glutes from sitting in spilled hot coffee; and on 8/27/2024, R204 experienced pain and swelling from an infiltrated intravenous site, resulting in R204 being sent to the emergency room (ER) for treatment and observation. Cross Refer F689 and F694 During an interview and record review with the facility Director of Nursing (DON) on 1/29/2025 at 9:30 am she did not understand why the Minimum Data Set (MDS) nurse did not include the dysphagia diagnosis in the R200's chart and care plan. When asked about who is responsible for auditing the MDS and care plans for accuracy, the DON stated the facility has had many transfers of ownership and leadership in the last year and audit processes are not perfect right now, but they are working on it. During an interview on 1/29/2025 at 9:50 am, the DON confirmed that her expectations were that nurses were supposed to be rounding at least every couple of hours when a resident has a continuous IV. During an interview on 1/29/2025 at 12:05 pm, the Director of Rehabilitation remembered prescribing R200 one-on-one assistance while he was eating to make sure that he was eating at a proper pace so he and not eat too fast or drink. During an interview on 1/29/2025 at 12:19 pm, the MDS Nurse, Registered Nurse (RN) NNN, stated that they do not always enter therapy diagnosis with the medical diagnosis. She confirmed that R200's medical record listed a diagnosis of oral pharyngeal impairment (dysphagia) and that R200 required a specialized diet and close supervision to prevent an incident of aspiration. She stated that she did not remember the specifics because it had been too long ago. During an interview with the facility DON on 1/30/2025 at 5:50 pm she stated she could not remember if R200's dysphagia or incidents related to dysphagia were discussed in Quality Assurance Performance Improvement (QAPI) meetings. The DON stated, I would have to review my QAPI notes. During an interview on 2/19/2025 at 3:21 pm, the DON confirmed R46 required two-person assistance. The DON stated that that two people were required to transfer the resident and an in-service was also completed to ensure all staff understood that a mechanical lift required two staff to transfer a resident. The DON confirmed that the CNA does not work at the facility anymore and that she was a contract employee. The facility implemented the following actions to remove the IJ: On 2/3/2025, a Root Cause Analysis (RCA) of the Care plans for residents with a diagnosis of dysphagia and ADL care for dependent residents who require assistance with dining system breakdown was completed by the Regional Director of Operation (RDC), Regional Director of Clinical Operations (RDCO), Administrator, and DON. Documentation of analysis was put on the RCA Tool and was included in the Ad Hoc meeting. The administrator hosted an Ad Hoc QAPI meeting on 2/3/2025, with the Medical Director, DON, RDCO, and Director of Operations to review the center's ADL Care for Dependent Residents and Care Plan performance improvement measures outlined in this document. The Regional Director of Operations (RDO), RDCO, Medical Director, Administrator, and DON reviewed residents receiving swallow therapy in the past thirty (30) days to identify residents with a diagnosis of dysphagia to ensure that care plans were updated as appropriate, on 2/3/2025. Findings were shared at the next scheduled QAPI Meeting. The Administrator identified Improvement Activities and Performance Improvement Projects (PIP) based on trends and identified potential opportunities upon completion of the care plan and swallowing therapy audit reviewed on 2/3/2025. PIP plans and RCA documents were maintained as part of the QAPI process. A review of the residents receiving swallow therapy audit was reviewed by the IDT members on 2/3/2025, to validate care plans were updated appropriately to identify the level of dining assistance required. The MDS Nurse (s) reviewed and updated care plans on residents identified with a diagnosis of dysphagia as of 2/3/2025. Recommendations were reviewed at the next scheduled regular QAPI meeting. The RDCO provided re-education on 2/3/2025 to the Administrator and DON on the policies and procedures related to ADL Care for Dependent Residents and Comprehensive Care Plans. The DON will assign Nurse Managers daily to each unit to provide supervision during meal service for those residents diagnosed with dysphagia, including those who are non-verbal or visually impaired. The Administrator reviewed the results of the audits and shared the findings with the Ad Hoc QAPI Committee in February 2025. All corrective actions were completed on 2/4/2025 and the IJ was removed on 2/5/2025. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: A review of the diagnosis report after the facility audited the residents diagnosed with dysphagia on 2/4/2025 discovered that 30 of 45 needed updates to their care plan interventions for feeding assistance. There were 23 residents assigned meal supervision on 2/4/2025, the assignments were revised on 2/5/2025 to 45 residents assigned meal supervision as an intervention for their individualized risk. A review of the IJ Removal Plan showed that there were QAPI Meeting Minutes that occurred on 2/3/2025. The signature includes the Administrator, DON, RDO, RDCO, Dietary, Social Services, and the Medical Director. The topic included an annual survey and IJ citations that were issued. Also, performance improvement plans were included. There were two new diagnoses of dysphagia identified in the last 30-day review of the diagnosis report after the facility audited the residents diagnosed with dysphagia on 2/4/2025 and updates to their care plans were updated as appropriate. Dated (1/23/2025 and 1/28/2025) A review of the RCA PIP template that was started on 2/3/2025 was completed. The Root Cause and Contributing Factors included staffing challenges in the kitchen and nursing staff to prepare and deliver meals on time; updating the get-up list for nursing staff to collaborate; poor coordination and communication between dietary staff and nursing staff related to meal readiness, delivery, and resident needs; inadequate coordination of get-ups times with meal delivery schedules; meal service workflow, review serving line efficiency in the kitchen. The plan further included the root cause, the corrective action, the responsible individual/group, and the completion deadline. A review of the diagnosis report after the facility audited the residents diagnosed with dysphagia on 2/4/2025 discovered that 30 of 45 needed updates to their care plan interventions for feeding assistance. There were 23 residents assigned meal supervision on 2/4/2025, the assignments were revised on 2/5/2025 to 45 residents assigned meal supervision as an intervention for their individualized risk. A review of the diagnosis report after the facility audited the residents diagnosed with dysphagia on 2/4/2025 discovered that 30 of 45 needed updates to their care plan interventions for feeding assistance. There were 23 residents assigned meal supervision on 2/4/2025, the assignments were revised on 2/5/2025 to 45 residents assigned meal supervision as an intervention for their individualized risk. A review of the diagnosis report after the facility audited the residents diagnosed with dysphagia on 2/4/2025 discovered that 30 of 45 needed updates to their care plan interventions for feeding assistance. There were 23 residents assigned meal supervision on 2/4/2025, the assignments were revised on 2/5/2025 to 45 residents assigned meal supervision as an intervention for their individualized risk. A review of the facility's education/in-service record revealed the following: The presenters of in-service were the Clinical leadership that was composed of the (DON, Unit Manager (UMs), and RDCO). The date of the education was 2/3/2025. The Administrator and the DON completed a review of staffing levels to ensure adequate assistance availability during mealtimes. They had no concerns identified. A daily assignment sheet will be used to identify residents who require assistance with ADLs, specifically dining to ensure availability of assistance, as appropriate. The Administrator and DON will review assignment sheets daily to monitor compliance. Both the Administrator and DON signed off on the acknowledgment. A review of the Facility's daily assignment sheets included the following: The staff that is scheduled, residents that are identified as 'need to feed; Residents that are NPO, Snack times; Pass Ice; residents with scheduled showers, residents who are on the get-up list and residents who have appointments/visit time his section identified the residents by room and bed number that need to be fed. NPO residents are identified. Interviews were conducted with staff to ensure that staff were in-serviced and were knowledgeable of where to retrieve assignments on a daily basis, but to additionally ensure that staff understood requirements for supervision, one-on-one assistance and tray set-up for residents. During an interview on 2/5/2025 at 11:23 am, CNA OO revealed they must stay and complete feeding a resident even if meals are served late due to kitchen staff shortage. During an interview on 2/5/2025 at 12:09 pm UM/ Licensed Practical Nurse (LPN) TT stated that a staff is required to have the resident's meal tray when they leave the rooms. They enter the room with the tray and exit the room with the tray in hand. During an interview on 2/5/2025 at 12:34 pm, CNA WW stated one of the re-educations was to ensure the trays go in the resident room when they are ready to leave, and the tray goes out with the CNA when they leave the resident rooms A new Dining Time for Meal Delivered to Units was implemented during the week of 1/26/2025. New dining times for breakfast range from 7:30 am to 8:30 am; lunch from 11:30 am to 12:30 pm and dinner from 4:30 pm to 5:30 pm. Meal carts have been monitored since the new implementation and are ongoing and noted to have improvements. All corrective actions were completed on 2/4/2025 and the IJ was removed on 2/5/2025.