**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to seek emergency care for a resident with Type 2 Diabetes Mellitus who was experiencing elevated blood sugars too high for accurate readings to be obtained with facility glucose monitoring device for 1 of 3 residents (R16) reviewed for change in condition in a sample of 29. This failure resulted in R16's death with cause of death listed as possible diabetic ketoacidosis. This failure resulted in an Immediate Jeopardy, which was identified to have begun on [DATE] when the facility failed to seek emergency care for R16 who was experiencing high blood sugar readings which lead to R16's death as possible diabetic ketoacidosis. V1 (Administrator), V33 (Regional Reimbursement), and V34 (Regional Clinical Nurse) were notified of the Immediate Jeopardy on [DATE] at 11:35 AM. The surveyor confirmed through observation, interview, and record review that the Immediate Jeopardy was removed, and the deficient practice corrected on [DATE], but the noncompliance remains at Level Two due to additional time to evaluate implementation and effectiveness of training. Findings Include: R16's admission Record documents an admission date of [DATE] with diagnoses of Cerebral Palsy, Type 2 Diabetes Mellitus with Ketoacidosis, without coma, Hyperlipidemia, Hyperkalemia, Epileptic Syndrome, Quadriplegia, Acute Kidney Failure, Chronic Kidney Disease, Microcephaly. R16's MDS (Minimum Data Set) dated [DATE] includes a BIMS (Brief Interview for Mental Status) assessment that suggests BIMS should not be conducted as resident rarely/never understood. R16's MDS documents R16 requires substantial/max assist with oral hygiene, putting on/off footwear, roll from left to right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed -to- chair transfers, and toilet transfers. R16's MDS documents R16 is dependent upper and lower body dressing. R16's Physician Orders dated [DATE] to [DATE] documents orders for Humalog Kwikpen (insulin) 100 units/3 milliliters, inject 6 units subcutaneous three times a day (8:00AM, 11:00AM, and 4:00PM) with meals. Lantus (insulin) 100 units/milliliters, inject 23 units subcutaneous once daily (8:00AM). Fingerstick glucose monitoring three times a day (8:00AM, 11:00AM, and 6:00PM) with meals with sliding scale insulin including parameters: less than 150 =0 units, 151-200= 2 units, 201-250=4 units, 251-300=6 units, 301-350=8 units, 351-400=10 units, and over 400 give 12 units and call the physician. R16's December medication administration Record (MAR) documents orders for Fingersticks Glucose Monitoring: TID (three times a day) with meals with sliding scale insulin at 8:00AM, 11:00AM, and 6:00PM. The Blood Glucose Monitoring System, User Instruction Manual on page 53 documents your blood sugar is more than 600mg/dl (milligrams per deciliter). Instructions to repeat test with new test strip. If the message shows, again contact your healthcare professional right away. If blood sugar is over 600mg/dl the monitor will read HI. On [DATE] at 11:59AM, V20 (Certified Nurse Assistant/CNA) stated we got R16 up that morning and he was acting ok but seemed tired. As the day progressed, he didn't seem right like yelling at us, so we told the nurse. V19 (Agency Licensed Practical Nurse/LPN) was the nurse, and she checked R16's BS (blood sugar) and it was high. We told the nurse that he needs to be sent out to the hospital, but V19 did not listen and said she was going to try some things first. V20 stated V19 would not listen to the CNA's and the nurse is just temporary and does not know the residents like we do. V20 stated R16 didn't eat much that day. Right before lunch is when R16 started getting worse. V20 stated in the evening V19 kept checking R16's blood sugar and it kept reading high. V20 stated V19 had never worked dayshift before so she did not know how R16 was during the day. On [DATE] at 11:59AM, V19 (LPN) stated she was working the dayshift 6A-6PM on [DATE]. V19 stated she was the charge nurse for R16. V19 stated R16 was mostly fine through the earlier part of the day. V19 stated she really didn't know R16 that well. V19 stated around 3:00-3:30PM the CNA's reported to her that R16 wasn't acting right, and he looked bad. V19 stated she checked R16's blood sugar around 3:30PM and the glucometer just read HI. V19 stated she gave R16, 12 units of regular insulin at this time and called the on-call physician but had to leave a message. V19 stated at 4:00PM she gave 6 more units of regular insulin as scheduled. V19 stated R16 was a little sluggish and was acting tired. V19 stated as she was waiting for the return call from the physician, she called V2 (Director of Nursing/DON) and V2 informed her that this has happened before with R16 and sometimes they send him to the hospital if the physician orders to send to the emergency room. V19 stated that V2 said to just wait on the physician to call back and see what the physician wants to do. V19 was asked if she has had training at the facility on change in condition, blood glucose monitoring such as how high does the glucometers read, and V19 stated she has not had any kind of any training at the facility. V19 stated she had no idea of how high the blood sugar is when it read HI. V19 stated R16's vital signs were within normal limits, and she did not receive a return call from the physician during the remainder of her (day) shift that ended at 6PM. On [DATE] at 2:00PM, V19 stated she was not sure what number she called for the on-call physician on [DATE], it was on a note at the nurse's station. V19 stated she doesn't know about the facility's (electronic communication system) and communication like that. V19 stated, I was advised by V2 to wait for the physician to call back and if V2 would have said send R16 to the ER (Emergency Room), I would have sent him to the ER. V19 stated she gave report to V22 (Agency Registered Nurse/RN) when she came in at 6PM with information about R16's high blood sugars and a call placed to the on-call physician. On [DATE] at 11:04AM, V22 (Agency Registered Nurse/RN) stated she worked on [DATE], 6AM -6PM. V22 stated she received in report that R16 had been running high blood sugars and insulin per orders was given and the on-call physician was called, and a message was left for a return call. V22 stated she went to R16's room around 6:30PM to check on R16, she stated she could arouse R16, and he would answer yes or no to questions. R16's blood sugar was checked at this time and the reading was HI. V22 stated she had put in another call to the on-call physician and left a message. V22 stated she received a call back from a physician around 7:30PM and received orders to give another dose of 12 units of insulin, in addition to the scheduled dose of 6 units and recheck in a little while. V22 said that she was not sure who the physician was that called. V22 stated she did not document the physician's name in the medical record and did not write the orders given to her on the Physician Order Sheet. V22 stated she was the only nurse in the facility for that shift. V22 stated she could arouse R16 at that time and he was unchanged from previous assessment at around 6:30PM. V22 stated she remembers rechecking R16's blood sugar about 45 minutes later, approximately 8:15PM and the blood sugar was down to 488. V22 stated, I thought we were finally going in the right direction with the blood sugar going down. V22 stated, Sometime around 10:00 PM, I was called to R16's room by a CNA, upon entering room R16 was having a hard time breathing, heart rate was irregular, color was bad and R16 was nonresponsive. V22 stated at this time she and the CNA lowered R16 to the floor to prepare for CPR (Cardiopulmonary Resuscitation), when lowering R16 to the floor, R16 stopped breathing. V22 stated CPR was started and help was called for from the other CNA's. When the other CNA entered the room V22 asked her to call 911 and the CNA stated, CNAs are not allowed to call 911, so that CNA took over chest compression and V22 went to call 911 and check R16's chart for code status. V22 stated code status was found and R16 was a DNR (Do Not Resuscitate) so she went to the room and stopped CPR. V22 stated EMS (Emergency Medical Service) arrived and pronounced death around 10:30ish. V22 stated she remembers R16 having a strong sweet fruity smell as they were transferring him to the floor. V22 stated she has had no training at the facility on policies or resources to look up policies. On [DATE] at 1:20PM, V21 (Certified Nurse Assistant/CNA) stated, she came into work on [DATE] at 6:00PM and shortly after getting to work she saw R16. V21 stated R16 was not responding to the staff and his color was not good. V21 described R16's color as not a good color and sort of gray. V21 stated, As the evening went on there really was not many changes with R16. V21 stated, I was working on another hall when I heard someone yell and when I got down there, the nurse was doing chest compressions on R16. When another CNA got in there, she took over chest compressions and the nurse went to check the chart to see if R16 was a DNR or a Full Code. The nurse returned stating R16 was a DNR, so the CPR stopped. When EMS arrived, they checked R16 and stated to leave R16 in the floor until cleared by the coroner. V21 stated, When I got report from the day shift CNA's, the CNA's reported that R16 was not doing good at all and the CNA's tried to get the dayshift nurse to send him to the Emergency Room, but she wanted to try some other things first. V21 stated this was an agency nurse and they do not know the residents like we do. On [DATE] at 4:20PM, V25 (CNA) stated she was working the night R16 passed. V25 stated she worked 6PM -6AM that day. V25 stated she had checked in on R16 a few times and R16 was sleeping. V25 stated when she went in to do bed check on R16 she noted he was gray in color and not responding. V25 stated she was unsure of the time. V25 stated she yelled for help, and everybody came. V25 stated they moved him to the floor and started CPR. V25 stated they did CPR for about 15 minutes until EMS arrived then they stopped CPR. V25 stated R16 had been out to the hospital multiple times in the past because of his blood sugars. On [DATE] at 12:18PM, V2 (DON) stated she remembers the phone call she received from V19 LPN on [DATE]. V2 stated it seems like it was somewhere around 5:00PM. V2 stated V19 was an agency nurse that informed her that R16's blood sugar was reading HI and that she had followed doctor's orders and had given him insulin and was waiting on the physician to call her back. V2 stated she asked how R16 was doing, and the nurse stated his vital signs seemed to be normal. V2 stated the nurse stated she thought he was acting ok to her. V2 stated she told the nurse that if she felt like he needed to be sent out that she could do that or just wait on the physician to call back with orders. V2 was asked if she had investigated R16's death records. V2 stated, I read the nurses notes because she didn't see anything really concerning. V2 stated she talked with the night nurse V22 after R16 passed. V2 stated the night nurse said R16 acted fine at 6:00pm when she arrived at work and then V22 was called to his room later and she called 911. V2 stated she thought V22 had called back the doctor or the doctor called her and order more insulin. V2 stated she had seen where his blood sugar went down a bit after V22 gave the ordered insulin. V2 stated his blood sugar was down in the 400's after that. V2 was asked if she would have sent him out with the high blood sugars, V2 stated, If he was not acting right, I would have. V2 stated his blood sugars reading high meant it was over 500. V2 was asked how high the glucometers reads and V2 stated, I believe 500 or 550 but I would have to read the book on that to make sure. V2 was informed the Owners' Manual to the glucometer states these glucometers read up to 600 then automatically go to read HI. V2 stated Wow! V2 stated she would have sent him out knowing his blood sugar was over 600. V2 stated she feels it was a long time for the physician to get back with the facility and this is unusual, and she would have sent him out. V2 stated R16 had started making a pattern of having DKA (Diabetic Ketoacidosis) and he had been placed in ICU (Intensive Care Unit) with an Insulin drip over the last several months, with the last time was [DATE]. V2 stated R16 was normally very active, talking to the staff, V2 stated he had the mind of a child, and we all loved him. V2 was asked if the (Nurses Agency Staffing Organization) nurses receive any or are required to complete any training at the facility level, V2 stated the only requirement is a valid nurse's license. V2 stated she doesn't like to have agency nurses in her facility working because they don't know the residents usually, but we don't have a choice right now. On [DATE] at 1:45PM, V1 (Administrator), stated she has been employed at the facility for 5 years and she was very familiar with R16. V1 stated she had not investigated R16's death. V1 stated R16 had been sent to the hospital several times for elevated blood sugars, DKA, and R16 would get treated and return. V1 was handed R16's progress notes from the day he expired. V1 was asked to read the progress notes. V1 then stated, I would have sent him out at 488 but I would have sent him out before that when the blood sugar was too high to read on the glucometer. V1 stated she and V15 (Nurse Practitioner/NP) had talked about this after his death and R16's life expectancy was only to live until his 20's, he was in his 50's and he had many health issues. V1 stated the nurse that was working that day was an agency nurse. V1 stated, I would have sent him out and if they would have sent him out when it was high, he would still be alive, but I was very familiar with R16 and knew his medical issues. On [DATE] at 1:50PM, V23 (R16's sister/Power of Attorney) stated R16 was her brother, and he had resided in the facility for a few years. V23 stated up until the last several months the care was good and R16 was thriving, but the last several months had been bad. The facility has a lot of nurses that only work occasionally, and they do not know the residents or how to care for them. V23 stated on [DATE] she came to visit R16 in the afternoon and R16 did not seem himself and seemed very tired. V23 stated she thought maybe he was just sleepy as no staff said anything to her about his blood sugars or anything being wrong. V23 stated, The next thing I knew I got a call between 10:30PM and 11:00PM that my brother had passed. V23 stated R16 was in the hospital recently with Ketoacidosis on [DATE]. V23 stated if R16 doesn't get his insulin right his blood sugars get too high. On [DATE] at 9:25AM, V24 (Medical Director), was asked if he was familiar with R16. V24 stated, That name does not ring a bell, I don't know him. V2 was asked how the on-call services work and V24 stated, The nurses have to use (facility notification system) to reach the nurse practitioner and on weekends from 9PM to 6AM there is a number to call and usually I am the one on call. V24 was asked if he received any calls on [DATE] or after midnight on [DATE], V24 checked his records and personal phone and stated, No I did not. V24 was explained the condition of R16 and his high blood sugars. V24 stated, We can sometimes manage high blood sugars in the facility but if we give treatment and the condition doesn't change then they need to be sent to the hospital. V24 stated he believes the problem is with the nursing staff and some of them only being in the facility a few times. V24 was asked if he thought that hindered communication with physicians and he stated, Yes if they do not know our system. V24 was asked when the last time he made rounds in the facility to see the residents and V24 stated, I do not see the patients, the Nurse Practitioners see the patients and they work through me. I only come per requirement quarterly for the meeting. V24 stated the facility should have done a better job with R16, and I am sorry for his death. V24 stated education needs to be done and corrected. On [DATE] at 12:04PM, V15 (NP) stated she was looking for messages on [DATE] on the call log and on her cell phone and no messages were left and there were no missed calls for this facility for [DATE]. On [DATE] at 2:20PM, a call was placed to the Physician Service office and spoke with the receptionist/secretary (V35) who stated she would send a call log for the date of [DATE] for this facility. The call log was received and did not show that the Physician Service office received any calls from the Facility log on [DATE]. R16's Nurses Notes authored by V19 dated, [DATE] at 5:50PM, documents, right before dinner had started it was time for me to check R16's. I checked his blood sugar, and the monitor said high. So I check it again on another finger and it still said high. I looked at his chart to see his sliding scale, I followed the sliding scale and called the on-call doctor like it stated on his order. I called and left and voicemail for the on-call doctor letting him know what was going on and what he would like for me to do next. I checked R16's vital signs before I called the doctor, and his vital signs were wnl (within normal limits). While waiting on the call back I checked R16's blood sugar again 40 minutes later after given insulin, and it still said high. So, I called the DON and told her what was going on and she said he had issues with his blood sugar being high before. While doing shift change, I informed the on-coming nurse about what was going on and that she should receive a call from the doctor soon. I also charted what was going on, on the shift change sheet. R16's Nurses Notes authored by V22, dated [DATE] at 1:00AM, documents report received at approximately 6PM from the day shift nurse that resident's blood sugar had been running high today and most recent blood sugar reading prior to evening meal read hi on the blood glucose monitoring machine. Dayshift nurse reports calling provider on call for further insulin orders. Call back from PCP (Primary Care Provider) received at approx. 7:30PM with new orders for additional 12 units insulin x 1. Insulin given per orders RUQ (right upper quadrant) abd (Abdomen). At that time resident able to respond yes/no to questions asked. No active distress. Respirations even and unlabored, heart RRR (regular rate and rhythm), BS (Bowel Sounds) per 4 quads. Skin color WNL. Recheck of blood sugar at approx. 8:30PM with result of 488. No change in condition from an hour ago. No acute distress. During med pass CNA's notified this nurse that resident looked terrible. Upon entering resident's room, he was laying in bed color pale resp uneven and labored, fruity/sweet smell odor noted to resident's breath, unresponsive, heart irregular rate and rhythm. V/S (Vital signs) 56/32, 56, 28, 96.2 unable to obtain O2 (Oxygen) sat. Resident moved to the floor in anticipation of CPR if required, while this writer and CNA moved resident to floor, he stopped breathing, chart checked for code status and rescue breaths given. POLST (Physician's Order for Life Sustaining Treatment) form - DNR (Do Not Resucitate). No further breaths given. Emergency responders/fire department arrived at facility at approx. 10:33PM. Time of death 10:33PM. This writer called sister/guardian at 10:35 PM and 11:15, sister returned call to facility and spoke with this nurse with situation relayed. Sister began crying and stated she was glad for being able to see him this morning for a visit and was thankful to all facility staff for care given to brother. On-call after hours MD (medical doctor) called x2 awaiting call back. This nurse called local funeral home and body removed from facility at approximately 12:45AM. R16's [DATE] MAR (Medication Administration Record) documents on [DATE], R16's blood sugar at 8:00AM has numbers that are scribbled out but looks like 200 written beside the scribbles with V19's initials. On [DATE] at 11:00AM, the MAR documents blood sugar of 272 with initials of V19. There was no amount of sliding scale insulin documented to be given at that time, however the scheduled Humalog Kwikpn 6 units at 11:00AM and initialed by V19. On [DATE] 4:00PM, the MAR documents 6 units of Humalog Insulin was given as scheduled and initialed by V19, and at 6:00PM fingerstick glucose monitoring is initialed by V19 and results were scribbled out. On [DATE] at 2:00PM, V19 was asked about the blood glucose monitoring checks being scribbled out on MAR and V19 stated she did not do that. R16's December MAR contains no documentation that 12 units of Humalog insulin were given around 4:00PM on [DATE]. The MAR does document at 7:30PM on [DATE] R16 received 12 units of Humalog due to blood sugar reading Hi on Blood Glucose monitoring machine. R16's State of Illinois Certificate of Death includes a date of death for [DATE], and cause of death Probable Diabetic Ketoacidosis. Time of death 10:33PM. Facility Physician- Family Notification-Change in Condition Policy with a revision date of [DATE], documents in part: The facility will inform the resident; consult with the resident's physician or authorized designee such as Nurse Practitioner; and if known, notify the resident's legal representative or an interested family member when there is: .(B) A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); Life-threatening conditions are such things as a heart attack or stroke. Clinical complications are such things as development of a stage II pressure sore, onset or recurrent periods of delirium, recurrent urinary tract infection, or onset of depression. (C) A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); A need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (e.g., an adverse drug reaction), or commence a new form of treatment to deal with a problem (e.g., the use of any medical procedure, or therapy that has not been used on that resident before). (D) A decision to transfer or discharge the resident from the facility. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: Facility administrator was in-serviced by Regional Reimbursement Consultant on [DATE] on ensuring that glucometer values out of normal range are communicated to the attending physician or authorized designee in a timely, efficient and effective manner. Facility administrator was in-serviced by Regional Reimbursement Consultant on [DATE] on ensuring that licensed nursing personnel will inform the physician or authorized designee with any change in condition of the resident in an effective, timely and efficient manner. Facility administrator was in-serviced by Regional Reimbursement Consultant on [DATE] on medications being administered in accordance with the good nursing principles and practices and only by persons legally authorized to do so and only after they have been properly oriented to the facility's medication distribution system. Facility's administrator in-serviced by Regional Reimbursement Consultant on [DATE] on using nursing judgement to seek emergency treatment when appropriate. Facility Administrator initiated in-servicing on [DATE] for nursing staff on using nursing judgement to seek emergency treatment when appropriate. Facility Administrator initiated in-servicing on [DATE], for all nursing staff, on ensuring glucometer values out of normal range are communicated to the attending physician or authorized designee in a timely, efficient and effective manner to be completed before the start of their next shift. Facility Administrator initiated in-servicing on [DATE], for all nursing staff, on medications being administered in accordance with the good nursing principles and practices and only by legally authorized to do so and only after they have been properly oriented to the facility's medication distribution system, to be completed before the start of their next shift. Facility policy for physician notification has been reviewed by Regional Director of Operations and has been found to be in compliance on [DATE]. Facility completed an audit of all diabetic residents to ensure that their blood sugars are within therapeutic range and a weekly audit will be per formed by the DON or designee weekly for four weeks. Quality Assurance and Performance Improvement (QAPI) plan has been revised to include that the facility will ensure residents experiencing an acute critical situation receive timely emergency care and lacks a process for physician notification and receiving orders in an acute situation. QAPI revisions will be discussed at the next QAPI meeting in [DATE]. Monitoring will be ongoing in the morning Quality Assurance (QA) meeting by the QA team (Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Minimum Data Set (MDS)), the QA team will review the 24-hour report and follow up on any changes in condition to ensure that proper care was received and proper procedures were followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide safe administration of peritoneal dialysis by qualified trained staff as ordered by a physician for 1 (R22) of 3 residents reviewed for dialysis in the sample of 29. This failure resulted in R22 experiencing severe shortness of breath requiring transfer to local hospital, R22 receiving intubation and mechanical ventilation for respiratory failure to prevent imminent deterioration and further organ dysfunction from hypoxia and hypercarbia. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 10/22/24 at 11:15 AM when V29 (Registered Nurse/RN) and V30 (Licensed Practical Nurse/LPN) manually infused 2.5 liters of dialysate fluid into R22's peritoneal space (totaling approximately 4 liters of dialysate fluid in R22's peritoneal space) causing R22 to experience shortness of breath and be transferred to the hospital for further treatment. This past non-compliance occurred from 10/22/24 to 10/31/24. V1 (Administrator) and V7 (Regional Director of Operations) were notified of the Immediate Jeopardy on 3/18/25 at 4:00 PM. The Surveyor confirmed by observation, interview, and record review that the immediacy was removed on 10/31/24. Findings include: R22's New admission Information documented an admission date of 9/10/24. R22's Cumulative Diagnosis Log documented diagnoses that included sepsis, peritonitis, and dependence on dialysis. R22's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. On 3/11/25 at 2:45 PM, V33 (Regional Reimbursement) said the facility was not able to produce R22's Care Plans due to a change of ownership and was now unable to access the electronic medical records. On 3/12/25 at 2:14 PM, V2 (Director of Nursing/DON) said when she came into the facility on [DATE] the nursing staff were having some issues with R22's Peritoneal Dialysis (PD) infusion due to the PD cycler alarming through the night. V2 said she was told by V30 (LPN) that due to R22's PD cycler alarming, V30 had called V28 (Dialysis Company Registered Nurse). V2 said around 9:30 AM to 10:00 AM, V28 called the facility requesting to speak with V2 to give new orders for R22. V2 said the facility did not have the bag of dialysate that V28 gave an order for and had to go to the dialysis company to pick up the bag of dialysate. V2 said she returned to the facility and V29 (RN) was the nurse caring for R22. V2 said she gave V29 the order for a 1.5 liter PD manual fill and asked V29 if V29 was familiar with how to set and infuse a PD manual fill because V2 was not familiar with infusing PD solution with gravity. V2 said V29 said she was used to completing PD manual fills and had completed them in the past. V2 said R22 received 2.5 liters of PD dialysate, started to have some shortness of breath, and was sent to the hospital for further evaluation. V2 said she had never completed a PD manual fill of dialysate at that time. V2 said she had received training from the dialysis company for PD but the training only included how to hook a resident up to the PD cycler. On 3/13/25 at 10:13 AM, V30 (LPN) said R22's peritoneal cycler machine messed up. V30 said she called the dialysis company and was unable to fix it when the dialysis company said to come to the dialysis facility to get a bag of dialysate solution for R22. V30 said V2 brought R22's dialysate solution back to the facility. V30 said V29 (RN) asked V30 if V30 could walk V29 through how to put the fluid into R22's peritoneal space. V30 said V2 did not speak to V30 about R22's peritoneal dialysis order when she returned from the dialysis facility. V30 said V29 was the staff that approached her to assist with infusing R22's dialysate fluid. V30 said she did not check R22's orders because R22 was not her patient and V30 was only there to tell V29 how to hook up the manual dialysate tubing to R22 because V29 had not been trained. V30 said she had not received any training by the dialysis company on how to manually fill or drain a peritoneal dialysis patient. V30 said after R22 had been hooked up to the bag of dialysate fluid V29 infused the whole bag (2.5 L). V30 said R22 became short of breath and was transferred to the hospital. V30 said when she was on the phone with the dialysis company earlier in the day the dialysis nurse had not told V30 how much dialysate fluid to infuse. V30 stated the dialysis nurse just said come get a bag to put in. On 3/7/25 at 11:53 AM, V29 (RN) said she was caring for R22 on 10/22/24. V29 said she had received information in report from the night shift nurse R22's Peritoneal Dialysis (PD) cycler had been alarming throughout the night and V29 would need to follow up with the dialysis company to make sure R22's PD cycle had completed and ask if there were any new orders if it hadn't. V29 said she called the dialysis company and told them R22 had trouble with the PD cycler and V30 (LPN) took over the phone call. V29 said V2 came into the facility with a box from the dialysis company and placed it in R22's room. V29 said she was hard of hearing and deaf in one ear. V29 said she did not know what V2 said to her. V29 said she and V30 went to R22's room and V29 hooked R22's PD catheter up to the bag of dialysate and V30 unclamped the tubing infusing R22 with the dialysate. V29 said she was not sure how much dialysate was supposed to be infused. V29 said the dialysate bag was a 2.5-liter bag and if only 1 liter or however much was supposed to be put in was ordered why would V2 not have told the nurse (V29) who was going to be completing the treatment. V29 said after the dialysate was infused into R22, R22 looked like R22 was in fluid overload. V29 said R22 became hypotensive and short of breath with very low blood oxygen saturations. V29 said she put oxygen on R22 and called an ambulance to transport R22 to the hospital. V29 stated I was just observing. I didn't hook (R22) up. I just connected it. (V30) unclamped it and the fluid started going in. V29 said the whole 2.5 liters of dialysate was infused in R22 and no orders were written so V30 could not have known how much to infuse. V29 said she had not received any training on dialysis. V29 said training was completed through the dialysis company and due to V29 being a float nurse from a sister facility no dialysis training was ever offered to V29. V29 said she thought V30 was certified in dialysis. V29 said during the facility's investigation V29 was told R22 was supposed to receive 1.5 liters of the manual fill dialysate solution but nothing was written in R22's medical record. V29 said she had been in communication with V28 (Dialysis Company RN) and V29 had given V28 some of the readings from R22's PD cycler but when V28 started asking more questions she handed the call off to V30. V29 said she was not sure if there were any infusion directions in R22's Medication Administration Record. On 3/14/25 at 4:31 PM, V32 (Nephrologist) said overfilling of dialysate fluids can cause lung problems and discomfort with breathing. V32 said extra fluid in the abdomen pushes on the diaphragm and causes discomfort with breathing and can make it difficult. V32 said he knew R22 and R22 was already compromised respiratory wise as R22 just had pneumonia and had pulmonary edema. V32 said the normal amount of fluid left in the abdomen is 1.5 liters. V32 said the facility is supposed to follow the orders from the dialysis center. V32 said the dialysis center faxes over the orders to the facility and the facility should not be doing dialysis without current orders. V32 said if a nurse does not know how to perform or was never trained in peritoneal dialysis they should not perform the dialysis and should call the dialysis center. On 3/13/25 at 10:42 AM, V36 (Emergency Department Physician) said he was the Physician treating R22 on 10/22/24. V36 said he was not made aware by the facility R22's peritoneal space had been overfilled. V36 said the more fluid in the abdomen would push up on the diaphragm making it difficult to breathe. V36 said R22's CT (Computed Tomography) scan documented moderate volume ascites (fluid in the abdomen). V36 said, looking at R22's CT scan, they called it moderate, but it looks like a lot. V36 said the fluid in R22's abdomen would have made it harder to breath. V36 said R22's CT scan of the lungs did show pneumonia with consolidations in bilateral lungs, but the extra fluid would have made it even harder to breath. R22's dialysis company's Progress Note dated 10/22/24 at 8:30 AM documented in part Patient had been discharged from the hospital on [DATE]. RN unaware of discharge from the hospital back to SNF (Skilled Nursing Facility). (V30/LPN) . called and states 'We are having trouble with the patient's machine. It has been alarming for 20-30 minutes and it has not completed the last fill. The whole treatment is done but it hasn't done the purple bag' Writer advised (V30) to terminate the treatment and instructed to do a manual last fill. Discussed with (V30) supplies that were needed and would need to be picked up from dialysis facility . spoke with (V2/DON). Discussed with her the conversation of the above with (V30). And RN concerned supplies had not been picked up. (V2) then asked about a manual last fill that should be put into the peritoneum. Writer gave instructions at this time. Last fill would be 1.5L or 1500ml. It would not have to be manually drained, that it would drain during the initial drain with treatment this evening . R22's 10/21/24 through 10/22/24 dialysis company's Treatment Summary Report documented a cycler total on 10/22/24 at 8:48 AM of 1552 ml being in R22's peritoneal space. On 3/13/25 at 9:00 AM, V1 (Administrator) said the facility was unable to produce any orders for R22 from the dialysis company. V1 said after reviewing R22's medical record no orders for what peritoneal dialysis solutions were being administered was ever written on R22's September 2024 or October 2024 Physician's Order sheets. V1 said she did not know how staff were completing R22's peritoneal dialysis with no written orders. R22's Physician's Orders documented a 10/22/24 order documenting in part . T.O. (Telephone Order) Administer 1.5 L (Liters) of purple bag . manually. Hold purple bag night of 10/22/24 . R22's Nurse's Notes dated 10/22/24 at 11:15 AM and completed by V2 (DON) documented in part . This nurse received a call from (V28 Dialysis Registered Nurse) at (dialysis company) who gave T.O. to do a manual fill of 1500 ml (1.5L) to (R22). This nurse was instructed to come to (dialysis company) and pick up bag needed for manual fill . R22's Nurse's Note dated 10/22/24 at 11:50 AM completed by V2 documented in part . This nurse returned to facility with dialysis bag needed for manual fill . this nurse placed unopened box in (R22's) room and explained to (R22) what (dialysis company) wanted (V29/RN) floor nurse to do for her next appointment on 10/23/24. This nurse spoke to (V29) about what orders (V28) at (dialysis company) gave and what supplies were brought back . R22's Physician's Orders dated 10/1/24 through 10/31/24 included a 10/22/24 order documenting in part . Administer 1.5 L (1500 ml) of purple bag (dialysate fluid) .manually . No other orders for peritoneal dialysis were documented. R22's Medication Administration Record (MAR) dated 10/1/24 through 10/31/24 documented no orders for peritoneal dialysis other than the 10/22/24 order for 1.5 L manual fill. R22's Nurse's Note dated 10/22/24 at 12:30 PM completed by V29 documented in part .(R22) was doing well this AM had visitor, awake, conversating. No (signs/symptoms) of distress. Was called to room by staff. (R22) was noted to be in respiratory distress (blood oxygen saturation) in the 70's placed on (oxygen at 5 Liters via nasal cannula oxygen saturation) wouldn't go above 81. States 'I can't breath' (Blood pressure) 88/42 . Lung fields sound tight to auscultation . Sending to (hospital emergency department) . R22's Nursing Home to Hospital Transfer Form dated 10/22/24 completed by V29 documented in part . Additional Relevant Information . Just completed (peritoneal dialysis) last bag by gravity she said she feels like her stomach is about to blow up. Unable to breath (blood oxygen saturation) in the 70's. Placed on (5 Liters of oxygen blood oxygen saturation) 70's-81 . R22's Emergency Department Encounter dated 10/22/24 documented in part . presents to the (Emergency Department with) severe shortness of breath . is dusky and diffusely cyanotic (oxygen saturation) 80's on (15 liters of oxygen via non-rebreather) on arrival, panting . abdominal distention noted . repeating help me . (R22) was intubated due to respiratory distress . R22's Progress Notes & Medical Decision Making form dated 10/22/24 documented in part . Seen and assessed on arrival, weak inspiratory effort, dusky and mottled on arrival. Intubated due to severe respiratory failure . R22's hospital Progress Note dated 10/22/24 at 6:00 PM by dialysis nurse documented in part . Initial drain >3900 ml abdomen is no longer firm . Reported (initial drain) volume to primary RN . R22's ICU (Intensive Care Unit) Progress Note dated 10/23/24 documented in part .Assessment and Plan . Pulmonary: Acute hypoxemic respiratory failure: intubated due to respiratory distress. Continue managing the mechanical ventilation for respiratory failure to prevent imminent deterioration and further organ dysfunction from hypoxia and hypercarbia . Renal: . Nephrology is following. ?excessive (sic) dialysate instillation at NH (Nursing Home) as 4L removed overnight . R22's ICU Progress Note dated 10/26/24 documented in part .Assessment . Acute respiratory failure with hypoxia status post intubation on mechanical ventilation, extubated 10/25/24 . R22's hospital Discharge summary dated [DATE] through 10/21/24 documented a 10/21/24 chest Xray documenting in part . Impression: Suggestion of small bilateral pleural effusion with bibasilar atelectasis or pneumonia . The facility's 10/30/24 final report regarding R22's 10/22/24 incident documented in part . On 10/22/24 at approximately (3:00 PM) this administrator was notified that (R22) was noted to be in respiratory distress and was being sent to the (hospital) for evaluation . Investigation reveals that (R22) was connected to the dialysis cycler at approximately (8:00 AM). The cycler continued to alarm, was turned off and (dialysis company) notified. At approximately (11:15 AM) the facility received orders from (dialysis company) for a manual fill of 1.5 L bag. (V2) picked up supplies from (dialysis company) which were (sic) 2.5 L bags. (V29) and (V30) connected (R22) to the manual fill bag at approximately (12:00 PM). At approximately (12:30 PM) (V29) was notified by staff (R22) appeared to be in (respiratory) distress . sent to (hospital) for evaluation . In conclusion, the facility was able to substantiate that (R22) experienced an adverse reaction secondary to receiving a manual fill during peritoneal dialysis . The surveyor confirmed through interview and record review that the facility took the following actions, which were initiated on 10/23/24 and completed on 10/31/24 to remove the Immediate Jeopardy: The contract for dialysis was terminated with the facility 10/31/2024. Facility Administrator (V1) and Director of Nursing (V2) reviewed all the residents at the time of the event and no other residents were receiving PD (peritoneal dialysis) services at the time of the event and no other residents have received PD services since this event. Facility Administrator (V1) and Director of Nursing (V2) were in-serviced by (dialysis company) on manual fill PD on 10/24/2024. Both nurses involved in the event were suspended pending investigation 10/23/2024 and terminated on 10/28/2024. Facility policy for dialysis was reviewed by Regional Director of Operations and found to be in compliance on 10/24/2024. QA (Quality Assurance) meeting was held on 10/24/2024 with (dialysis company) and policies and procedures were reviewed. Administrator or designee will review PD patients weekly times 4 weeks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to use appropriate alternatives prior to installation of bed rails, adequately assess and monitor residents for risk of injury/entrapment prior to installation, ensure adherence to appropriate dimensions and manufacturer's recommendations, and failed to obtain a physician order for use of bed rails for 6 (R2, R3, R4, R7, R8, R9) of 9 residents reviewed for bed rails in the sample of 29. This failure resulted in R2's death by positional asphyxiation, when R2 was found in the sitting position on the floor beside the bed with legs straight out and head and neck between mattress and bed rail. This failure also has the potential for risk of serious harm/injury and possible death for R3, R4, R7, R8 and R9. This failure resulted in an Immediate Jeopardy, which was identified to have begun on [DATE] when the facility added side rails to R2's bed without proper assessment and installation per manufacturer's recommendations which resulted in R2's death via asphyxiation on [DATE]. V1 (Administrator), V34 (Regional Clinical Director), V16 (Regional Minimum Data Set Coordinator), and V33 (Regional Reimbursement) were notified of the Immediate Jeopardy on [DATE] at 9:57am. The surveyor confirmed through observation, interview, and record review that the Immediate Jeopardy was removed, and the deficient practice corrected on [DATE], but the noncompliance remains at Level Two due to additional time to evaluate implementation and effectiveness of training. Findings include: 1. R2's admission Record documented an admission date of [DATE], and included diagnoses of Parkinson's Disease, Type 2 diabetes mellitus, morbid obesity, dementia, and hydrocephalus. R2's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Under Functional Abilities and Goals, the MDS documented R2 had no impairment to upper and lower extremity, R2 used a wheelchair (w/c) for mobility, R2 required partial/moderate assistance for eating and oral hygiene, was dependent for toilet hygiene, bath/showers, lower body dressing, putting on and taking off footwear, and personal hygiene, and R2 required substantial/maximal assistance for upper body dressing. Under Cognitive Patterns, the MDS documented R2 exhibited no physical or verbal behaviors, and under Restraints and Alarms, a 0 was entered to indicate not used for bed rails as well as any bed, chair, or other alarm. R2's Baseline Care Plan dated the day of admission ([DATE]) had the following items checked: Assist of 2+ for bed mobility, Assist of 2+ and Dependent for transfer, Ambulation was marked N/A (not applicable), and Assist of 1 and Wheelchair were checked for Locomotion. Under the section titled Identified Safety Risks: Safety Plan of Care, the following boxes were checked: High Risk Fall Assessment, Poor Safety Awareness, Fall History, Gait, Balance, and Weakness. The section titled Enabler/Positioning Device/Positioning Cushion/Alarm/Safety Device Plan of Care is incomplete with nothing checked for any assessments or devices in use. This baseline care plan is blank in the section for any updates and signatures. Problem areas identified on [DATE] included: R2 requires staff assist with ADL's (Activities of Daily Living), R2 is at risk for falls, risk for injury from falls r/t (related to) unsteady gait/Parkinson's/history of falls, R2 is at risk for uncontrolled movement r/t Parkinson's, R2 has impaired cognition, and confusion at times r/t Parkinson's Dementia. Interventions for these identified areas included assist with bed mobility, transfers, bathing/toileting, etc., call light and personal items in reach (all dated [DATE]); Proper Footwear (dated [DATE]) and Pin Alarm (dated [DATE]). This care plan had no documentation addressing the use of side rails for R2. The next Care Plan for R2 documented Focus areas initiated on [DATE] that included R2 was a Full Code, had impaired cognitive function r/t dementia, Parkinson's, and hydrocephalus, and noted R2's Parkinson's affected speech and thought processes. This Care Plan did not include information regarding R2's risk for falls or history of falls and did not include any documentation addressing the use of side rails. The facility document titled Physical Restraint/Enabler Consent has R2's name and a date of [DATE] (date of admission) written in. The Reason for Restraint/Enabler: is documented as 1/2 side rails and the Type of restraint/enabler: is documented as positioning and bed mobility. The consent further states Please be advised all residents using physical restraints/enablers will be assessed for a reduction program. All reductions will be based on the assessment performed by a Licensed Nurse in the facility . The consent is signed by V9 (R2's Power of Attorney/POA) . The facility's [DATE] Fall Log documented R2 had a fall on [DATE] at 10:00AM, location Residents room, root cause is weakness/loss of balance, intervention in place is educated nursing staff to assure patient is wearing proper footwear. The facility's [DATE] Fall Log documented R2 had a fall on [DATE] at 3:30PM. Location resident's room, root cause was attempting to sit on side of bed independently, intervention is orders obtained for pin alarm to person while awake. R2's Bed Rail/Transfer Bar Evaluation dated [DATE] is a two page document with instructions that state to Check all that apply in last 7 days. This document includes handwritten check marks, but also has handwritten Y (yes) and N (No) answers in some of the boxes. Under Medical Need Affecting Bed Mobility/Transfer Safety the following items have a check mark: Weakness, Pain, difficulty moving to a sitting position on the side of the bed, difficulty with balance sitting on bed and/or getting in/out of bed, poor trunk control, difficulty/unable to move legs in bed without device, changes in blood glucose levels, knees buckle, and mattress requires/suggests use of side rails. The following items are marked N for no: Difficulty/Unable to move trunk in bed without device, visual deficit, orthostatic hypotension and/or vertigo, musculoskeletal disorders affecting resident (fractures/contractures, etc.), neurological disorders causing involuntary movements, and history of falls in last 30 days. Under Mental Status Affecting Bed Mobility/Transfer the following items have a check mark: Able to make needs known, fluctuations in level of consciousness and altered/poor cognitive status. N is marked for Able/Willing to participate in bed mobility. Under Alternative Attempted Prior to Bed Rail/Transfer the following items have a check mark: Assisted Transfer, Frequent Staff monitoring/assisted turning and positioning while in bed, and reminders to use call light. The following items are marked N for no: Physical or Occupational Therapy, Restorative Care, Bedside Commode and/or Urinal/Bedpan, periodic assisted toileting, altered bed height, transfer bar and trapeze. Under indications for bed rail/transfer bar, all items are marked N for no and include: bed rails do not appear to be indicated at this time, at least two medical needs exist and two alternatives have been attempted ., resident has been evaluated-does not overhang bed-able to turn comfortably, serves to remind resident to seek help-unaware of physical limits, serves as Enabler - unable to enter or exit bed independently without enabler use, serves as Enabler to promote independence in turning side to side and puling self to lying/sitting and resident expresses desire to have the side rail for security. On the 2nd page under Benefits of Bed Rail/Transfer Bar Use, the following items are checked: Enhanced functional ability-decrease dependence on others for ADL's (Activities of Daily Living), Reduce injury related to random/unpredictable movements during transfers and prevent injury to self or others. Under Entrapment Considerations during use, N for no is marked for the following questions: Is resident at risk for climbing over rails?, Is there a Neurological Disorder causing involuntary movements?, Is Resident combative with care?, Is Resident known to have any thrashing, jerking or unpredictable physical movements that may cause entanglement in bar? Y or yes was answered in response to the following questions: Does the bar prevent resident from exiting bed? (Yes = Restraint-Additional complications may be possible obtain consent-CP (care plan) accordingly) and Does the bar interfere with the resident's access to their own body? (Yes = Restraint-Additional complications may be possible obtain consent-CP accordingly). The bottom of the 2nd page of the evaluation has four sections to indicate quarterly review, each stating The IDT (Interdisciplinary Team) has reviewed the resident's capabilities, needs and preferences in relation to bed rail use and has determined with boxes for the team to choose No Bed Rail Indicated, Benefits of enabler outweigh risks; consent obtained for: Assist Bar: Bilat (bilateral) Rt (right) Lt (left), Full Side Rail: Bilat, Rt, Lt, 1/2 Side Rails: Bilat, Rt, Lt, 1/4 Side Rails: Bilat, Rt, Lt, an area for comments, and an area for staff signature, initials and date. These four sections on R2's evaluation are left blank, therefore incomplete. A second Bed Rail/Transfer Bar Evaluation was completed the next day on [DATE] and some items were answered differently on this evaluation, such as difficulty/unable to move legs in bed without device and knees buckle were both answered N for no. The whole section under Alternative Attempted Prior to Bed Rail/Transfer had no alternatives checked, and Bed rails do not appear to be indicated at this time was checked. The differences under the Benefits of Bed Rail/Transfer Bar Use documents: enhanced safety during ADLS, and reduced potential for falls. Again, the bottom four sections of this evaluation form where the IDT reviews and makes determinations regarding bed rails were left blank with nothing selected and no staff signatures, initials or dates. The local Fire Department incident report documents an EMS (Emergency Medical Services) call with an incident date of [DATE] at 1:04 AM. Under Patient Narrative, the following is documented: Responded to nursing home facility for male patient unresponsive, not breathing. Upon arrival, find [AGE] year-old male supine on floor next to bed. Nursing staff performing chest compressions and ventilations with BVM (bag-valve-mask). Patient is pulseless and apneic. Skin is cold and cyanotic. Cardiac monitor applied showing asystole. Nursing staff reports possible down time 45 minutes or more. Resuscitation efforts discontinued; medical control contacted to confirm. Staff reports patient had been found with most of his body on the floor, with head and upper torso stuck between bed and bed rail. Coroner contacted via dispatch. Cleared scene with nursing staff awaiting communication with coroner. End of Report. R2's Progress Notes dated [DATE] at 3:25AM, documented the following Late Entry: At approximately 0100 (1:00AM), CNA (Certified Nurse Assistant) alert this nurse that resident needed immediate assist. This nurse immediately ran into resident room and saw the resident in a compromised position. Resident appeared to be in sideways sitting position with head between grab bar and mattress. Resident unresponsive and no pulse palpable. Resident lowered to the floor. CPR (Cardiopulmonary Resuscitation) initiated. All staff alerted EMS alerted. This nurse and other nurse continued CPR until EMS arrived. Time of Death 0110 (1:10AM). IDT (Interdisciplinary Team) notified. EMS notified coroner. Family Notified. The Medical Examiner/Coroner Certificate of Death documented R2's date of death was [DATE] and time of death was 1:15AM. Under Cause of Death, Part 1, a. documented Positional Asphyxiation, due to or as a consequence of b. found in a seated position on floor beside bed, due to or as a consequence of c. legs straight out and head and neck between mattress and bed rail. Part 2 lists the following under Enter other significant conditions contributing to death but not resulting in the underlying cause given in Part 1 Diabetes, hypertension, Parkinson's, dementia, and obesity. The manner of death is documented as Accidental with date of injury listed as [DATE], time of injury listed as 1:00AM, and place of injury listed as Nursing Home. The death certificate was certified by V5 (Coroner) on [DATE]. On [DATE] at 11:10 AM, V5 (Coroner) stated he was the one that determined the cause of death for R2. V5 stated he was notified by EMS that the resident (R2) was expired upon arrival and R2 was very cold to touch. V5 stated EMS relayed that the nurses were doing CPR upon their arrival but the efforts were stopped upon assessment due to the condition of R2. V5 stated the EMS estimated R2 had been expired for at least 45 minutes upon their assessment. V5 stated he came to the facility and met with the nurse (V3 - Licensed Practical Nurse/LPN) who was working the night of R2's death. V5 stated V3 demonstrated the position of R2 when V3 entered the room and the position of R2's head in between the mattress and the bedrail. V5 stated the nurse demonstrated the position of R2's body as sitting on the floor with his legs straight out and body turned sideways with head caught in between the mattress and bedrail, which made it difficult to impossible for R2 to breathe. V5 stated R2's cause of death was positional asphyxiation. V5 stated he had the EMS report and has reviewed all records. V5 stated the cause of death was due to R2's head being trapped between the mattress and bedrail causing positional asphyxiation. On [DATE] at 12:56PM V2 (Director of Nursing/DON) was asked who at the facility does the Side Rail assessments and who decides if they are needed. V2 stated she wasn't familiar with Side Rail Assessments, and she was not sure who does them. V2 was asked who obtains the consents and again V2 stated she wasn't sure. V2 was asked if there was documentation regarding alternative interventions attempted prior to implementing side rails or where that documentation would be and V2 stated she was not aware of any such documentation, but she would look for it. V2 was asked if she completed side rail assessments for R2, to which she responded No. V2 stated she is new in the position since October or November of 2024, and she was not sure who does assessments or consents. V2 stated she assumes bed rails are used for bed mobility. On [DATE] at 1:34PM, V1 (Administrator) was asked for the incident/investigation report on R2's incident that occurred on [DATE]. V1 stated we did not do one because we did not think his death was related to a fall or any type of injury. V1 was asked if there was an incident report made on this occurrence and V1 stated no. On [DATE] at 2:20PM, V3 (LPN) stated she was the nurse in charge of R2's care on the morning R2 expired ([DATE]). V3 stated she was an agency nurse but had worked at this facility several times. V3 stated she was summoned to (R2's) room at approximately 1:00AM by V11 (CNA) and the V11 stated R2 was needing assistance. V3 stated when she entered R2's room, he was noted to be in a compromised position. V3 was asked to explain what she meant by that and V3 stated R2 was sitting on his bottom on the floor with his legs stretched out and he was sort of turned with his head lodged between the mattress and handrail. V3 stated R2 did not have a pulse or respirations. V3 stated she and V11 had to lift R2 up to get his head and torso out of the rail so she could lay him flat on the floor to start CPR. V3 stated R2 was cold to touch. V3 stated she had already sent V12 (CNA) to call 911 while she continued CPR. V3 stated when EMS arrived, they stopped the CPR and called the coroner. V3 stated the bed R2 was in was a very old-style bed. V3 stated the siderail present on the bed was the old brown metal ones that mount on the bed and were very big. V3 stated there was a large gap between the mattress and siderail, estimating it was at least a 6-inch gap. V3 stated it was the most horrible thing she has ever seen as a nurse. V3 stated she notified V1 and V2 of R2's incident and his death. V3 stated the staff that were working that night told her R2 has tried to get out of bed numerous times in the past. When questioned if R2 had an alarm, V3 stated she was not aware of an alarm and no alarm was sounding. V3 stated she met with the coroner at the facility a few days after the incident and reenacted the position R2 was in and his condition when she entered the room. V3 stated she knew it was due to his head being stuck between the rail and mattress and it was asphyxiation. On [DATE] at 10:05AM, V1 stated she received a call from V11 at 1:09AM on [DATE] and V11 stated R2 was hanging out of bed gasping for air, and it did not look good. V11 stated CPR was being started. The next call was from V3 at 1:50AM stating R2 had expired. V1 stated when I went in with the coroner for the reenactment, I knew something major had happened. V1 stated I also thought something was up when the coroner kept coming into the facility. V1 stated R2 had a history of throwing his legs out of the bed. V1 was asked what intervention was put into place for R2 throwing his legs out of bed and V1 stated there are no interventions for that, but it is sort of a common thing for people to do that. V1 stated R2 had a clip-on alarm when he was up in his wheelchair. V1 stated R2 would not have had that while in bed. V1 stated the clip-alarm was for a fall intervention. V1 stated R2 had siderails on for positioning, he would help roll himself in bed. V1 stated maintenance puts on the siderails and we do routine checks on siderails. V1 stated I don't know about the gaps on siderails, but maintenance does all of that. V1 stated, R2 had an air mattress on his bed. V1 was asked if she knew the manufacturers recommendation for side rails with the air mattress and V1 stated no, I don't know anything about gaps. V1 was asked what process they use to determine who needs side rails and V11 stated well sometimes the family wants them on so we put them on, and sometimes physical therapy may recommend. V1 said there should be a side rail assessment, consent, and (physician) order completed at the time of installation of siderails. On [DATE] at 12:41PM, V6 (Maintenance Director) stated he is the person that puts on the side rails. V6 was asked who sends him the work order or request for side rails, and V6 stated either a CNA, Nurse, or Administrator just comes and tells him who needs side rails put on. V6 stated he went to other facilities that have closed and got all the side rails he could find as he was told to gather all of them and bring them to this facility. V6 stated these side rails are very old but so are the beds. V6 stated he did not receive any Owner's Manual or specifications on the side rails or beds from the other facilities. V6 stated he had not seen any specs on the beds, side rails, or mattresses in the facility. V6 was asked if he checks the gap when he installs the side rails and V6 stated all I know is that the side rails must be 4 inches from the headboard. V6 was asked what the gap space was for between the side rail and mattress and V6 stated he didn't know anything about that. V6 stated he is told to keep a few vacant beds with side rails installed for any new admissions. V6 was asked if he checks the side rails monthly or routinely and V6 stated I was asked that same question this morning by V1 and I told her I did not know anything about needing to do that, so no I never go check the side rails. I will start doing that from now on. V6 stated I did find a book under my desk that has the logs to check side rails and gaps, but it has not been kept up or has not been done for a long time, the last one done was in 2023. V6 was asked if he remembers putting R2's side rails on and V6 stated No I really don't remember if I did, and chances are they were already on the bed. V6 was asked if he at any time checked R2's siderails and V6 stated No. V6 stated he started the job in October of 2024, and he is learning as he goes. V6 was asked if he could show this surveyor the bed that R2 was last in before he expired and V6 stated No I couldn't be sure as we switch beds all the time. V6 stated he doesn't even recall what type of bed R2 had or what type of side rails were on his bed. On [DATE] at 1:35PM, V2 (DON) stated she got notified by V3 (LPN) that R2 had passed. V2 stated R2 was a full code, and they did CPR but he did not make it. V2 stated V3 reported that R2 was found with no vitals, so they lowered him to the floor and started CPR while V12 (CNA) called 911, then EMS took over and stopped working on R2. V2 stated that V3 said R2's head was against the rail, and he was in a compromised position. It looked to her like R2 may have sat on the side of the bed and slid down onto the floor. She stated he had to be moved away from the rail to get him to the floor. He had an air mattress on the bed at the time. V2 stated R2 did have an order for a pin alarm to be on during hours R2 was awake. V2 said I don't think you use a pin alarm in the bed on residents. The next workday I went in and looked at the room and looked at the progress note and contacted the CNAs to start getting statements. V2 stated she also had to get documents for the coroner. V2 said At this point my opinion is that you really can't strangulate from a siderail. I feel like this was cardiac. I am afraid an event happened prior to him slipping. I have seen him move himself around with no issues. V2 stated she was not sure what type of bed R2 was in at the time he expired. V1 stated, I do know that he had an air mattress on. V2 stated she has never been trained on gap measurements for beds with side rails and did not know that these had to be checked. On [DATE] at 2:32PM, V8 (Registered Nurse/RN - Resident Care Coordinator/RCC) stated she cared for R2 several times. V8 stated R2 had started sitting on the side of bed and trying to get up recently. V8 stated R2's health issues were bad when he first admitted but he was getting much better. R2's wife visited every day but recently she was in the hospital herself. V8 stated she only remembered R2 having one fall. V8 stated I assume he had the siderails because he tried to get out bed, but his side rails were too big, they were just too big for the bed. V8 said the nurses do the siderail assessments and the MDS Coordinator decides if they need siderails. V8 stated side rail consents are in the admission packet, so we automatically get them signed for permission for siderails upon admission in case they ever need side rails. V8 stated she was told by V3 that R2 coded, and it was very unfortunate. V8 stated R2 was alert with confusion and no behaviors or hallucinations. V8 said that daily R2 would constantly throw his legs out (of bed). V8 stated when she worked and R2 would start throwing his legs out of the bed, she would have the staff get him up in his wheelchair. V8 stated she was not aware of R2 having an alarm of any kind. V8 stated there should be side rail assessments completed with a consent and orders before side rails are installed on any resident. On [DATE] at 2:44PM, V9 (Family/Power of Attorney/POA) stated she doesn't remember when or why R2 had bed rails put on his bed. V9 stated no staff ever told her why but she thought it was because R2 kept trying to get out of bed. V9 stated she doesn't ever remember signing a consent for side rails. V9 stated she visited R2 every day. V9 stated she was told of one fall, and they did not tell her of any interventions. V9 stated she asked for an alarm for R2 while in bed because R2 would try to get out of bed. V9 stated R2 had confusion most of the time. V9 was asked if she ever attended a care plan meeting and she replied she was never told of such a meeting, and it would have been nice to have one. V9 stated she just doesn't understand why they had the side rails on except to keep him in the bed. V9 stated the plan was to get R2 back home so she and her daughter could provide care for him at home. On [DATE] at 7:53 PM, V11 (CNA) stated she was working on [DATE] when R2 expired. V11 stated she is the one that found R2. V11 stated she had done a bed check on R2 at 10:00PM, and the next time she went into R2's room was around 1:00AM when she had walked by and seen his feet were not in the bed. V11 stated R2 was constantly throwing his legs out of bed and trying to get up. V11 stated when she entered R2's room at around 1:00AM, she saw him sitting on the floor beside the bed sort of sideways with his neck caught between the bed rail and bed frame. V11 stated it was like he was hung by his neck, but his body was on the ground. V11 stated R2 was not breathing, and she noted he was discolored. V11 stated she ran and got the nurse and she and the nurse had to lift R2 up to get his neck out from the bedrail because it was stuck. V11 stated they finally got him loose and started CPR. V11 was asked if she knew why R2 was out of the bed and V11 stated yes R2 was really wet, and he was poopy too. V11 was asked if anyone else had checked on R2 between 10:00PM and 1:00AM and V11 stated I don't know. V11 stated they really aren't assigned a specific hall; they all just work together. V11 stated she thinks R2 was on a special mattress but doesn't know the name of it. V11 stated there was a big gap between the mattress/bed rail and bed frame and was big enough for his head and neck to fit in and get stuck in. V11 stated R2 has had 1/2 rails on his bed for a long time and they were the big old rails too. V11 stated R2 was confused and did not usually use a call light. V11 didn't know anything about an alarm for R2. V11 stated she called V1 and explained what had happened and she stated she told V1 that R2 was found hung in the side rail and he expired but they were doing CPR. On [DATE] at 8:54 AM, V14 (LPN) stated she was working the morning of [DATE] at the time R2 expired. V14 stated she was summoned to R2's room to assist with CPR for R2. V14 said when she entered the room CPR was in progress and she took over helping the other nurse (V3). V14 stated she didn't notice R2 being extremely cold, but she did notice his color was bad. V14 stated once EMS got there, the paramedics took over and stopped CPR as it was evident R2 was expired. V14 stated she remembered when she stood up her pants were wet from urine that was on the floor from R2. V14 stated she was not familiar with R2 as she has never worked the hall R2 was on. On [DATE] at 8:21AM, V1 stated maintenance had not been checking the specification on the beds, mattresses, or side rails before installation. V1 stated the Side Rail Installation assessment should be done by maintenance prior to installation. V1 stated she does not believe she has the specifications for the beds or bed rails due to the equipment being so old and most of the beds in use came from other facilities that closed. V1 stated she would try to find them but does not know if she will find them as she has never seen them. V1 stated she plans on taking off all side rails in use due to safety. On [DATE] at 8:45AM, V6 (Maintenance Director) stated he does not measure the beds, mattresses, or side rails before installation of side rails. V6 stated he put most of the side rails that are in use on the beds. V6 stated some of the beds he brought from other facilities already had side rails in place, so they just left them on. V6 stated he does not check the weight or height of the residents either. V6 stated he does not have the specifications on the beds, mattresses, or side rails that are in use currently in the facility. V6 stated he brought most of the beds in use from other facilities along with side rails and he did not get the specifications or Owners Manuals on the beds or bed rails. On [DATE] at 9:00AM, V13 (MDS Coordinator) stated she does not do the initial Side Rail Assessments or consents; these are included in the admission packets and the floor nurses do all assessments upon admission. V13 stated she does the quarterly assessments. V13 stated she does the care plans too. V13 stated she doesn't have all the side rails put on the care plans as she is behind and just started mid-November. V13 was asked if she could provide a list of when the siderails were installed on each residents' beds and V13 stated she has never seen a list or log of when the siderails were put in place on any of the residents and without orders it is impossible to determine. On [DATE] at 9:14AM, V12 (CNA) stated she was working the night R2 expired. V12 stated there were 3 CNAs and 2 Nurses working that night. V12 stated she and another CNA were just coming in from a smoke break when V11 (CNA) came running and told them to get to R2's room to help with CPR. V12 stated when she entered the room, R2 was lying on the floor beside the bed and V3 was performing chest compressions. V12 stated she was directed to call 911, so she did and stayed on the phone with the dispatcher until EMS arrived approximately 6 minutes after she called. V12 stated she followed them to the room and after EMS assessed R2 they stopped CPR. V12 was asked when she last saw R2 alive and V12 stated at 10:00PM she helped with a bed check on R2. V12 was asked if she had checked on him in between 10:00PM and 1:00AM and V12 stated No. V12 stated the CNA's usually get bed checks done every 3 hours. V12 was asked how R2 was at 10:00PM and she stated, he was his normal self, confused but very nice. V12 stated R2 was constantly throwing his legs out of bed and trying to get out of bed. On [DATE] at approximately 8:00AM, V1 stated they found where R2's bed was moved to another room. On [DATE] at approximately 10:52 AM, this surveyor and V6 (Maintenance Director) observed the bed that R2 was in at the time he expired. The bed had an air loss mattress on it with metal ½ side rail in place and gaps were observed between the mattress and the side rails. V6 was asked to measure the gap on the left side between the mattress and the side rail (as this was the side of the bed where R2's head/neck was caught). The gap measured approximately 4 ¼ inches. This surveyor then sat on the air mattress on the left side and the gap expanded to 5 inches. This surveyor reached out to grab the left side rail and it was loose and moved outward, so V6 was asked to measure again and noted a 7 1/8-inch gap. R2's Physician Orders dated 10/2024, 11/2024, 12/2024, and 1/2025 had no documented orders for side rails. 2. R3's admission Record documented an admission date of [DATE] and included diagnoses of Ischemic Cardiomyopathy, Depression, Anxiety, Vascular Dementia, and Insomnia. R3's MDS dated [DATE] documented a BIMS score of 2, indicating R3 has severe cognitive impairment. Under Functional Abilities and Goals, the MDS documented R3 was dependent for rolling left to right, the ability to roll from lying on back to left and right side and return to lying on back on the bed, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer and tub/shower transfer. R3 was also dependent for eating, oral hygiene, toileting, shower/bathe, upper body dress[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a mechanically altered diet as ordered for 1 of 4 (R17) residents reviewed for mechanically altered diets in a sample of 35. This resulted in R17 choking on 9/6/23, requiring the Heimlich maneuver, chest compressions, and evaluation in the emergency room, and a subsequent choking episode on 10/28/23, in which the Heimlich maneuver was again required. These failures resulted in an Immediate Jeopardy, which was identified to have begun on 9/6/23, when the facility failed to provide the proper mechanically altered diet as ordered. V1 (Administrator) was notified of the Immediate Jeopardy on 11/20/23 at 2:58 pm. This surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 11/20/23, but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: 1. R17's New admission Information documented an admission date of 11/2/20. R17's Cumulative Diagnosis Log documented diagnoses: anxiety, lewy body dementia, dementia with agitation, and physical deconditioning. R17's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. R17's MDS section G documented limited one person assistance with setup or clean-up assistance with eating. R17's care plan documented an 11/10/20 potential risk for altered nutritional status with a 1/17/21 intervention that R17 must be monitored during meals related to choking hazard. R17's Social Services Interim Treatment Plan, dated 11/2/20, documented, . List perceived weakness based on admission assessment: a choking risk- doesn't appear to take the time to chew properly- must be monitored . R17's 11/29/22 Nutritional Assessment documented R17 was edentulous (no top or bottom teeth). R17's Speech Therapy Daily Treatment Note, dated 4/20/21, documented, . was seen for skilled dysphasia therapy this date during lunch meal with (R17) continuing with trial of mechanical soft solids. (R17) demonstrates adequate mastication and bolus formation given (minimal) verbal cues for use of bite size and rate of modification. Continue with current diet trail of mechanical soft solids R17's August 2023 Physician's Orders documented a 11/1/22 diet order of .Mechanical Soft Solids . Must be monitored at meals (related to) choking . R17's September 2023 Physician's Orders documented a 9/11/23 diet order change to pureed solids and a 9/27/23 diet order change to . (Mechanical) Soft Solids, (Finely Chopped and Heavy Moistened with) No Breads . R17's Skilled Progress Note, dated 9/6/23 at 11:50 am, by V5 (Licensed Practical Nurse/ LPN) documented . sitting in dining room CNA (Certified Nursing Assistant) . noticed (R17) was choking on pizza. (V4, LPN) and other CNAs started the Heimlich (maneuver). (V5, LPN) switched with (V4) and attempted the Heimlich (maneuver) as well. Resident legs started to buckle and lose consciousness. We then lowered (R17) to the ground while 911 was being contacted . started CPR compressions as (V5) went to grab the (ambu-bag). There was pieces of pizza crust retrieved. (R17) regained consciousness as the fire department and police department arrived at 11:55 am . ambulance arrived at 11:57 am and took (R17) to the hospital . On 11/16/23 at 12:27 pm, V4 (LPN) said she was caring for R17 on 9/6/23 during the noon time meal. V4 said she was called by a CNA due to R17 choking. V4 said R17 had been served a whole piece of pizza by Dietary staff. V4 said she and other facility staff had attempted the Heimlich maneuver on R17, and were not able to clear R17's airway. V4 said R17 then lost consciousness and was lowered to the floor and facility staff started chest compressions on R17. V4 said she was able to complete a finger sweep to remove the pizza crust from R17's throat. V4 said by the time Emergency Medical Services (EMS) arrived, R17 had regained consciousness and was transferred to the Emergency Department (ED) for further evaluation. V4 said R17 returned to the facility the same day from the ED. On 11/16/23 at 12:42 pm, V5 (LPN) said she was present on 9/6/23 when R17 choked on a piece of pizza. V5 said R17 was served a whole piece of pizza from Dietary staff. V5 said R17 was sitting in the dining room when R17 choked. V5 said the Heimlich maneuver failed to clear R17's airway and chest compressions had been started, and two pieces of bite sized pizza crust were removed from R17's throat. V5 said R17 had several instances of choking in the past. On 11/16/23 at 12:58 pm, V3 (Dietary Manager) said a piece of pizza was considered mechanically soft. V3 said pizza has always been considered mechanically soft, and no one had ever told her otherwise. On 11/16/23 at 2:50 pm, V3 said there was no difference between the pizza served to residents with regular diet orders and mechanically soft diet orders; all the pizza served was made with a biscuit crust. V3 was asked how thick the pizza crust was supposed to be, V3 responded about half an inch to an inch thick depending on who is cooking. V3 said the pizza served on 9/6/23 to residents with mechanically soft diet orders did not have sausage and was only cheese pizza. On 11/16/23 at 1:47 pm, V7 (Speech Pathologist) said mechanically soft diets should be defined as foods that are soft and fork tender with ground meats. V7 said the texture of the food should have a moist cohesive texture. V7 said she would not expect resident's with orders for mechanically soft diets to receive pizza with crust. V7 said even when using a biscuit mix for the pizza crust, V7 did not feel it would be appropriate for residents with mechanically soft diet orders. On 11/16/23 at 1:56 pm, V8 (Regional Dietitian) said, The facility did not have a recipe for mechanically soft pizza. Dietary staff should ensure the crust of the pizza is soft, the meats are ground, and there is added moisture. V8 was asked how staff were trained to know it is soft enough to be appropriate for mechanically soft diets, V8 responded staff were trained upon hire to know what on the diet spreadsheet is soft enough to serve to residents with mechanically soft diet orders. On 11/16/23 at 2:10 pm, V6 (Social Services Director) said she had made a note on 11/2/20, when R17 was first admitted to the facility, that R17 was at risk for choking to alert staff to cut up R17's food and to monitor for choking. V6 said she expected staff were assisting R17 to cut R17's food into bite sized pieces due to having some difficulty swallowing. V6 said R17 eats very fast, and must be monitored by staff at all times when eating. R17's hospital After Visit Summary, dated 9/6/23, documented, . Diagnoses . Choking episode . Choking due to food in larynx . The facility's Diet Spreadsheet Week 3 documented on 9/6/23 the evening meal was substituted for the noon time meal, and mechanical soft diets should receive cheese pizza with soft crust. The undated facility recipe for Sausage Pizza which included using a biscuit dough crust did not indicate what type of diet it was for, and did not contain any special instructions for mechanically soft diets. R17's Speech Therapy Plan of Care, dated 9/11/23, documented, . Treatment Diagnosis . Dysphagia, Oropharyngeal . was referred to skilled speech therapy by nursing staff following a choking episode on 9/6/23 in which (R17) had to be administered the Heimlich maneuver and was found to have pieces of unchewed food blocking her airway . Diet Level . Prior Level . Mechanical Soft . Current Level . Puree . R17's Speech Therapy Daily Treatment Note documented a 9/14/23 note . (R17) was seen during the evening meal with (R17) receiving a tray of puree solids and thin liquids. (R17) is visibly opposed to current puree diet, making statements such as I'm not eating that and that looks gross. A 9/19/23 note, . (R17) was seen during the noon meal with (R17) receiving a trial of mechanical soft solids (without bread) and thin liquids. (R17) requires supervision through entire meal as impulsive behaviors appear periodically . demonstrates effective bolus formation and swallow initiation, (minimal) to no oral stasis and effective airway protection . A 9/27/23 note, . Staff inservice / education provided regarding diet change and maintenance program to maximize (R17's) safety during (oral) intake while providing (R17) with the safest, least restrictive diet . R17's Nurse's Notes, dated 10/28/23 at 12:45 pm, by V4 (LPN) documented, . began choking at lunch (related to) was given potato wedges for lunch. Able to encourage resident to cough, staff began Heimlich (maneuver) and potato wedge became dislodged and was in side of throat and this scribe was able to remove with finger sweep. Spoke with kitchen (manager) about approved foods for resident based on diet order . On 11/17/23 at 10:11 am, V4 (LPN) said she was caring for R17 on 10/28/23 during the noon time meal. V4 said R17 was served whole potato wedges from the Dietary staff. V4 said R17 was sitting in the dining room when R17 began to cough, then choked on a potato wedge. V4 said she was able to clear R17's airway by completing the Heimlich maneuver. V4 said V4 then went to the kitchen to speak with V3 (Dietary Manager). V4 said she told V3 that R17 should never be served anything like whole potato wedges, due to R17s frequent choking events. V4 said after the potato wedge was cleared from R17's airway, V4 removed the rest of the potato wedges from R17 plate and R17 received mashed potatoes as a replacement. V4 said EMS was not called due to V4 being able to clear R17's airway. On 11/16/23 at 2:50 pm, V3 (Dietary Manager) said the potato wedges served to R17 on 10/28/23 did have a skin on them. V3 said residents with mechanically soft diets should not have been served potato wedges, but instead mashed potatoes. V3 said she did recall speaking with V4 (LPN) about mechanically soft diets, but did not recall the specifics of the conversation due to the conversation happening over two weeks ago. On 11/21/23 at 9:30 am, V7 (Speech Therapist) stated the facility should not have provided the potato wedge to a mechanical soft diet on 10/28/23, unless it was cut up in small pieces and no skin. V7 went on to state she would expect the facility to follow the diet spreadsheet for a mechanical soft diet. If the spreadsheet indicated mashed potatoes, she would expect them to follow the recipe for mashed potatoes. The facility's Diet Spreadsheets Week 2 documented on 10/28/23 the noon time meal mechanical soft diets should have received mashed potatoes to replace the potato wedges. On 11/16/23 at 3:36 pm, V1 (Administrator) said she did not investigate R17's 9/6/23 choking incident because V1 was present, therefore, she had no documentation to provide in addition to what was in the nursing notes for that incident. V1 said she had not completed an investigation on the 10/28/23 incident when R17 choked on a potato wedge due to V1 not having knowledge of the incident until 11/17/23. On 11/21/23 at approximately 2:30 pm just prior to exit, V1 produced a 9/7/23 Quality Improvement Review document that was handwritten by V1 documenting R17's 9/6/23 choking event. The document described R17's 9/6/23 choking event to be different from V4 (LPN) and V5's (LPN) interviews, and documented, . Staff reported resident in DR (dining room) choking. Nurse on duty attending to another resident. (V1) immediately responded. Upon assessment noted resident staring but not talking or coughing. Unable to perform Heimlich (related to) resident size (and) inability to stand long enough. (R17) taken to the floor (and) chest thrusts preformed until food particles able to be observed. Able to extract some of the loose pasty food from airway . CNA present for meal stated pizza product served. Was soft, cut up (and) bread like, food extracted was wet (and) in small little bits . The facility's Therapeutic & Mechanically Altered Diets policy, revised 10/2020, documented, . A mechanically altered diet is a diet specifically prepared to alter the consistency of food in order to facilitate oral intake . 1. A physician's order is written for all diets including therapeutic and mechanically altered diets . 3. The Food Service Manager and/ or dietitian write an extension of the regular diets using the same food when possible. 4. The dietitian approves signs and dates all menus . 8. The facility prepares and serves all therapeutic and mechanically altered diets as planned . The facility's undated Mechanical Soft Diet policy documented vegetables to avoid .most raw or undercooked vegetables and those with tough skins . Fried Vegetables . and grains to avoid as .Breads, rolls, muffins with dry hard crusts . The Immediate Jeopardy that began on 9/6/23 was removed on 11/20/23/23, when the facility took the following actions to remove the immediacy as confirmed through observation, interview, and record review: Immediate actions: 1. For the Resident found to be affected by the alleged deficient practice, the following corrective action has been taken to achieve compliance: A. V3 (Dietary Manager) and V1 (Administrator) reconciled all diets to ensure residents diet orders were current and correct. B. Current Dietary Policy and Procedure for Mechanically Altered Diets was reviewed and found to be current and is being utilized for in-servicing of Dietary staff and additional staff that assist with delivery of meals. C. V1 (Administrator) was in-serviced by the regional team on dietary orders and mechanically altered diets. D. Current Dietary staff was in-serviced by V1 (Administrator) on all residents' dietary orders and mechanically altered diets. E. All other Dietary staff will be in-serviced by V1 (Administrator) on following resident's dietary orders and mechanically altered diets prior to starting their next scheduled shift. F. All staff currently working were in-serviced by V1 (Administrator) on mechanically altered diets and on reading the diet order cards for each resident prior to serving a meal, to ensure that proper diet is being served. G. All staff and Department Managers will be in-serviced by V1 (Administrator) on mechanically altered diets and reading the diet order cards for each resident prior to serving meal, to ensure that proper diet is being provided, prior to starting their next scheduled shift. H. Review of all residents with swallowing guidelines or other feeding recommendations was completed and noted on resident's diet card, if applicable. I. R17's MDS, section GG, was reviewed and updated. J. Removal Plan reviewed and approved by the V11 (Medical Director). 2. The following systematic measures have been implemented to ensure that proper diets are being followed: A. All newly hired Dietary staff will be in-serviced on following individualized plan, menus, and mechanically altered diets. B. V1 (Administrator) or Nurse Manager will monitor all meals for 7 days to ensure the proper diets are being served. Any concerns will be immediately corrected and addressed with employee through additional education. C. V3 (Dietary Manager) will monitor serve out of meals, at various times, 3 times weekly for 1 month to ensure Dietary servers are providing diets as ordered and then randomly, thereafter. 3. As part of the facilities ongoing quality assurance program: A. Any identified break in procedure noted by observations will be addressed immediately. B. Progress and identified problems noted during observations will be discussed during morning QA and action plan developed to prevent further occurrence. C. Compliance will be monitored through the internal QA process.