Based on observation, interview and record review, the facility failed to conduct COVID-19 testing on residents that displayed COVID-19 like symptoms for five residents (R2, R7, R15, R16 and R17) out of 16 residents reviewed for COVID-19 testing in a sample of 24. The facility also failed to perform COVID-19 testing on employees that displayed COVID-19 like symptoms prior to providing direct care and services to residents in the facility. This failure has the potential to cause COVID-19 infection to all 80 residents residing in the facility. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 3/6/23 when the facility failed to conduct COVID-19 testing on R16 after R16 started displaying COVID-19 like symptoms. V15, Regional [NAME] President of Operations (RVP) was notified of the Immediate Jeopardy on 3/23/23 at 3:20 PM. While the immediacy was removed on 3/23/23, the facility remains out of compliance at Severity Level two due to the facility's ongoing monitoring of their plan of correction, completion of in-service training, and Quality Assurance (QA) team meetings to identify residents at risk for communicable diseases during the QA process. The abatement plan was received from the facility on 3/23/23 at 4:28 PM. The abatement plan was returned to the facility on 3/24/23 at 9:03 AM to be updated with additional information needed. The facility returned the updated abatement plan on 3/24/23 at 9:27 AM. The abatement plan was accepted on 3/24/23 at 10:42 AM and the facility was notified of accepted abatement plan at 10:43 AM. Findings include: The facility's Infection Control - Interim COVID-19 policy revised 10/31/22 documents Screening of Visitors, Staff and Residents: Establish a process to make everyone entering the facility aware of recommended actions to prevent transmission to others if they have any of the following three criteria: 1) a positive viral test for SARS-CoV-2 2) symptoms of COVID-19, or 3) close contact with someone with SARS-CoV-2 infection (for patients and visitors) or higher risk exposure (for healthcare personnel (HCP)). Staff: Instruct HCP to report any of the three above criteria to occupational health or another point designated by the facility so these HCP can be properly managed. The facility's Interim COVID-19 Testing - Residents and Staff policy revised 10/21/22 documents Testing of Staff and Residents: Testing Trigger - Symptomatic individual identified. Staff, regardless of vaccination status, with signs or symptoms must be tested. Residents, regardless of vaccination status, with signs or symptoms must be tested. Testing of Symptomatic Individuals: Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible. Symptoms include: 1) Temperature greater than 100.0 Fahrenheit. 2) Significant decrease in oxygen saturation from baseline or oxygen saturation less than 92%, cough. 3) Cough, cold symptoms. 4) Sore throat. 5) New loss of smell/taste. 6) Headache. 7) Chills. 8) Muscle pain. 9) GI (Gastrointestinal) symptoms (nausea, vomiting, diarrhea). If using an antigen test, a negative result should be confirmed be either a negative NAAT (molecular PCR The polymerase chain reaction (PCR) test for COVID-19 is a molecular test that analyzes your upper respiratory specimen, looking for genetic material (ribonucleic acid or RNA) of SARS-CoV-2, the virus that causes COVID-19.) or a second negative antigen test taken 48 hours after the first negative test and maintain transmission-based precautions until results are confirmed. Staff with symptoms or signs of COVID-19 must be tested and are expected to be restricted from the facility pending results of COVID-19 testing. The facility's census report dated 3/21/23 documents 80 residents residing in the facility. 1. On 3/21/23 at 8:14 AM, during an observation of medication administration, R2 noted to have cough and mucus hanging down from his nose. V3, Registered Nurse (RN), stated, You don't look to good. You feeling ok? R2 replied, I don't feel well. I haven't felt well in days. V3 turned to surveyor and stated, He's been like this for a couple of weeks. I'm going to give him a breathing treatment. On 3/21/23 at 9:03 AM, V2, Director of Nursing/Infection Preventionist (DON/IP) was asked for all infection control tracking documentation to include employee and resident symptoms tracking and screening along with employee and resident COVID-19 testing for the last month. V2, DON/IP, stated, We haven't screened anyone in months. Our policy says we don't have to because our community transmission level is green. We just started wearing masks today. We haven't tested resident for COVID in months because we haven't had an outbreak or a positive employee. When asked about symptom tracking and COVID-19 testing for resident given R2's observed COVID-19 like symptoms, V2, DON/IP, stated, (R2) didn't have to be tested for COVID because our community transmission is green. (R2) has another respiratory issue. We didn't test him. R2's medical record dated 3/14/23 documents, Per report, resident had low-grade fever last night. Assessed resident this morning. Oxygen saturation is 91-92% on room air. Diminished breath sounds throughout lungs. Noted increased wet cough. Daughter at bedside. Primary care physician in facility and saw resident. Received order for stat chest X-ray and as needed Tylenol for fever. R2's medical record dated 3/14/23 documents, Physician progress note. Patient with fever yesterday, had mild cough. Poor appetite last couple of days, sore throat per family member. Plan: 1. Reviewed therapy notes and discussed any issues with the patient. Continue current therapy regimen. 2. Patient with fever and cough since yesterday. Chest X-ray is pending. Has poor appetite, recommend COVID-19 swab. R7's medical record dated 3/8/23 documents, Resident has a coarse, non-productive cough. Crackles auscultated to bilateral lower lobes. Oxygen saturation 93 % on room air. Medical doctor (MD) notified and order for Chest X-ray received. R7's medical record dated 3/8/23 documents, Chest X-ray results are within normal limits. MD notified. No new order. The facility's monthly infection control log dated March 2023 documents that on 3/6/23 R16 had an onset of fever, cough, and shortness of breath, on 3/7/23 R15 had an onset of a cough and on 3/12/23 R17 had an onset of increased coughing, lowered oxygen saturation and colored phlegm. On 3/21/23 at 3:20 PM, V2, Director of Nursing/Infection Preventionist, (DON/IP), stated You asked for the resident COVID symptom tracking and testing, that COVID resident line list I gave is it. (R19) was the last resident we had and (V5, Dietary Housekeeping Supervisor) was the last employee we had that tested positive. We tested (R2) today around 11:00 am. I did see in the progress notes that the doctor wanted a COVID test on him (R2) last week, but he never wrote an order for it so we missed it. I'll be honest with you, the only reason we tested him today was because you're here in the building. The facility's COVID-19 Resident line listing and symptom tracking log documents the last resident to have symptoms and tested for COVID-19 was R19 on 11/20/22. The facility's COVID-19 Resident line listing and COVID-19 symptom tracking log does not include R2, R7, R15, R16, and R17. R2, R7, R15, R16 and R17's medical record does not document a COVID-19 test was performed. R7's medical record documents R7 tested positive for COVID-19 on 3/22/23. On 3/22/23 at 11:42 AM, V15, Regional [NAME] President of Operations (RVP), stated, We don't need an order to test residents for COVID. If they have any of the symptoms identified by the CDC (Center for Disease Control) as COVID symptoms, then we should be testing. On 3/23/23 at 9:50 AM, V15, RVP, stated, I looked into those residents you asked me about. (R15, R16 and R17) were not tested for COVID prior to the outbreak. Yes, they should have been tested given their symptoms. (R2) should have been tested when staff identified his symptoms. Any resident that has COVID like symptoms should be tested immediately. 2. The facility's COVID-19 outbreak testing results dated 3/22/23, documents six of the nine residents, R9 through R14, that reside on C Hall tested positive for COVID-19. The facility's COVID-19 Staff line listing and symptom tracking log documents V5, Housekeeping/Dietary Supervisor (HDS), tested positive for community acquired COVID-19 on 3/16/23 with her last day of work on 3/13/23. On 3/21/23, at 1:45 PM V2, DON/IP, stated, The last positive COVID we had was (V5, HDS). She tested positive on 3/16/23, but the last day she worked was 3/13/23. Therefore, it was community acquired. She wasn't here in the building to expose the residents. V2, DON/IP, was asked if there were any employees over the last month that have come to work with COVID like symptoms or that had an illness and went home due to illness. V2, DON/IP, replied No, we haven't had any employees sick while here at work that went home or had to be sent home due to illness. On 3/21/23 at 2:55 PM, V5, HDS, confirmed a COVID-19 test was not conducted prior to her working on 3/16/23 and stated, I came into work last Thursday (3/16/23) and I was sick. I went straight to my office around 6:30 AM. I called the doctor to get some medicine for my symptoms, but they wouldn't call any in. So, I left work around 11:30 AM, went home and did an at home COVID test. It was positive. I called (V2, DON/IP) the same day to let her know I tested positive and that I was at work. On 3/22/23 at 8:24 AM, V9, CNA, stated, There's been a few CNAs that have worked while sick over the last few weeks. I don't know their names. On 3/22/23 at 8:25 AM, V10, CNA stated, There's been a couple of employees that worked while sick, but I can't tell you their names. On 3/22/23 at 8:28 AM, V11, CNA, stated, There were two employees who had to go home due to illness over the last couple of weeks. (V8, CNA) left her shift early sometime last week because she was sick and the other was (V7, CNA). She went home yesterday because she was sick. Those are the only two that I know of. On 3/22/23 at 8:31 AM, V2, DON/IP, stated, (V7, CNA) went home yesterday (3/21/2023) due to respiratory symptoms, but her rapid test was negative. She was supposed to do a COVID PCR test before she left, but I forgot to collect it. When the employee has symptoms and tests negative on a rapid test, we must do a PCR test and send it to the lab. (V8, CNA) went home sick (3/15/2023) on her own accord. She wasn't sent home. I didn't find out until after she went home that she left because she was sick. I found out around 3:00 PM that day. I tried calling her the next morning to have her test, but she didn't answer her phone so I left her a message. This morning she came to work and when we told her she had to test due to an outbreak, she refused and left so we never did get her tested. On 3/22/23 at 8:44 AM, V7, CNA, stated, I came to work sick yesterday. I didn't screen or test because I thought we didn't have to do that anymore. I got to work at 6:00 AM and around 11:00 AM (V2, DON/IP) tested me and sent me home. I showed up to work with a cough and congestion, but it got worse. V7's, Certified Nursing Assistant (CNA), timecard report documents V7 worked on 3/21/23 from 6:09 AM to 11:03 AM and worked on C Hall. V7's Point of Care COVID-19 testing sheet dated 3/21/23 and signed by V2, DON/IP, documents, Is this person exhibiting any symptoms consistent with COVID-19? Yes. On 3/22/23 at 9:51 AM, V8, CNA, stated, Last Wednesday (3/15/23) I got to work around 6:00 AM and wound up having to leave at about 10:00 AM because I was vomiting and had diarrhea. My symptoms actually started a few days prior to that. I was having a headache and body aches for a few days, but they stopped the day I went to work. The day I went to work, I only had the nausea and diarrhea, but I wound up vomiting, so I told the scheduler I was sick, and I went home. (V2, DON/IP) called me the next morning and told me that I needed to let her know if I left work. I never tested for COVID. I thought I would be ok. V8's, CNA, timecard report documents V8 worked on 3/15/23 from 6:00 AM to 10:13 AM and worked on C Hall. On 3/23/23 at 9:24 AM, V14, Housekeeping, observed in the hallway going into resident rooms and cleaning. During the interview with V14, her voice sounded hoarse. V14 stated Yeah, I've been sick over a week now. It started last week. I came to work (3/15/23) with a headache, sore throat, and stiff neck. After a couple of days of working, it started getting worse, so I went to the nurses' station and asked for a rapid test. It was negative, so I went back to work. I didn't tell anyone I was sick until I did the test. I'm housekeeping, so I go all over the facility. On 3/23/23 at 9:50 AM, V1, Administrator, and V15, RVP, were informed of V14, Housekeeping, and requested V14's COVID-19 testing record. V14's, Housekeeping, timecard report documents V14 worked 7.5 hours on 3/15/23, 3/16/23, 3/17/23, 3/20/23, 3/21/23 and 3/22/23. The time report also documents V14 punched in to work on 3/23/23 at 6:28 AM, with no time punch out. On 3/23/23 at 11:53 AM, V15, RVP, stated, I just wanted to let you know that (V14, Housekeeping) tested negative on the rapid test when we did the whole facility, but because she's symptomatic, she has to do a PCR test. We did collect the PCR and sent her home, immediately after you informed us, and told her that she can't return to work until we get the PCR test results back. The employees have been in-serviced about not coming to work with COVID symptoms. If they're having symptoms, they have to notify management and get a rapid COVID test. If the rapid test is negative, and they're symptomatic, then they have to do a PCR test and can't return to work until we get the results. If the PCR is negative, they can return to work. The surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 3/22/23 throughout the day from 8:24 AM to 3:30 PM, observations of employee and resident COVID-19 testing observed. 2. On 3/24/23 at 10:40 AM, review of the resident roster and resident COVID-19 testing dated 3/22/23 verified all residents to include R2, R7, R15, R16 and R17 were tested by V17, Nurse Manager on 3/22/23. 3. On 3/24/23 at 12:18 PM, The facility's employee COVID-19 in-servicing and staff COVID-19 testing sheets dated 3/22/23 and 3/23/23 were reviewed and reconciled against the facility staffing schedule dated 3/22/23 and 3/23/23 and verified the facility tested and educated all employees working on 3/22/23 and 3/23/23 on COVID-19 testing residents and staff and COVID-19 Infection Control Guidelines by V1, Administrator, and V15, RVP. Staff on vacation or FMLA (Family Medical Leave Act) will be in-serviced before returning to work by the Administrator. New hires will be in-serviced before beginning work by the Administrator. The facility's surveillance plan also reviewed and verified the Facility is tracking all resident and employee symptoms along with COVID-19 tracking. 4. All residents displaying any of the COVID-19 like symptoms as identified by the CDC will be tested immediately by Nurse Management or floor nurse. The Nurse Management or floor nurse will test all symptomatic employees prior to working. 5. The Administrator or designee will audit testing of symptomatic staff and residents for twelve weeks. The findings of the audit tools will be reviewed in the QA meeting. If the Administrator is not available, the Administrator will appoint the designee to review with QA Committee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to directly supervise a resident (R1) who required supervision and assistance while eating. This failure resulted in R1, who has a history of dysphagia, is on a mechanically altered diet, is impulsive with eating and needs verbal cuing to eat slowly and take small bites, being served a lunch meal tray within R1's reach without staff members directly present. R1 subsequently choked on food items from R1's lunch tray. R1 required the Heimlich Maneuver, Cardiopulmonary Resuscitation efforts and transfer to the local area hospital where R1 expired. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 11/16/22, the facility remains out of compliance at a severity level II while the facility continues to: monitor the effectiveness of education and training on supervising residents who require assistance with eating and on Emergency Procedures, develops a Quality Improvement and Performance Improvement (QAPI) plan after a QAPI meeting is held, and continue to provide ongoing education and training on Assisted Dining policy and procedures. Findings include: The facility's Dining Experience: Staff Roles policy, 2020, states, Staff members will strive to enhance the resident's quality of life while serving meals that meet nutritional needs, offers choice, is served with dignity and considers the person-centered care plan. Staff will offer personal attention to each resident and monitor the resident's satisfaction and food intake. Procedure: 4. Staff members serving in the dining room will offer personal attention to each resident, giving consideration to the resident's plan of care, their preferences, intolerances and allergies. The facility's Feeding and Assisting Residents to Eat policy, undated, documents nursing personnel assisting should be positioned/seated at eye level with the resident to provide a relaxed and comfortable environment and documents that chewing and swallowing should be encouraged. The facility's Dental Soft/Mechanical Soft Diet policy, dated 2017, states, The Dental Soft/Mechanical Soft Diet is for individuals with limited or difficulty in chewing regular consistency foods. If a mechanical soft diet is ordered, the Dental Soft/Mechanical Soft Diet would be appropriate if there is a chewing/dentition problem. This diet may also be used by a Speech Language Pathologist/SLP in the treatment of dysphagia with individualization per recommendations by the SLP. For individuals that have any swallowing problems or dysphagia, it is recommended that a SLP be consulted and one of the Dysphagia Level Diets may need to be implemented. R1's Facesheet documents R1 with diagnoses to include but not limited to: Dysphagia; Epilepsy; Unspecified Dementia; Schizophrenia; Bipolar Disorder; Unspecified Intellectual Disability and Postural Kyphosis. The Facesheet documents R1 with an original admission date of 4/18/2016. R1's Minimum Data Set Assessment, dated 10/4/22, documents the following: R1 can comprehend most conversation; requires extensive assistance of one person physical assist for eating; and R1 is on a mechanically altered diet. R1's current Care Plan documents R1 has an Activity of Daily Living/ADL self-care performance deficit and needs assistance to complete ADL care related to Postural Kyphosis, Lack of Coordination and Weakness. Interventions/Tasks are stated as Eating: Requires hands on assist, extensive assist of one. This same Care Plan documents R1 with short and long term memory impairments and impaired decision making. R1's Physician Order Sheet, dated 9/20/21 at 1:30 PM status post video swallow study, states, Recommend mechanical soft solids, thin liquids. No more than one ounce to be presented to the patient (R1) at a time, due to impulsivity. (R1) to be seated upright, 90 degrees during all meals. (R1) to take small bites of food, small sips of liquids and eat slowly. Recommend cough/throat clear periodically during meals as well. R1's Dietary Initial/Quarterly Evaluation, dated 9/2/22, documents R1 requires extensive assistance for eating. R1's Speech Therapy Plan of Care notes on 8/26/21 documents R1 required speech therapy services for evaluation and treatment of swallowing dysfunction and documents R1 required prompting for safe intake patterns. R1's Speech Therapy Discharge summary, dated [DATE], documents R1 at risk for aspiration of liquids and R1 was discharged from therapy services on a mechanical soft diet with nectar thick liquids and supervision during meals. This form states, Pt (patient/R1) training on safe swallowing strategies. Constant supervision with verbal prompting for consistent use. R1's Physician Progress Note on 11/8/22 at 10:29 AM documents R1 was evaluated by V3 (R1's Physician). This same note states, 15. History of dysphagia: status post video swallow. (R1) is followed by speech therapy. We will continue to monitor their recommendations and monitor the patient clinically on his current diet. R1's current Physician Order Sheet/POS documents the following orders: General diet, mechanical soft texture, nectar consistency; Give no more than one ounce of fluid at a time d/t (due to) impulsivity. Take small bites of food and small sips of liquids for oral dysphagia with a start date of 9/21/21; Have (R1) drink liquids after 2-3 (two to three) bites of food with a start date of 11/4/21; Please have resident stay upright for 2-3 hours after meals with a start date of 11/4/21. R1's Meal Card documents R1 was on a mechanical soft diet with nectar thick liquids. The facility's Diet Spreadsheet week two, day 13-Friday documents the dental/mechanical soft menu as Ground Beef Stew, Biscuit, Soft Cooked Vegetable, Apple Streusel Cake and Beverage. R1's Nursing Note on 11/11/22 at 12:10 PM, signed and dated by V2 (Director of Nursing/Registered Nurse/RN), states, This RN (V2) was notified by RN and CNA (Certified Nursing Assistant) that (R1) was choking. (V2) proceeded to do the Heimlich Maneuver on (R1) while in his chair. This RN (V2) could not get behind (R1) to do the proper maneuver. (V2) instructed for 911 to be called. (V2) proceeded to place (R1) on the floor on his left side. This RN (V2) did a mouth sweep and noticed some food that was obstructing (R1's) airway. This RN (V2) instructed for another RN to get the suction off the crash cart. Suction hooked up and was initiated by this RN. EMS (Emergency Medical Services) took over residents care. EMS started compressions and called (local area hospital) ED (Emergency Department) doctor due to resident was a DNR (Do Not Resuscitate) code. Doctor instructed for EMS to bring (R1) in and to continue to code (R1). (R1) left with EMS via ambulance (to local area hospital). R1's Code Blue Event note, signed and dated by V2 on 11/11/22, documents R1 was brought to V2 by another staff member after R1 was found to have choked on R1's lunch. This form documents Code Blue was called on 11/11/22 at 12:10 PM, 911 was called on 11/11/22 at 12:20 PM, and CPR was initiated on 11/11/22 at 12:28 PM. This same form documents suctioning, and the Heimlich Maneuver were performed on R1. Paramedics are documented to have arrived at 12:28 PM on 11/11/22 and R1 was transported to the nearest emergency room. R1's condition at the time of transfer is documented as unresponsive and cool. This same form states, Time of Death: 11/11/22 at 12:40 PM. R1's Emergency Medical Service/EMS Report documents on 11/11/22, EMS was dispatched to the facility for R1 who was choking and not breathing. This same report states, (R1) was found on the ground and not breathing but (R1) still had a pulse present. The known downtime was five minutes prior to our arrival. (R1) is visible cyanotic. There were CNAs and Nurses around the patient suctioning the patients airway trying to dislodge the food. Medic15 had continued to suction (R1's) airway and was able to get more food out of (R1's) airway. At this time, Medic24 had checked for a pulse and there was none present. This report documents that CPR and lifesaving measures were continued the entire time en route to the local area hospital. R1 remained in Asystole with no pulse regained. The emergency room doctor ceased all efforts at this time and presented (R1) as deceased . R1's Emergency Department note dated 11/11/22 at 12:34 PM, states, Chief Complaint: Respiratory Arrest. Stated Complaint: Unresponsive. Initial Comments: (R1) brought in from the nursing home as a full arrest. (R1) was reportedly eating, then choked on food. Paramedics called and by the time they arrived, (R1) had suffered a cardiac and respiratory arrest. On scene, paramedics removed the visible food from (R1's) oropharynx and ultimately intubated (R1), performed CPR and transported (R1) to the Emergency Department. This same note documents R1 with a medical history of Cognitive Impairment, Schizophrenia, Bipolar Disorder and that R1 is wheelchair bound. Physical Exam: (R1) is asystolic with no blood pressure and no spontaneous respirations. Intubated. Unresponsive to verbal or painful stimuli. Pupils fixed and dilated. Progress/Clinical Impression: (R1) asystole on the monitor. (R1) has a history of DNR (Do Not Resuscitate) order. Since there is no readily identifiable reversible cause of patient's arrest, resuscitation efforts were discontinued and (R1) was pronounced dead at 12:40 PM. The facility's Initial Report to the local state agency documents that on 11/11/22 at 12:10 PM, R1 choked in the dining room; 911 was called, Heimlich and suctioning were performed. EMS arrived and transported R1 to the local area hospital. V7s (Certified Nursing Assistant) written statement, dated 11/11/22, states, (V4/R2's Family Member) yelled, 'He's choking.' I got up and yelled for a nurse and started pushing (R1) towards the Nurse's Station. I was at the table next to (R1) but (my) back was towards (R1). I was feeding (R7 and R8). After (V4) yelled when I looked at (R1) he was turning blue. I saw V5 (Licensed Practical Nurse/LPN and she took (R1). I moved residents out of the way. I helped get (R1) on the ground and held his head while (V2) was trying to suction. V5's (Licensed Practical Nurse) written statement, dated 11/11/22, states, I pulled (V11/CNA) out of the dining room because (R4) was threatening to throw herself down. (V12/CNA) was in with (R4) and she asked me to go get one of the girls. (V11) came to help her. Then as I was walking towards the dining room with some pills, (V7) hollered that (R1) was turning blue. I grabbed (R1) and pulled him towards the nurse's station and yelled for (V2). (V2) then started giving (R1) the Heimlich. (V2) tried suctioning him and the paramedics came. V13's (CNA) written statement, dated 11/11/22, states, I was feeding (R6) and (R1) was at another table. I could see the back of (R1). (V4) yelled (R1) was choking. We stood up and (R1) was turning purple. (V7) grabbed (R1) and started moving him towards the nurse's desk. Then (V5) was coming, so she took him. I stayed in the dining room with the other residents. V6's (LPN) written statement, dated 11/11/22, states, I was standing at the nurse's station. I heard (V7/CNA) yell at (V5/LPN). I saw him turning blue. I called 911. I pulled up (R1's) chart for code status and printed out his paperwork. I tried to help (V2) with suctioning before the paramedics came. V11's (CNA) written statement, dated 11/11/22, states, I was sitting in between (R1) and (R3). (V5) came to get me because (V5) needed help with (R4). I got up to help (V12/CNA) with (R4). (R1) wasn't eating when I walked away. (R1) had just finished a bite of coleslaw. (R1) did have a biscuit on his plate but I hadn't given it to (R1). (V9/CNA), (V13/CNA), and (V7/CNA) were in the dining room. When I was walking back towards the dining room, I saw (V5/LPN) pushing (R1) towards the nurse's station. V14's (Dietary Manager) written statement, dated 11/11/22, documents R1 is a mechanical soft diet, and that stew, biscuit cabbage and dessert were served for lunch on 11/11/22. V9's (CNA) written statement, dated 11/11/22, states, I was in the dining room. I was sitting with (R5). I had my back towards (R1). (V4) yelled, 'I think he's choking.' (V7/CNA) got up and started pushing him towards the nurse's desk and (V5/LPN) took (R1). I stayed in the dining room with the other residents. V12's written statement, dated 11/11/22, states, I was on C Hall in R4's room. (R4) was threatening to throw herself on the floor and trying to climb out of her bed. I asked (V5) to help me because I couldn't leave (R4). (V11) came to help me. (V11 and V12) got (R4) in her chair. I think it was a little after noon. As we were coming out of (R4's) room, we saw everyone in the hallway with (R1). V4's (R2's Family Member) written statement, dated 11/11/22, states, I was sitting with (R2) and (R1) picked up a roll. The girl (V11) at the table had left. I saw (R1) was choking. A girl (V7) behind him got up. It seemed like forever. (V7) immediately wheeled him back by the nurse's station. (R1) was turning blue. On 11/11/22 at 7:08 PM, V2 (Director of Nursing) stated, On 11/11/22, in the main dining room, at lunch time, the CNA (V11) was called away from (R1) due to another resident (R4) threatening to put herself on the floor. (V11) left the table. (V4) was sitting with (R2) at the table. (R1) was at the table in (R1's) wheelchair and (V4) was next to (R1). (V4) told (V7) that (R1) was choking. (V7) took (R1) out of the dining room and wheeled (R1) to the nurse's station. I was at the nurse's station at that time. I tried to do the Heimlich Maneuver. I didn't have enough strength to do it right. We lowered R1 to the floor and I told (V6) to call 911. R1's body is curved (contracted) to the side and he has Kyphosis, so he can't lay flat very well. I was laying on the floor with him doing the Heimlich. I could see something in (R1's) mouth so I did a finger sweep. I got a fingertip worth of mushy biscuit. I got the (suction catheter) and started sucking. (R1's) lips were turning blue. (R1) was not able to talk but he had a pulse. EMS came and started CPR. EMS pulled two large forceps full of mushy biscuit out of (R1's) mouth. They continued CPR and left with (R1). The coroner called me and said that (R1) passed away at 12:40 PM. V2 stated that R1 sat at the assisted dining table and that R1 needed small bite cues V2 stated, (R1) likes to shove food in his mouth at times. (R1) needs reminded to take sips (of liquids) after bites and to slow down. V2 stated V11 should not have left R1 while R1 was eating. If (V11) was called away, she should have told someone to come over and sit with (R1) or push (R1's) plate away from him. There is enough room on that table to move the plate away and it is not near another resident or within (R1's) reach. V2 stated two residents sit with one CNA for assisted dining. At this time, V2 verified that no staff members were sitting at R1's table monitoring R1 with R1's tray of food. On 11/12/22 at 9:48 AM, V4 (R2's Family Member) stated that on 11/11/22, V4 was eating lunch with R2 at the same assisted dining table as R1. V4 stated there was not any staff members present at the table at all. V4 stated, I saw (R1) pick something up and put it in his mouth. (R1) started gagging. I yelled out 'He's choking.' (R1) was turning blue. I had to yell three times before any of the staff responded and then they immediately wheeled him to the nursing station and closed the doors. This should not have happened, no one was watching him (R1) eat. On 11/11/22 at 7:41 PM, V15 (LPN) stated that residents who require supervision/assistance with dining should never be left alone while eating. V15 stated, They don't even start delivering trays until staff is present with the residents. On 11/11/22 at 7:53 PM, V8 (CNA) stated that assisted dining table residents should never be left unattended while eating. On 11/11/22 at 7:55 PM, V10 (CNA) stated, (R1) sat at the assisted dining table because (R1) would eat too quickly and shove everything in too fast and shove too much food in. (R1) needs cues to slow down. (R1) should never be left alone with his meal tray. On 11/11/22 at 7:59 PM, V16 (Registered Nurse) stated that R1 sat at the assisted dining table and that R1 was a high risk for choking. V16 stated, Oh, of course not. (R1) should not be left alone with (R1's) meal tray. On 11/11/22 at 8:05 PM, V17 (CNA) stated that R1 sat at the assisted dining table and that R1 was able to feed himself at times. V17 stated R1 would eat too fast and that staff sat with R1 to remind R1 to slow down and take small bites. V17 stated, No one at that table (assisted dining table) should ever be left alone. They don't even deliver the trays until a staff member is present. On 11/11/22 at 8:21 PM, V11 stated, I was sitting at the lunch table with (R1). (V5) came and told me that (V12) needed help. I left (R1) to help her because the other resident (R4) was trying to get out of bed. (R1) had his tray in front of him when I left him. When we walked out of (R4's) room, I saw (R1) in the area by the nurse's station. I was probably gone five to ten minutes. We dressed (R4), got the (mechanical lift) sling underneath her and got her up with the (mechanical lift). V11 stated R1 sat at the assisted dining table because R1 would need physical assistance with certain food items. V11 stated R1 could hold toast but holding a spoon would be hard for R1. V11 stated R1 would need physical assistance with eating and R1 would also need cues to take drinks in between bites and that sometimes R1 would eat too fast. V11 stated, I checked (R1's) plate after everything happened, his coleslaw and biscuit were gone. At this time, V11 verified the following: V11 did not push R1's tray out of R1's reach before leaving R1's table, did not say anything to R1 before leaving the table; and did not ask anyone else to watch R1 while V11 was gone. V11 stated, I should not have left (R1) unattended. I left when the nurse (V5) came and got me. (V5) didn't stay with (R1) either, she was doing med pass. There were three staff members at the other feeding table, but they were feeding (residents) too. No one was directly laying eyes on (R1). On 11/11/22 at 8:41 PM, V1 (Administrator) stated, (On 11/11/22) I was in my office, I heard V6 (Licensed Practical Nurse) page maintenance (V18/Maintenance Director) to the nurses' desk immediately. I went back there to see what was going on. I saw (V2) trying to give (R1) the Heimlich in his chair. She was trying to get up underneath him. He was real floppy. He was awake but blue. (V2) said, 'Let's get him out of the chair.' (R1) had the (mechanical lift sling) under him so a bunch of staff lowered him to the floor. (V2) said to get suction. Once (R1) was on the ground, (V5) ran and got suction and we rolled (R1) on his side. The suction plug was too far away from where he was lying, so I ran to get an extension cord. When I came back, they already had the suction working and (V2) was suctioning (R1). (V2) said, 'Come on (R1), let's get it out.' It looked like they were suctioning wet cracker out of his mouth. They kept checking a pulse and said that he still had one. EMT (Emergency Medical Technician) got there and used a device to open his throat and look down. They pulled up what looked like chewed up cracker. Then they said he didn't have a pulse. EMT started compressions. (V6) said he was a DNR. The paramedics then called the ER (Emergency Room) doctor and the doctor said that if something was obstructing his airway, to bring him in so they took him to the ER. EMT was doing CPR the whole time. No one here did CPR. (V2) said he had a pulse and was suctioning him. V1 stated, We couldn't get a grip around him, He couldn't sit up on his own. V2 was trying. V1 stated that R1 should not have been left alone with R1's food tray at the assisted dining table. V1 stated, There were three other CNAs in the dining room helping feed but from where they were sitting, they didn't see (R1) was choking until (V4) yelled out and (V7) ran over. On 11/12/22 at 11:57 AM, V5 (LPN) stated, (On 11/11/22), I had to pull one of the CNAs from the dining room to help with a behavior down the hall. I go back out to the dining room and was notified by another CNA that (R1) was turning blue. (R1) was still in his wheelchair, we were able to get (R1) over to the side to get behind him enough to do the Heimlich Maneuver. We then used the (mechanical lift) sling that was under (R1) to lower him to the floor. V5 stated that R1 sat at the assisted dining table because R1 required assistance with eating. V5 stated that R1 should not have been left alone with his food tray. On 11/12/22 at 12:14 PM, V9 (CNA) stated, (On 11/11/22), I was sitting at the other feeder table. No one was observing (R1) directly. My back was towards (R1). (R1) sits at the assisted dining table because he is a choke risk. (V4) yelled, 'I think he is choking' and then they took (R1) through the doors. At this time, V9 verified no staff was present at R1's table when R1 was eating. On 11/12/22 at 12:28 PM, V13 stated, (On 11/11/22), I was feeding (R6). (R1's) back was to me at the other table. No staff was at the table with (R1) and (R1) had his food tray. (R1) sits at the assisted dining table because he has problems swallowing. His liquids are thickened, and he uses (adaptive cups). (V4) started yelling, 'I think he's choking.' There was a CNA (V7) behind him. (V7) took (R1) to (V5) and (V5) took him out of the main dining room. (R1's) face was purple. No staff was at (R1's) table. (V11) was supposed to be at that table. I didn't see when she left. There was an empty chair between (R1) and (R3). That's the chair for us to use to feed them. I know that (R1) eats fast and grabs large amounts of food with his hands and puts it in his mouth. On 11/12/22 at 12:36 PM, V12 stated, (On 11/11/22), I was in (R4's) room. I asked (V5) to get me help. (V11) came to help me. (R1) should not be left alone with food. (R1) is on nectar thickened liquids, he has a hard time swallowing. He was choking on the thin liquids. We have to sit with (R1) to watch him and make sure he's ok. Sometimes he can feed himself and sometimes he needs help. On 11/12/22 at 12:43 PM, V6 (LPN) stated, (On 11/11/22), I was standing behind (V2) at the nurse's station. (V5 and V7) brought (R1) to the nurse's desk. He was cyanotic. (V2) was attempting the Heimlich Maneuver. I'm nine months pregnant so I was no help with lifting. They lowered him to the floor and was suctioning food out of his mouth. The (catheter tube) clogged so I ran to get water to help clear the tubing. V6 continued to say that R1 sat at the assisted dining table because (R1) got impulsive with eating and would not take appropriate size bites. V6 stated, (R1) should not have been left alone with his food tray. No feeder should be left alone with a food tray. It's not a good idea, it's unsafe. On 11/14/22 at 10:09 AM, V7 (CNA) stated, (On 11/11/22), I was in the dining room feeding (R7 and R8). (V4) got my attention that (R1) was choking. I could see that (R1's) face had turned blue. I yelled for another CNA to get the nurse. (V5) then took (R1) from me and they were trying to suction the food out of his mouth, but they couldn't. We (V7 and R1) were sitting with our backs to each other in the main dining room at the time of the incident. (R1) was not in my direct line of vision. No one was at the table with (R1). Another CNA (V11) was originally sitting with R1. She did not say anything to me that she was getting up from the table with (R1). (R1) needs assistance with feeding and has thickened liquids. (R1) has difficulty handling silverware but can feed himself finger foods. (R1) should not have been left unsupervised with his tray. I did not attempt Heimlich Maneuver, I wanted to wait for the supervisors and get him out of the dining room. (V2 and V5) immediately took over. Once he was on the floor, I helped hold his head while they were suctioning him. I couldn't see anything in his mouth directly. I think this could have been prevented if staff was with (R1) while he was eating, or we could have at least got to him quicker. (R1) looked like he had been choking for a while before anyone noticed. Had I known the staff was leaving (R1), I would have sat with him. On 11/15/22 at 4:13 PM, V3 (R1's Physician) verified that R1 has chronic dysphagia and requires assistance with eating. R1's Death Certificate, signed and dated 11/14/22 by V19 (Medical Examiner/Coroner) documents R1's date of death as 11/11/22. The cause of death is documented as Choking and Food Aspiration. This same certificate states, Describe how injury occurred: (R1) was seated at the dining table when he put a whole biscuit into his mouth and then started choking on it. (R1) was transported to the hospital and soon pronounced dead. The manner of death is documented as Accidental. The Immediate Jeopardy began on 11/11/22 when R1 was left unsupervised with R1's lunch meal tray, eating food off the tray without staff supervising or assisting R1. R1 choked on food items on the tray and required Heimlich Maneuver and CPR efforts. R1 was transferred to the local area hospital where R1 expired. On 11/15/22 at 2:17 PM, V1 (Administrator) was notified of the Immediate Jeopardy. On 11/15/22 and 11/16/22, the surveyor confirmed through observation, interview and record review the facility took the following actions to remove the Immediate Jeopardy: 1. Staff will be in-serviced on dysphagia and residents that are at risk for choking. All staff members re-educated on facility policy and procedures for residents who require feeding assistance/supervision. Education will be ongoing. Staff on vacation or FMLA/Family Medical Leave Act will be in-serviced before returning to work by V2 (Director of Nursing) and V1 (Administrator). On 11/15/22, all interviewed staff state they were in-serviced on Emergency Procedures: CPR and Heimlich Maneuver and Assisted Dining Residents/Protocols. All interviewed staff state they could not start their shift without this re-education. Staff members were seen entering V1's office to receive this face-to-face re-education. In-servicing sign in sheets provided by V1 document the training was initiated on 11/12/22 to Nursing and CNAs and is ongoing. Heimlich in-servicing sign in sheets document training began on 11/15/22 and is ongoing. 2. New hires will be trained on choking risk, policy and procedure of dining room supervision. Training will be conducted by V1 (Administrator). 3. Dining room and residents have been re-arranged to ensure all residents who need assistance are always in direct view of staff. On 11/14/22, V1 and V2 confirmed that V1 and V2 rearranged the assisted dining tables so that all residents are facing out into the dining room. On 11/15/22, during the dinner meal service, all residents who sit at the assisted dining table were facing outward to the dining room. Staff members were seated between all residents who require assistance with eating. 4. All residents who require assistance will not have meal trays without direct staff supervision. On 11/15/22, dinner meal observations noted that assisted dining residents were not served their meal tray until a staff member was directly present. Interviewed staff state they were re-educated on this policy prior to their shift beginning. 5. QAPI (Quality Assurance and Performance Improvement) review with V3/Medical Director to review identified residents who require assistance and/or altered diets. Action plan will be reviewed monthly at QAPI meeting. On 11/16/22, V1 stated this meeting is scheduled to occur on 11/17/22. 6. All residents with a diagnosis of dysphagia and/or require assistance with meals will have care plan reviewed and updated appropriately, staff will be educated on specific needs. On 11/16/22, Assisted Dining Resident List provided by V29 (Regional [NAME] President of Operations). All reviewed charts documented care plan updated. 7. Resident charts reviewed to ensure appropriate diets, supervision during meals, tray card and diet orders- audit completed by V27 (RN Clinical Risk Management Consultant) and V28 (Regional Nurse Consultant). All charts were updated. 8. Policy and procedure for resident dining and seating to address when/if staff must leave a resident they are assisting. Policy will include that staff must either have staff replace them prior to leaving or remove all food and drink items from residents reach prior to leaving. On 11/16/22, Policy provided by V29 (Regional [NAME] President of Operations) documents updated dining policy and procedures as stated.