**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 42 residents with three residents reviewed for code status. Based on interviews and record review, the facility failed to ensure staff provided cardiopulmonary resuscitation (CPR) to Resident (R) 1, who desired resuscitative measures indicated by her full code status. At 05:20 PM on [DATE] Licensed Nurse (LN) G left R1's room to obtain a breathing treatment for R1. Before she could return to the room, Certified Medication Aide (CMA) R told LN G that R1's spouse reported R1 was unresponsive. LN G assessed R1 and noted a weak apical pulse. LN G asked R1's spouse if he wanted staff to start CPR and R1's non-DPOA spouse nodded and confirmed that was what R1 wanted. R1's spouse then recanted and told staff not to start compressions. At 05:29 PM R1 had no heartbeat but staff did not initiate resuscitative measures despite her full code status. This deficient practice placed R1 and all 22 residents with full code status in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), lymphedema (swelling caused by accumulation of lymph), heart failure congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), and hypertension (high blood pressure). The admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS documented R1 required maximum assistance for toileting, bathing, dressing, bed mobility, and transfer. The MDS documented R1 required continuous oxygen and a non-invasive mechanical ventilator (Trilogy machine - bilevel positive airway pressure BiPAP-medical device which helps with breathing). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated [DATE], documented R1 had orientation, memory, and recall deficits. The care plan would be initiated to improve R1's cognitive status, activity of daily living (ADLs) status, and mobility. The Functional Ability CAA, dated [DATE], documented R1 required assistance with ADLs, had impaired balance and transition during transfers, and functional impairment in activity. R1's care plan would be initiated to improve her current ADL status and functional abilities. R1's Care Plan, dated [DATE], documented R1 requested that CPR measures be performed and R1 was a full code. The care plan documented the facility staff would respect R1's wishes and rights to have CPR performed. The care plan directed staff to communicate R1's choice to all appropriate staff members, continue to administer ordered medications and treatments per physician's orders, follow the instructions as detailed in the Advanced Directives and/or Living Will, and initiate CPR when appropriate and continue until paramedics arrive to take over. R1's banner on her EMR page showed R1 was a full code. The Physician's Order, dated [DATE], documented R1 was a full code. The Full-Code Resuscitate Directive, dated [DATE], documented R1 understood that Code meant that if her heart stopped beating or if R1 stopped breathing, medical procedures to restart R1's breathing or heart functioning would be instituted. The request documented R1 understood this decision would not prevent her from obtaining other medical care by care providers or medical care directed by a physician prior to R1's death. The directive documented the code directive would remain in effect while R1 was admitted to a medical care facility or care home as well as during transport to or from a home or facility. The directive was signed by R1 with a witness declaration of the said signage and was signed by the attending physician. The Nursing Progress Note, dated [DATE] at 02:10 AM, documented the nurse entered R1's room to administer her nebulizer treatments and R1 appeared to be short of air and used accessory muscles to breathe. R1's oxygen saturation was 68% on the Trilogy with two liters (L) of oxygen. R1's oxygen was increased to 3L and R1's oxygen saturation increased to 72%. R1's lung sounds had rhonchi (low-pitched continuous lung sounds that are caused by fluid in the respiratory system), crackles (discontinuous and explosive sounds that can be heard in the lungs of someone with respiratory disease when they inhale), and wheezes (a high-pitched whistling or rattling sound that occurs when air moves through narrowed airways in the lungs). Staff notified R1's provider of R1's condition at 09:30 PM and orders were received to send R1 to the emergency room. Staff called Emergency Medical Staff (EMS) at 09:32 PM. At 09:40 PM, EMS arrived at the facility. R1's oxygen saturation had increased to 88-90% with the Trilogy using 3L of oxygen. EMS evaluated R1. R1 and her spouse decided not to go to the emergency room. At 09:52 PM, EMS left the facility. At 09:53 PM, staff notified R1's provider of R1's choice not to go to the emergency room. The provider directed the nurse to watch R1 and if R1 changed her mind and wanted to go to the emergency room then she had the order to send. The Nursing Progress Note, dated [DATE] at 08:51 AM, documented R1 struggled with air hunger at 07:00 AM. R1's oxygen saturation fluctuated from 67% to 90% on the Trilogy with respirations between 20 to 24 breaths per minute. The Trilogy foam filter was checked and cleaned. R1 received treatments by mask to help with breathing issues. R1's spouse went home to get new filters for the Trilogy. Staff administered lorazepam (medication to help relieve anxiety) to R1 at 07:45 AM. R1's oxygen saturations stabilized between 85-90% with respirations between 14 to 17 breaths per minute. R1 rested easier with the Trilogy machine on. The Nursing Progress Note, dated [DATE] at 07:40 PM, documented R1 had been resting throughout the day with the Trilogy mask except during her respiratory therapy treatments. R1's spouse was by R1's side most of the day. LN G asked R1's spouse if he was okay with R1 resting with her Trilogy here at the facility and informed the spouse this is what the hospital would do for R1 if she was there. R1's spouse was okay with how R1 was being cared for at the facility. At approximately 05:15 PM, LN G went in to check on R1 and see if R1's spouse wanted R1 to do her respiratory therapy treatment that was due and R1's spouse said Okay. R1's oxygen saturation was 85%. LN G left to get R1's respiratory treatments. At approximately 05:20 PM, LN G was headed back to R1's room when CMA R came around the corner and stated R1 was not responding. LN G went back to R1's room and sent CMA R to get a stethoscope so LN G could listen for a heartbeat. R1's heartbeat was very weak. LN G asked R1's spouse if he wanted staff to start chest compressions. R1's spouse said, That is what she wanted. R1's spouse then paused for a moment and stated, No, do not start compressions. LN G clarified with R1's spouse a couple of times. The note documented that compressions were not attempted. Staff notified Administrative Nurse D and R1's provider at approximately 05:29 PM that R1 was without a heartbeat. Staff then notified Administrative Staff A. Physician GG's Physician Progress Note, dated [DATE], documented the provider was notified of R1's death over the weekend. R1 had end-stage cardiac disease as well as end-stage hypoxic (insufficient oxygen) respiratory failure due to severe COPD. R1 had multiple hospitalizations in recent months for exacerbations of her respiratory failure, which indicated R1's prognosis was very poor. Despite aggressive interventions, R1 continued to decline. The provider documented that during R1's final day, R1 deteriorated quickly, and she did not wish to return to the hospital. R1 quickly declined and died. Given R1's end-stage disease and inevitable death that was rapidly approaching, there was no medical indication to perform advanced cardiac life support (ACLS-refers to a set of clinical guidelines established by the American Heart Association for the urgent and emergent treatment of cardiac arrest using advanced medical procedures, medications, and techniques) since there was no probability of changing the inevitability of R1's death on that day. Physician GG documented that performing chest compressions could have indeed caused R1 suffering. The note documented that R1's spouse appropriately requested no chest compressions despite R1's full code status and there was no rationale for performing CPR if R1 did not want to be hospitalized again. Consultant GG noted that per ACLS protocols, it was not appropriate to perform chest compressions when there was no probability of success. The note documented that attention to R1's peaceful passing was the medically appropriate approach. A review of LN G's CPR certification documented LN G had an active basic life support (BLS) CPR certification. On [DATE] at 10:45 AM, Certified Nurse Aide (CNA) M stated there was no physical sign in resident's rooms to distinguish which residents were full code and which residents were do not resuscitate (DNR). CNA M stated staff had to check the resident's EMR to find out the resident's code status. On [DATE] at 11:15 AM CMA R stated R1's spouse came out of R1's room and stopped her and told her R1 was not breathing. CMA R stated she knew R1 was a full code and that was why she got LN G. CMA R stated it happened during supper meal pass and she ran and got the crash cart and stopped the Certified Nurse Aides (CNAs) from delivering meals and told them all hands-on deck in R1's room. CMA R stated she felt really bad for not providing CPR to R1 because it was R1's wish to be a full code. CMA R said she followed the chain of command. On [DATE] at 11:30 AM, LN G stated she asked R1's husband what he wanted LN G to do, start compressions or not. At first, R1's husband said to start compressions and then he told her to not start compressions. LN G stated she verified with R1's husband several times he did not want staff to start compressions, so staff did not start compressions. On [DATE] at 11:00 AM, Administrative Nurse D stated that she expected the staff at the facility to follow the resident's code status if a resident was found unresponsive. Administrative Nurse D stated CPR was not initiated on R1 because her husband said not to start compressions and LN G tried to keep her comfortable during the dying process. Administrative Nurse D stated R1 did not want to go to the hospital the previous night when she was having breathing difficulty. Administrative Nurse D stated there were twenty-two residents out of forty-two residents that were full code. Administrative Nurse D stated the facility had nineteen staff at the facility who were CPR-certified, and the scheduler always made sure CPR-certified staff were on shift. The facility's Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS) Policy, revised 11/2023, documented that the community staff, certified in CPR, will provide basic life support, including CPR, to a resident requiring such an emergency prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advanced directives. Staff certified in CPR will be available 24 hours a day. This is posted in the community. Verify the presence of advanced directives regarding CPR upon admission per policy. If the CPR order is missing or the resident's wishes are different from the admission order, notify the physician immediately to update such order and document it in the medical record. If CPR is to be withheld, or awaiting the physician's order, document discussions with the resident or their representative, including as needed the wish to withhold CPR. Verbal declination of CPR by the resident or representative should be witnessed by two staff members or per state directives. While waiting on a change in a physician's order, the current order will be honored. If an individual is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or There are obvious signs of irreversible death (e.g., rigor mortis, lividity) then initiate CPR. On [DATE] at 12:58 PM, Administrative Staff A received a copy of the Immediate Jeopardy Template and was informed the facility failure to ensure staff provided CPR to R1, who desired resuscitative measures indicated by her full code status, placed R1 and all 22 residents with full code status in immediate jeopardy. The facility submitted an acceptable plan to remove the immediacy on [DATE] at 03:26 PM which included the following corrective actions: Current nursing staff were re-educated on initiating the current code status. When a resident is declining, review the code status with the resident and/or DPOA and if changes are desired, notify the provider. Educated current nurses to initiate advance directives as ordered until new orders are obtained from the provider. Current residents were audited and updated as needed for desired code status. Current residents' code statuses were audited for validation of code status. On [DATE], an onsite survey verified the facility completed the above corrective actions to remove immediacy. The deficient practice remained at a scope and severity of G.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 39 residents with five selected for review. Based on interview and record review, the facility failed to ensure competent nursing staff implemented interventions for choking Resident (R)1. On 07/02/23, R1 sat at the table during supper and exhibited signs of choking. The staff alerted the Licensed Nurse that R1 was not breathing right. When the Licensed Nurse responded, R1 was grayish in color with blue lips, her oxygen saturation level was 36%, and she was breathing rapidly. The Licensed Nurse increased R1's oxygen from three to five liters and called 911. The Licensed Nurse failed to implement any interventions to address R1's choking. While in the EMS (Emergency Medical Service) transport vehicle, EMS staff discovered the presence of food in R1's airway and removed multiple pieces. R1 went into respiratory arrest and during compressions, a small amount of meat passed from the side of her vocal cords, and more meat came forth from her esophagus. R1 admitted to the hospital on [DATE], required intubation, and expired on 07/12/23 following removal of ventilation, per family request. The lack of competent nursing staff to implement interventions to address the signs of R1's choking, placed R1 in immediate jeopardy. Findings included: - The hospital Nursing Home admission Orders dated 06/05/23 for R1 included diagnoses of pneumonia (inflammation of the lungs) and respiratory failure and noted R1 admitted to the hospital on [DATE]. The Medical Diagnosis tab located in the Electronic Medical Record (EMR) for R1 included diagnoses of pneumonia, acute respiratory failure with hypoxia (inadequate supply of oxygen), Chronic Obstructive Pulmonary Disease (COPD, progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), chronic respiratory failure, anxiety (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) disorder, dysphagia (swallowing difficulty) following cerebral infarction (stroke, damage to tissues in the brain due to a loss of oxygen to the area), hemiplegia (paralysis of one side of the body) affecting left nondominant side, and schizoaffective disorder (mental disorder in which a person experiences a combination of symptoms of schizophrenia [psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought] and mood disorder [any of several psychological disorders characterized by abnormalities of emotional state]). The Quarterly Minimum Data Set (MDS) dated [DATE] assessed R1 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. R1 had physical behaviors one to three days of the assessment period and verbal and other behavioral symptoms four to six days of the assessment period. R1 did not reject care. She required supervision and setup assistance for eating, had range of motion impairment to one side of the upper extremities, received a mechanically altered diet, and did not display signs and symptoms of a swallowing disorder. R1 required oxygen and did not require respiratory services, speech therapy, or restorative nursing for eating and/or swallowing. The Annual MDS dated 06/21/23 assessed R1 with a BIMS score of 12, indicating moderately impaired cognition. R1 did not have any physical behavior symptoms or rejection of care and continued to have verbal and other behavior symptoms four to six days of the assessment period. She continued to have limited range of motion to one side of her upper extremities and required limited assistance of one staff for eating. She had signs of swallowing disorder of coughing and choking during meals or when swallowing medications and continued to have a mechanically altered diet. She continued to require oxygen and did not require respiratory services, speech therapy, or restorative nursing for eating and/or swallowing. The Nutritional Status Care Area Assessment (CAA) dated 07/05/23 revealed R1 required a mechanical soft diet and was at risk for aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident). The Dental Care CAA dated 07/05/23 revealed R1 had broken teeth and the care plan would be reviewed to maintain her chewing and swallowing ability. The Care Plan dated 06/14/23 revealed R1 had multiple broken and missing teeth, preferred to eat in the dining room for meals, required oxygen, had a contracture to her left hand, and could feed herself. Her behaviors of banging items resolved on 06/14/23. The Care Plan for R1 lacked interventions regarding signs of a swallowing disorder, dysphagia, risk for aspiration, or a mechanically altered diet. The Order tab for R1 revealed an order dated for 03/01/23 for regular diet, mechanical soft, chopped meat texture (discontinued on 06/08/23) and a new order entered, dated 06/08/23, for a regular diet, mechanical soft, ground meat texture. The facility failed to ensure the meal Tray Ticket changed on 06/08/23 to reflect the order to downgrade the consistency of the meat served to R1, from chopped to ground. The Tray Ticket for R1's evening/supper meal dated 07/02/23 (24 days after the order to change to ground meat) revealed a diet order of regular, mechanical soft, with chopped meat. The facility's investigation dated 07/24/23 revealed R1's diet was not properly sent over via the electronic medical record system to the tray card and R1's diet continued to show chopped meat diet and she was served chopped meat up until 07/02/23. The Nursing Note dated 07/02/23 at 08:40 PM by Administrative Nurse D revealed she was called to the dining hall because R1 was having difficulty breathing. Administrative Nurse D noted when arrived, R1 had a grey color to her face, and she was cold and clammy. Administrative Nurse D checked R1's oxygen tank and noted it was on 3 liters, and found R1's oxygen saturation level measured at 36%, her pulse was 136 beats per minute, respirations at 21 breaths per minute, and blood pressure was 142/88 millimeters of mercury (mmHg). The staff connected R1's oxygen to a concentrator and her oxygen level did not come up. Around 05:25 PM, staff called 911 and EMS arrived at 05:40 PM. When EMS checked R1's oxygen level, it was 55%. The EMS staff, Certified Nurse Aides (CNAs), and Administrative Nurse D moved R1 from the wheelchair to the stretcher. The note lacked any other assessment or interventions performed by the Administrative Nurse or other staff in the facility. The EMS Patient Care Report for service date of 07/02/23 for R1 revealed EMS received a call from the facility at 05:35 PM regarding a female with a breathing problem, not responding, and with oxygen saturations in the 40%'s. EMS arrived to the patient at 05:42 PM, and found R1 seated in a wheelchair in the dining hall, held in the seated position by staff members. R1 had a slightly painful response, and her breathing was very shallow and labored at approximately eight breathes per minute. R1 was ashen grey, pale in color, and cold to the touch. The staff advised EMS that R1 was seated at the dinner table and began banging on the table with a knife and residents began yelling for help. R1 was in respiratory distress and not responding and they placed her on her oxygen concentrator and noted no improvement, a rapid decline, and called 911. EMS asked the facility staff if R1 could have choked and if they took measures to possibly correct this and the facility staff denied this stating, they did not believe she choked and believed it was her COPD. EMS lifted and placed R1 on the EMS cot and ventilated R1 using a bag valve mask (BVM, handheld tool consisting of a self-inflating bag, one-way valve, mask, and an oxygen reservoir, used to deliver positive pressure ventilation to any subject with insufficient or ineffective breaths) at 15L of oxygen. R1 had improvement in color and her oxygen saturations increased to the high 80's to 90%. The EMS staff opened R1's airway and noted no visible object or foreign body at this time. EMS secured R1 to the cot and into the EMS unit. Once in the unit R1 began to have a clenched jaw and would move one arm upward but had no other response. EMS obtained R1's intravenous (IV, into the vein) access and administered Succinylcholine (medication used to provide a quick onset of skeletal muscle relaxation) for optimal intubation (placement of a breathing tube through the mouth and down the throat into the lungs). When EMS staff placed the King Vision laryngoscope (brand name of device used to look into the throat and larynx, designed to enable quick and easy intubation with a display to provide a view of a patient's airway) they found an obstruction blocking the view of the epiglottis (thin flap of cartilage in the throat which prevents food and drink from entering the trachea [wind pipe] and lungs). The EMS staff could not remove the obstruction with forceps due to lack of room with the King Vision in place, the King Vision removed and BVM ventilation resumed. Direct laryngoscopy then used to visualize the presence of food in R1's airway, and multiple pieces of food were removed from her airway. Due to a large amount of obstruction, EMS cleared some of the food and then ventilated R1. R1 had a decline in pulse, went into respiratory arrest, and then asystole (a heart rhythm indicating lack of a heartbeat) and EMS performed compressions. During compressions, a small piece of meat passed from the other side of R1's vocal cords and EMS removed, and noted more meat came forth from the esophagus which was removed and EMS performed orotracheal suctioning which allowed the vocal cords to be visible. EMS then intubated R1 and noted when they suctioned through the tube, they noted blood and food particles. The EMS departed with R1 at 06:17 PM. The hospital Discharge Summary dated 07/15/23 revealed R1 choked while eating dinner at the facility and was mechanically ventilated during the stay. She had a poor prognosis and anoxic (lack of oxygen) brain injury. On 07/12/23 R1 passed away following removal of mechanical ventilation per family request. On 07/24/23 at 01:04 PM Certified Nurse Aide (CNA) O stated R1 could feed herself and sometimes she would have off days where one of the staff would sit with her and feed her. CNA O stated R1 would cough when in the dining room and if she wanted to eat in her room, then a staff member would have to sit with her. On 07/24/23 at 01:57 PM Dietary Staff BB stated she prepared R1's meal on 07/02/23, which was a hot roast beef and cheddar sandwich. Dietary Staff BB stated she had cut her meat up for the sandwich, which she had dripping with the cheese, placed it on the sandwich, and cut the bun in half for R1 so she could eat it better. R1 ate the first sandwich, then wanted another, so Dietary Staff BB fixed her an additional sandwich just like the first one. Dietary Staff BB stated chopped meat would be cut up into bite size pieces using a knife and fork and ground meat would go through a blender. Dietary Staff BB stated she served her the diet that her tray ticket had on it. On 07/24/23 at 03:22 PM Administrative Nurse D stated R1 came in for dinner and sat in the middle of the dining room. Certified Medication Aide (CMA) R came to her and said R1 was having difficulty breathing, so she went to the dining room and saw R1 seated upright and breathing rapidly. Administrative Nurse D stated there were issues in the past where R1 took her oxygen off, however it was in place and when she checked her oxygen saturation level it was 36%. R1 had a grayish color to her face, her lips were a little blue, and her pulse was 136 beats per minute. Administrative Nurse D checked R1's oxygen tank and noted it was close to red (indicating approaching empty), and she turned it up from three to five liters and hollered for an aide to go get an oxygen concentrator. The aide was not moving fast enough so Administrative Nurse D told another aide to run and get one. Administrative Nurse D stated she was stroking R1's face and telling her to calm down, as R1 gets very high anxiety. R1's oxygen saturation increased to 46% and her pulse decreased to 99 beats per minute, and when asking her questions, she would respond with her eyes or move her head but would not talk. Administrative Nurse D stated she called 911 and told them she was a full code (indicating if her heart stopped beating, she wanted cardiopulmonary resuscitation [CPR] to be performed) and they needed to get to the facility now. Administrative Nurse D stated it took EMS about 12 minutes to arrive, R1 was still breathing and was basically calming down at that point. When EMS arrived and they put their pulse oximeter on her, her oxygen saturation level was 55%. Administrative Nurse D stated herself, two EMS personnel, and a facility aide moved R1 to the stretcher. Administrative Nurse D stated R1 was flat on the stretcher and EMS placed the BVM on her and then took R1 out of the facility. Administrative Nurse D stated R1's family came in the next day and was told by hospital staff R1 was choking and wanted to know why she was told R1 was having respiratory issues. Administrative Nurse D stated she went over the events and at no time was R1 choking, she never put her hands up to her neck, and kept them at her side the whole time. Administrative Nurse D stated it was common for R1 to complain she could not breathe and did not say that or any other words when with her in the dining room, she would just shake her head to respond and make contact with her eyes. Administrative Nurse D stated she felt R1's anxiety was so high the time that is why she did not talk. On 07/24/23 at 04:15 PM CNA M stated on 07/02/23 she sat at the table with R1 and she had asked for more chocolate milk, so she got up from the table to get some, and as she was turning around back toward her, R1 began banging her knife on the table. CNA M stated she sat down the milk, patted her on the back, and her color was normal at that time, however she looked like she was choking, looked like she could not hardly breathe, and was gasping for air. CNA M stated CMA R went to go alert the nurse, Administrative Nurse D. Until Administrative Nurse D arrived, R1 was gasping. When Administrative Nurse D arrived, she asked R1 questions and R1 would shake her head, and when asked if she could breathe, she shook her head to indicate no. CNA M stated she did not mention to Administrative Nurse D that she thought R1 was choking, as she was freaking out at the moment and R1's face had turned a little blue in color. On 07/25/23 at 02:55 PM CNA N stated on 07/02/23 CMA R went to go talk to R1 to calm her down as she was banging on the table with her knife, she did not see R1 do that, but turned around when she heard it. Her color was normal, and someone went to go get the nurse, then her color started fading to blue, but then would turn back to normal when Administrative Nurse D started talking to her. CNA N stated Administrative Nurse D checked her oxygen saturation level and thought it was in the 30's or 40's percent. CNA N stated Administrative Nurse D got R1 to calm down by the time EMS showed up. CNA N stated R1 kept breathing really heavy and kept eye contact with Administrative Nurse D and when Administrative Nurse D asked R1 if she was choking R1 did not answer. On 07/25/23 at 03:09 PM CMA R stated on 07/02/23 when R1 came back inside to the dining room following her smoke break she connected her back up to her oxygen, meanwhile R1 was saying she could not breath, which was normal for her, and she had checked to make sure the oxygen was on and it was. CMA R stated she turned to pass a tray and made eye contact with R1 and noticed she was trying to breathe, like she was trying to get air, making shallow short breaths, sounded like someone choking and she was reddish/grayish/purple in color like someone holding their breathe. CMA R stated she told R1 to spit out her food and she spit out roast beef. CMA R stated she was on her knees looking at R1 and she was still gasping after spitting the food out. Administrative Nurse D would ask her a question and R1 would nod her head in response but did not recall what questions she asked R1. On 07/25/23 at 03:55 PM Administrative Nurse D stated the staff told her R1 was having respiratory issues and breathing funny and did not tell her they had her spit food out of what was in her mouth. Administrative Nurse D stated she told R1 to calm down and she shook her head yes and asked if she was okay and she shook her head yes, however did not ask R1 if she was choking. On 07/25/23 at 04:00 PM CMA S stated she was in the kitchen getting herself food and heard banging on the table and seen silverware in R1's hands and CNA M and CMA R was beside her asking if she was okay. CMA S stated Administrative Nurse D arrived at her table and R1 was breathing heavy and not acting normal. CMA S stated Administrative Nurse D asked her to run and get a concentrator and when she got back EMS was called. CMA S stated Administrative Nurse D asked R1 if she was choking and R1 sat there heavily breathing and did not answer or nod her head, and she did not talk at all that she saw. On 07/25/23 at 04:18 PM Administrative Nurse D stated at no time did she think on 07/02/23 that R1 was choking, and that R1 was mouth breathing and she did not see any food in her mouth. On 07/25/23 at 04:44 PM Consultant Nurse GG stated Administrative Nurse D responded appropriately to R1 at the dining room table, however she should have visually assessed her mouth and would not have suctioned her if she did not think R1 was choking. The facility staff should have told Administrative Nurse D they thought she was choking and had her spit food out of her mouth. Consultant Nurse GG stated she believed Administrative Nurse D assessed her appropriately with the expectation R1 was hypoxic and with her low oxygen level would not have expected R1 to have normal color. Consultant Nurse GG stated she believed Administrative Nurse D would have performed the Heimlich if she truly thought R1 was choking. The facility lacked a policy regarding staff measures to be taken for possible choking. The facility failed to ensure competent nursing staff to implement interventions for choking experienced for R1 on 07/02/23, which placed R1 in immediate jeopardy. On 07/26/23 at 04:35 PM Administrative Staff A was informed the residents were in immediate jeopardy and was provided the Immediate Jeopardy Template for failure to provide interventions for choking experienced by R1. On 07/05/23 at 10:00 PM the facility completed corrective action of re-education to Licensed Nurse's on airway protection, hypoxemia, signs and symptoms of choking, and how to intervene. The deficient practice was deemed past non-compliance due to the implemented corrective actions prior to the surveyor entrance and the deficient practice existed at a J scope and severity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 39 residents with five residents selected for review for dietary services. Based on interview and record review, the facility failed to provide Resident (R)1, who had a history of aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident) and dysphagia (difficulty swallowing), her physician ordered mechanical soft diet with ground meat on 07/02/23. On 07/02/23 R1 displayed symptoms of choking and required Emergency Medical Services (EMS) transport for treatment. EMS discovered the presence of food in R1's airway and R1 went into respiratory distress while in the transport vehicle, and a small amount of meat passed from the side of her vocal cords and more meat came forth from her esophagus during compressions. EMS transported R1 to the hospital where she admitted on [DATE] and expired on 07/12/23 following removal of ventilation per family request. Failure of the facility to provide the physician ordered ground meat diet resulted in R1 choking and later died and placed in the resident in immediate jeopardy. Additionally, the facility placed R2 and R3 at risk, after recently returning from hospitalization and the facility failed to change/clarify the new diet order with the physician. Findings included: - The hospital Nursing Home admission Orders dated 06/05/23 for R1 included diagnoses of pneumonia (inflammation of the lungs) and respiratory failure, she had admitted to the hospital on [DATE], and ordered a regular diet. The Medical Diagnosis tab located in the electronic medical record (EMR) for R1 included but was not limited to diagnoses of pneumonia, acute respiratory failure with hypoxia (inadequate supply of oxygen), Chronic Obstructive Pulmonary Disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), chronic respiratory failure, anxiety (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) disorder, dysphagia (swallowing difficulty) following cerebral infarction (stroke - damage to tissues in the brain due to a loss of oxygen to the area), hemiplegia (paralysis of one side of the body) affecting left nondominant side, and schizoaffective disorder (mental disorder in which a person experiences a combination of symptoms of schizophrenia [psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought] and mood disorder [any of several psychological disorders characterized by abnormalities of emotional state]). The Quarterly Minimum Data Set (MDS) dated [DATE] assessed R1 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. R1 had physical behaviors one to three days of the assessment period and verbal and other behavioral symptoms four to six days of the assessment period. R1 did not reject care. She required supervision and setup assistance for eating, had range of motion impairment to one side of the upper extremities, received a mechanically altered diet, and did not display signs and symptoms of a swallowing disorder. R1 required oxygen and did not require respiratory services, speech therapy, or restorative nursing for eating and/or swallowing. The Annual MDS dated 06/21/23 assessed R1 with a BIMS score of 12 indicating moderately impaired cognition. R1 did not have any physical behavior symptoms or rejection of care and continued to have verbal and other behavior symptoms four to six days of the assessment period. She continued to have limited range of motion to one side of her upper extremities and required limited assistance of one staff for eating. She had signs of swallowing disorder of coughing and choking during meals or when swallowing medications and continued to have a mechanically altered diet. She continued to require oxygen and did not require respiratory services, speech therapy, or restorative nursing for eating and/or swallowing. The Nutritional Status Care Area Assessment (CAA) dated 07/05/23 revealed R1 required a mechanical soft diet and was at risk for aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident). The Dental Care CAA dated 07/05/23 revealed R1 had broken teeth and the care plan would be reviewed to maintain her chewing and swallowing ability. The Care Plan dated 06/14/23 revealed R1 had multiple broken and missing teeth, preferred to eat in the dining room for meals, required oxygen, had a contracture to her left hand, and could feed herself. Her behaviors of banging items resolved on 06/14/23. The Care Plan for R1 lacked interventions regarding signs of a swallowing disorder, dysphagia, risk for aspiration, or a mechanically altered diet. The Order tab for R1 revealed an order dated for 03/01/23 for regular diet, mechanical soft, chopped meat texture (discontinued on 06/08/23) and a new order entered, dated 06/08/23, for a regular diet, mechanical soft, ground meat texture. The facility failed to ensure the meal Tray Ticket changed on 06/08/23 to reflect the order to downgrade the consistency of the meat served to R1, from chopped to ground. The Tray Ticket for R1's evening/supper meal dated 07/02/23 (24 days after the order to change to ground meat) revealed a diet order of regular, mechanical soft, with chopped meat. The Nursing Note dated 07/02/23 at 08:40 PM by Administrative Nurse D revealed she was called to the dining hall because R1 was having difficulty breathing. Administrative Nurse D noted when arrived, R1 had a grey color to her face, and she was cold and clammy. Administrative Nurse D checked R1's oxygen tank and noted it was on 3 liters, and found R1's oxygen saturation level measured at36%, her pulse was 136 beats per minute, respirations at 21 breaths per minute, and blood pressure was 142/88 millimeters of mercury (mmHg). The staff connected R1's oxygen to a concentrator and her oxygen level did not come up. Around 05:25 PM, staff called 911 and EMS arrived at 05:40 PM. When EMS checked R1's oxygen level, it was 55%. The EMS staff, Certified Nurse Aides (CNAs), and Administrative Nurse D moved R1 from the wheelchair to the stretcher. The note lacked any other assessment or interventions performed by the Administrative Nurse or other staff in the facility. The EMS Patient Care Report for service date of 07/02/23 for R1 revealed EMS received a call from the facility at 05:35 PM regarding a female with a breathing problem, not responding, and with oxygen saturations in the 40%'s. EMS arrived to the patient at 05:42 PM, and found R1 seated in a wheelchair in the dining hall, held in the seated position by staff members. R1 had a slightly painful response, and her breathing was very shallow and labored at approximately eight breathes per minute. R1 was ashen grey, pale in color, and cold to the touch. The staff advised EMS that R1 was seated at the dinner table and began banging on the table with a knife and residents began yelling for help. R1 was in respiratory distress and not responding and they placed her on her oxygen concentrator and noted no improvement, a rapid decline, and called 911. EMS asked the facility staff if R1 could have choked and if they took measures to possibly correct this and the facilty staff denied this stating, they did not believe she choked and believed it was her COPD. EMS lifted and placed R1 on the EMS cot and ventilated R1 using a bag valve mask (BVM, handheld tool consisting of a self-inflating bag, one-way valve, mask and an oxygen reservoir, used to deliver positive pressure ventilation to any subject with insufficient or ineffective breaths) at 15L of oxygen. R1 had improvement in color and her oxygen saturations increased to the high 80's to 90%. The EMS staff opened R1's airway and noted no visible object or foreign body at this time. EMS secured R1 to the cot and into the EMS unit. Once in the unit R1 began to have a clenched jaw and would move one arm upward but had no other response. EMS obtained R1's intravenous (IV, into the vein) access and administered Succinylcholine (medication used to provide a quick onset of skeletal muscle relaxation) for optimal intubation (placement of a breathing tube through the mouth and down the throat into the lungs). When EMS staff placed the King Vision laryngoscope (brand name of device used to look into the throat and larynx, designed to enable quick and easy intubation with a display to provide a view of a patient's airway) they found an obstruction blocking the view of the epiglottis (thin flap of cartilage in the throat which prevents food and drink from entering the trachea [wind pipe] and lungs). The EMS staff could not remove the obstruction with forceps due to lack of room with the King Vision in place, the King Vision removed and BVM ventilation resumed. Direct laryngoscopy then used to visualize the presence of food in R1's airway, and multiple pieces of food were removed from her airway. Due to a large amount of obstruction, EMS cleared some of the food and then ventilated R1. R1 had a decline in pulse, went into respiratory arrest, and then asystole (a heart rhythm indicating lack of a heartbeat) and EMS performed compressions. During compressions, a small piece of meat passed from the other side of R1's vocal cords and EMS removed, and noted more meat came forth from the esophagus which was removed and EMS performed orotracheal suctioning which allowed the vocal cords to be visible. EMS then intubated R1 and noted when they suctioned through the tube, they noted blood and food particles. The EMS departed with R1 at 06:17 PM. The hospital Discharge Summary dated 07/15/23 revealed R1 choked while eating dinner at the facility and was mechanically ventilated during the course of the stay. She had a poor prognosis and anoxic (lack of oxygen) brain injury. On 07/12/23 R1 passed away following removal of mechanical ventilation per family request. The facility's investigation dated 07/24/23 revealed R1's diet was not properly sent over via the electronic medical record system to the tray card and R1's diet continued to show chopped meat diet and she was served chopped meat up until 07/02/23. On 07/24/23 at 01:57 PM Dietary Staff BB stated she prepared R1's meal on 07/02/23 which was a hot roast beef and cheddar sandwich. Dietary Staff BB stated she had cut her meat up for the sandwich, which she had dripping with the cheese, placed it on the sandwich, and cut the bun in half for R1 so she could eat it better. R1 ate the first sandwich, then wanted another, so Dietary Staff BB fixed her an additional sandwich just like the first one. Dietary Staff BB stated chopped meat would be cut up into bite size pieces using a knife and fork and ground meat would go through a blender. Dietary Staff BB stated she served R1 the diet that her tray ticket had on it. Dietary Staff BB stated the tray tickets have the diet order at the top of the ticket and the dietary manager prints out the tickets. If a diet order changed, she would was alerted by a group chat, in writing from nursing by a sheet they fill out and give to the kitchen, and a communication board in the kitchen. The dietary manager would ensure the tray ticket had the new order and if she was not there when the order was received, then the kitchen staff would write the new order on the tray ticket. On 07/24/23 at 02:36 PM Consultant Staff GG stated R1 had been diagnosed when in the hospital in May with aspiration pneumonia. Consultant Staff GG stated R1 admitted to the facility from the hospital on [DATE] on a regular diet and the facility was proactive and downgraded the diet on 06/08/23, she had been on a chopped diet prior. Consultant Staff GG stated when a new diet order was put in the EMR it triggered to the tray ticket program and the new order for R1 on 06/08/23 did not trigger and she remained on a chopped meat diet as the regular diet order when she returned on 06/05/23 did not get changed. Consultant Staff GG stated the regional dietician looked and there was a glitch in the system. Consultant Staff GG stated the dietary manager was alerted also with a diet communication form with changes in orders. On 07/24/23 at 03:22 PM Administrative Nurse D stated R1 came in for dinner and sat in the middle of the dining room. Certified Medication Aide (CMA) R came to her and said R1 was having difficulty breathing, so she went to the dining room and saw R1 seated upright and breathing rapidly. Administrative Nurse D stated there were issues in the past where R1 took her oxygen off, however it was in place and when she checked her oxygen saturation level it was 36%. R1 had a grayish color to her face, her lips were a little blue, and her pulse was 136 beats per minute. Administrative Nurse D checked R1's oxygen tank and noted it was close to red (indicating approaching empty), and she turned it up from three to five liters and hollered for an aide to go get an oxygen concentrator. The aide was not moving fast enough so Administrative Nurse D told another aide to run and get one. Administrative Nurse D stated she was stroking R1's face and telling her to calm down, as R1 gets very high anxiety. R1's oxygen saturation increased to 46% and her pulse decreased to 99 beats per minute, and when asking her questions, she would respond with her eyes or move her head but would not talk. Administrative Nurse D stated she called 911 and told them she was a full code (indicating if her heart stopped beating, she wanted cardiopulmonary resuscitation [CPR] to be performed) and they needed to get to the facility now. Administrative Nurse D stated it took EMS about 12 minutes to arrive, R1 was still breathing and was basically calming down at that point. When EMS arrived and they put their pulse oximeter on her, her oxygen saturation level was 55%. Administrative Nurse D stated herself, two EMS personnel, and a facility aide moved R1 to the stretcher. Administrative Nurse D stated R1 was flat on the stretcher and EMS placed the BVM on her and then took R1 out of the facility. Administrative Nurse D stated R1's family came in the next day and was told by hospital staff R1 was choking and wanted to know why she was told R1 was having respiratory issues. Administrative Nurse D stated she went over the events and at no time was R1 choking, she never put her hands up to her neck, and kept them at her side the whole time. Administrative Nurse D stated it was common for R1 to complain she could not breathe and did not say that or any other words when with her in the dining room, she would just shake her head to respond and make contact with her eyes. Administrative Nurse D stated she felt R1's anxiety was so high the time that is why she did not talk. 07/26/23 10:38 AM Administrative Nurse E stated she entered the order for R1 in the EMR on 06/08/23 for the ground meat diet and the process was to notify the kitchen with orders. Administrative Nurse E stated they discussed R1's diet in a clinical meeting, she had been asked to get an order to downgrade the diet, assumed dietary knew of the change, and she did not communicate the order to the dietary department. On 07/26/23 at 12:12 PM Dietary Staff CC stated before 07/02/23 the process for new diet orders was a new diet sheet would be presented to the kitchen or herself. If the tray tickets were printed, then she let the dietary staff know of the change and remake the ticket. Dietary Staff CC stated if she was not there when the diet changed, then the dietary staff were to write the change on the ticket and write on the communication board in the kitchen. Dietary Staff CC stated she had checked for R1's diet change form and did not have any for her when she looked back to March 2023 and did not receive a form for when the diet changed to ground meat on 06/08/23. On 07/26/23 at 12:50 PM Administrative Staff A stated she expected the nursing staff to notify the kitchen when there were diet order changes. The facility policy Interdepartmental Notification of Diet [Including Changes and Reports]) dated September 2022 revealed nursing services shall notify the Food Service Department of a resident's diet orders, including any changes in the resident's diet, meal service, and food preferences. When a new resident admitted , or a diet changed, the Nurse Supervisor shall ensure the Food Services Department receives a written notice of the diet order. The Food Services Department will also be notified verbally if the diet change or report occurs one hour or less before a scheduled meal, or if circumstances indicate that the written procedures will not be adequate to ensure service at the next meal. The facility failed to ensure staff served the appropriate diet to R1 to prevent choking on 07/02/23, and death of R1. The facility failed to notify the dietary department of a physician ordered diet of ground meat on 06/08/23 and served R1 a chopped meat diet from that time until 07/02/23. On 07/26/23 at 04:35 PM Administrative Staff A was informed of the immediate jeopardy and was provided the Immediate Jeopardy Template for failure to notify the dietary staff of physician ordered diet change for R1 and failure to serve the correct diet to R1, who subsequently choked. The facility provided a plan of removal of the immediacy on 07/31/23 at 04:56 PM, which included the following corrective measures to completed by 07/31/23 at 10:00 PM. 1. On 07/31/2023 an audit completed of current resident's diet orders in the electronic health record to tray card system and providers most recent diet order to ensure accuracy of diets. 2. The following reeducation initiated and completed with current nursing and dietary staff: a. Initiated on 7/26/2023: reeducation to Licensed nursing staff on the following topics: Diet orders to be reviewed and implemented with new admissions through communication via the electronic health record and completion of the diet communication tool. Readmissions are to have their orders discontinued upon discharge and new diet orders compared diet prior to discharge for any discrepancies. Any discrepancies found will be addressed upon admission with their provider. Completed via electronic messaging ([NAME] system) on 07/26/2023 at 08:54 PM. All signatures were obtained by 07/27/23 at 05:00 PM. b. Initiated on 07/31/2023: Reeducation of topic a above to Licensed nursing staff completed on 7/31/2023 at 10:00 PM. c. Initiated on 07/31/2023: reeducation to current nursing staff and dietary on the following topics: Reviewing meal ticket tray cards to ensure accuracy prior to reaching resident. Meal ticket tray cards are to remain with resident during the consumption of their meal. This was completed on 07/31/2023 at 10:00 PM. d. On 07/31/2023: initiated a test to current nursing and dietary to assess knowledge and understanding of the reeducation. This was completed on 07/31/2022 at 10:00 PM. e. For staff that were unable to complete sections b through d above have been notified that they will not return to work until completion of the reeducation and test. 3. Compliance will be monitored by IDT through the following: b. DON/Designee will audit current residents for any new or changed diet orders during morning clinical meeting. c. DON/Designee will audit that nursing is ensured communication to the dietary department via the diet communication tool with new admits and readmits. d. Dietary manager will audit current residents' diets on the tray card software for any discrepancies during morning clinical meeting. The surveyor verified the implementation of the above corrective actions onsite on 08/02/23 at 08:30 AM and the deficient practice remained at a G scope and severity. - The Medical Diagnosis tab located in the electronic medical record (EMR) for R2 included diagnoses of chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), altered mental status, acute and chronic respiratory failure, and pneumonia (inflammation of the lungs). The Annual Minimum Data Set (MDS) dated [DATE], assessed R2 with a Brief Interview of Mental Status (BIMS) score of 13, indicating intact cognition. R2 did not reject care, had no signs or symptoms of a swallowing disorder, required a therapeutic diet but not a mechanically altered diet, and required oxygen. R2 did not require speech therapy or restorative nursing services for eating/swallowing. The Nutritional Status Care Area Assessment (CAA) dated 10/03/22 revealed R2 was at risk for aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident). The Dental Status CAA dated 10/03/22 revealed R2 was edentulous (lacking natural teeth) with full upper and lower dentures and the care plan would be reviewed to maintain chewing and swallowing ability. The Quarterly MDS dated 06/28/23 assessed R2 with a BIMS score of 14, indicating intact cognition and she continued to not reject care. She had no signs or symptoms of a swallowing impairment, did not require a mechanically altered diet, speech therapy services, or restorative nursing services for eating/swallowing. R2 required a therapeutic diet and oxygen. The MDS tab revealed R2 discharged with return anticipated on 07/19/23 and re-entered the facility on 07/21/23. The Care Plan dated 03/15/23 revealed R2's dentures were lost while in the hospital and had been replaced on 06/28/23. An additional intervention dated 07/19/23 was to serve the diet as ordered. The hospital Nursing Home admission Orders dated 07/21/23 included a diet order of regular, renal diet and Juven (nutritional supplement) or renal house supplement with all meals. R2 had orders for speech therapy and diagnoses included acute/chronic respiratory failure, bilateral (both) pleural effusions (abnormal accumulation of fluid in the lungs), COPD, and end stage renal disease. The facility diet Order Listing Report dated 07/24/23 revealed two active diet orders for R2. On 07/13/23 an order for mechanical soft ground meat texture with extra gravy/house supplement with all meals and on 07/21/23 a regular texture diet. The Tray Ticket for R2 dated 07/24/23 at lunch time revealed a carbohydrate controlled, renal, mechanical soft, ground meat diet, and no added sodium. On 07/24/23 at 12:30 PM, staff served R2 a meal of two corn dogs and potato chips. On 07/24/23 at 12:31 PM, R2 stated she ordered the corn dogs and potato chips for lunch. On 07/24/23 at 01:07 PM R2 stated she did not have any problems swallowing and that her meat had to be ground up, however, she did okay with hot dogs. R2 stated she could eat potato chips but was not supposed to because she was on dialysis. R2 stated the facility provides her the right diet according to her physician orders unless she asks for something different. On 07/24/23 at 02:01 PM, Dietary Staff BB stated the tray tickets have the diet order at the top of the ticket and the dietary manager would print out the tickets. Dietary Staff BB stated if there was a change to a diet order, she would be alerted by a group chat, in writing by nursing by a sheet they fill out and give to the kitchen, and a communication board in the kitchen. The dietary manager would ensure the tray ticket had the new order and if she was not there when the order received, then the kitchen staff would write the new order on the tray ticket. Dietary Staff BB stated she worked on 07/21/23, 07/22/23, 07/23/22, and today (07/24/23) and was not aware of the new order. Dietary Staff BB stated she did not serve her potato chips but seen R2 had some and they were not mechanical soft however R2 would ask for them. Dietary Staff BB stated if she prepared R2's meal, she would have removed the corn dogs from the stick and cut them up for her. On 07/24/23 at 04:41 PM, Consultant Staff GG stated R2 readmitted on [DATE] with a regular diet, her previous diet was for chopped meat. The old diet had not been discontinued in the orders. On 07/26/23 at 12:29 PM Dietary Staff CC stated R2's diet order came in Friday (07/21/23) and did not get communicated to the kitchen. Dietary Staff CC stated she was home on [DATE] and noticed the order and told the staff to have the order changed by supper, and that she had spoken to one of the staff about the diet order before that. Dietary Staff CC stated R2 had two diets under her orders due to the previous order not getting discontinued in the EMR. Dietary Staff CC stated the nursing staff did not provide notification to the kitchen regarding the diet change. On 07/26/23 at 12:50 PM, Administrative Staff A stated she expected the nursing staff to notify the kitchen when there were diet order changes. The facility policy Interdepartmental Notification of Diet [Including Changes and Reports]) dated September 2022 revealed nursing services shall notify the Food Service Department of a resident's diet orders, including any changes in the resident's diet, meal service, and food preferences. When a new resident admitted , or a diet changed, the Nurse Supervisor shall ensure the Food Services Department receives a written notice of the diet order. The Food Services Department will also be notified verbally if the diet change or report occurs one hour or less before a scheduled meal, or if circumstances indicate that the written procedures will not be adequate to ensure service at the next meal. The facility failed to ensure the new diet order for R2 had been communicated to the kitchen when the order changed on 07/21/23. - The hospital Nursing Home admission Orders dated 07/18/23 for R3 included a diagnosis of diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The admission Minimum Data Set (MDS) dated [DATE] assessed R3 with a Brief Interview of Mental Status (BIMS) score of 13, indicating intact cognition. R3 had coughing/choking during meals or when swallowing medications, complained of pain with swallowing, and was on a mechanically altered diet. The Nutritional Status Care Area Assessment (CAA) dated 01/17/23 revealed R3 had swallowing issues, a mechanically altered diet, and was at risk for aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident). The Dental Care CAA dated 01/17/23 revealed R3 had broken teeth and the care plan would be initiated to maintain chewing and swallowing ability. The Quarterly MDS dated 05/20/23 assessed R3 with a BIMS score of 15 indicating intact cognition, she had no signs and symptoms of a swallowing disorder and was on a mechanically altered diet. The MDS tab revealed R3 discharged from the facility on 07/11/23 and returned on 07/18/23. The Care Plan dated 05/16/23 for R3 revealed a regular, mechanical soft, chopped meat texture diet. The staff were to ensure R3's food was appropriately prepared to provide safe intake of food and drinks. The hospital Nursing Home admission Orders dated 07/18/23 for R3 revealed a diet order for staff to provide regular consistency foods/drinks and an order for speech therapy to evaluate and treat. The facility Order Listing Report dated 07/24/23 revealed a diet order for R3 dated 01/04/23 for mechanical soft consistency and ground meat texture with gravy/sauce. The facility failed to update or clarify the change in diet order with the resident's physician or dietician upon return from the hospital. The lunch Tray Ticket dated 07/24/23 for R3 revealed a mechanical soft, ground meat diet. On 07/24/23 at 12:33 PM R3 sat on the side of her bed with an overbed table in front of her and her lunch on the table. R3 had goulash, green beans, and a popsicle. On 07/24/23 at 12:35 PM R3 denied having any problems swallowing and stated she would get ground meat if needs to be. On 07/24/23 at 02:01 PM Dietary Staff BB stated the tray tickets have the diet order at the top of the ticket and the dietary manager prints out the tickets. Dietary Staff BB stated if there was a change to a diet order, she would be alerted by a group chat, in writing from nursing by a designated sheet they filled out and gave to the kitchen, and/or a communication board located in the kitchen. The dietary manager would ensure the tray ticket had the new order and if she was not there when staff received the order, the kitchen staff would write the new order on the tray ticket. On 07/24/23 at 03:22 PM Administrative Nurse D stated the facility had a diet communication sheet they filled out to communicate a new diet order. When staff put a new diet order in the EMR, it went to the dietary tray ticket program and the dietary manager would update the tray ticket. On 07/26/23 at 12:33 PM Dietary Staff CC stated R3 returned with a regular diet order and from what she understood her orders were just found today (six days after returning to the facility). Dietary Staff CC stated R3 received chopped meat since she came back from the hospital (prior orders were for ground meat). Dietary Staff CC stated the facility came up with a new system today for new admissions or readmissions noting the nurse would start the orders and the unit managers would check the orders to make sure they were correct and delivered to where they needed to be. Dietary Staff CC stated sometimes when residents went to the hospital the diet order was left in the EMR and did not get changed when the resident came back to the facility. Dietary CC stated the facility would start discontinuing all diets and medication orders when a resident went out. On 07/26/23 at 12:50 PM Administrative Staff S stated the diet order in the EMR was her order on admission and the order did not get upgraded. Administrative Staff S stated she expected the nursing staff to notify the kitchen when there were diet order changes. The facility policy Interdepartmental Notification of Diet [Including Changes and Reports]) dated September 2022 revealed nursing services shall notify the Food Service Department of a resident's diet orders, including any changes in the resident's diet, meal service, and food preferences. When a new resident admitted , or a diet changed, the Nurse Supervisor shall ensure the Food Services Department receives a written notice of the diet order. The Food Services Department will also be notified verbally if the diet change or report occurs one hour or less before a scheduled meal, or if circumstances indicate that the written procedures will not be adequate to ensure service at the next meal. The facility failed to ensure staff communicated a new diet order for R3 to the kitchen when her diet order changed on 07/18/23.

The facility reported a census of 43 residents, with seven residents sampled. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 3, at high risk for falls, remained free from neglect. On 05/05/23 a Certified Nurse Aide (CNA) used a mechanical lift to transfer R3 by herself, against facility policy and the Occupational Safety and Health Administration (OSHA) guidelines, which documented the lift required two licensed/certified staff to be present with use. The CNA left the room and left R3 standing up in the lift, holding onto the handles, and suspended by the lift. R3 required oxygen via nasal cannula and the CNA did not check on the oxygen tank level for R3 before leaving the room, which was found empty. As a result of these failures R3 fell and was suspended by just the lift sling, was cyanotic (bluish/purple discoloration to the skin due to lack of oxygen) in the lips and face, and fractured (broke) her humerus (bone of the upper arm). The facility further failed to identify the fracture for seven days despite the resident's complaints of pain. This failure placed the resident in immediate jeopardy. Findings Included: - R3's diagnoses from the Electronic Health Record (EHR) included displaced fracture (traumatic bone break where two ends of the bone separate out of their normal positions) of the upper end of the humerus (bone of the upper arm), diabetes mellitus (disease in which the body's ability to produce or respond to the hormone insulin is impaired) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The 04/25/23 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of eight, indicating moderately impaired cognition. R3 required extensive assistance of two staff with all activities of daily living (ADL) and R3 used oxygen. The 04/25/23 Falls Care Area Assessment (CAA) documented R3 required assistance with ADL, had impaired balance and transition during transfers, and functional impairment in activity. The 05/15/23 Care Plan documented on 02/23/23 staff were to follow facility fall protocol, and staff were to encourage R3 to participate in activities that promoted exercise for strengthening and improved mobility. On 05/05/23, staff lowered R3 to the floor, after R3 became pale. On 05/11/23 R3 had a fractured right humerus with her arm in a sling, staff were to use a full lift with two staff members for transfers, and staff were to ensure R3 had oxygen in place, during transfers. Staff were to place a nonslip chair pad between the sling and the cushion in the wheelchair. The 03/22/23 Fall Risk assessment documented R3 was a high fall risk. The Progress Note dated 05/05/23 at 01:50 PM Licensed Nurse (LN) D heard a yell I need a nurse and she ran down the hall into R3's room and found her on the floor in between the sit-to-stand lift and the wall. LN D noted R3 was cyanotic (bluish/purple discoloration to the skin due to lack of oxygen) in the lips and face, and R3's lung sounds were clear. CNA E assisted R3 out of the mechanical lift to the floor, R3 did not hit her head. CNA F replaced the oxygen tank, as it was empty. The provider advised staff to monitor R3's oxygen saturations (measure of how much oxygen the blood carried as a percentage of the maximum it could carry) since R3 was put on the concentrator. LN G came into the room and offered an oxygen mask, which was placed on R3. R3 had a bowel movement and was cleaned up and placed into her bed. The Progress Note dated 05/05/23 at 06:31 PM, LN D documented R3 complained of right shoulder pain at an eight out of 10 (on a scale of one to 10, with 10 being the most pain). She obtained vital signs with a low oxygen saturation level of 82%, she educated R3 the oxygen cannula needed to stay in her nose and noted R3 had a low blood pressure. Recheck of R3's oxygen saturation level revealed 93%. LN D gave R3 acetaminophen for the pain. LN D notified the provider of the low blood pressure. The Progress Note dated 05/06/23 at 01:36 PM by LN H documented R3 complained of shoulder discomfort and staff applied analgesic cream to the affected area, per standing orders. The Progress Note dated 05/11/23 at 08:25 AM by LN I documented R3 complained of mild to moderate pain in her right shoulder. The Progress Note dated 05/11/23 at 02:21 AM by LN I documented R3 was transferred by facility transportation to the emergency room. The note included R3 had a fracture of the right shoulder, involving the surgical neck of the humerus. The Witness Statement for the incident on 05/05/23 regarding R3, by Administrative Staff A, documented late afternoon on Wednesday, 05/10/23, they were approached by family of R3. The family member of R3 stated R3's shoulder had been bothering her since the incident with the lift and said R3 was now in pain. Administrative Staff A stated she did not know of an incident with the lift and took R3's family member to the conference room to visit with LN H, LN D, and Administrative Nurse B. Administrative Nurse B confirmed the incident with R3 being lowered to the floor from the wheelchair of R3 by CNA E. Administrative Staff A stated she would let R3's nurse know about the pain and begin an investigation into the incident. The (typed by Social Service Designee (SSD) M) Witness Statement for the incident on 05/05/23 for R3, by R3's family member documented on 05/05/23 he was in R3's room and she pressed her call light. CNA E and Hospitality Aide L went in the room and answered the light. R3 requested to be changed and CNA E put R3 on the sit-to-stand lift. When R3 was in the air, staff noticed no wipes were in the room, and Hospitality Aide L left to find wipes; he did not come back. CNA E said I need wipes, I will be back while CNA E left R3 in the lift, and did not lower her down to the chair. R3's oxygen tank was running out during this process instead of switching R3 to the concentrator. R3 collapsed to a hanging position. CNA E entered the room with no wipes, saw what happened to R3, and lowered R3 to the floor with the sit-to-stand lift. At that point CNA E hollered for the nurse, and the medical team came in and assisted throughout the process of getting R3 up and in the chair. The nurse checked R3's blood sugar due to her thinking it was that [low blood sugar] which caused her to collapse. Once they found the blood sugar was okay, the staff checked her oxygen which was low. The nurse gave R3 oxygen to help regulate her stats. The (typed by SSD) Witness Statement for the incident on 05/05/23, revealed R3 stated she did not remember a lot of the events that occurred because her oxygen was out. R3 stated the last thing she remembered was she fell out of the sling while utilizing the sit-to-stand lift. The Witness Statement for the incident on 05/05/23, for R3 by CNA E, documented she and Hospitality Aide L went into R3's room. CNA E got R3 hooked up to the sit-to-stand and stood her up. CNA E noticed there were no wipes, she asked Hospitality Aide L to go get some. Hospitality Aide L took too long because he could not find any, so CNA E left the room, and ran to get some. When CNA E returned R3 was pale and non-responsive, so CNA E slowly lowered her to the ground and screamed for the nurse. They came in and figured out it was her oxygen. R3's oxygen raised, staff cleaned her up, and got her back in bed. The Witness Statement for the incident on 05/05/23 for R3, by Hospitality Aide L, documented he and CNA E helped R3 get changed and CNA E had me go get wipes while R3 was on the lift. Hospitality Aide L documented he had trouble finding them, so it took a while, and when he returned there were a bunch of people in R3's room and he guessed she fell when he was gone. The Witness Statement for the incident on 05/05/23 for R3, by LN D, documented LN D heard a yell need a nurse and ran down the hall into R3's room. LN D found R3 her on the floor in between the sit-to-stand (lift) and the wall. LN D grabbed vital signs. R3 was cyanotic in the lips and face, and her lungs were clear. CNA E found R3 and assisted her to the floor, out of the sit-to-stand. R3 did not hit her head according to R3 and R3's family member. CMA K followed LN D into the room and recorded vital signs. CNA F showed up to help, replaced the (oxygen) tank on back of R3's wheelchair, as it was empty. Took R3 off of the oxygen tank and put her on her oxygen concentrator. Administrative Nurse B and LN H came in to assist. Administrative Nurse B phoned the provider for notification of the incident, and LN D took the phone and stepped out of the room. The provider advised to monitor R3. LN G came in and asked if we wanted an oxygen mask, so she provided one. Staff rechecked R3's vital signs, R3 had a bowel movement and was cleaned, and moved into bed. R3 was resting comfortably with call light in reach. The Witness Statement for the incident on 05/05/23 for R3, by CNA F, documented R3 asked to be changed after CNA F was done with lunch trays. CNA F charted while waiting for staff (CNA E) to help. CNA E and Hospitality Aide L went to R3's room. Hospitality Aide L came out looking for wipes, and none were at the nurse's station, she he went to the south side. CNA E came out, so CNA F went to find some wipes in the bath house, and CNA E ran back to R3's room. When she got back, she yelled for a nurse and lowered R3 to the floor due to no oxygen and R3 was turning blue. The nurses ran to help and got R3's breathing back and staff cleaned her and put her back to bed, to be watched. The Witness Statement for the incident on 05/05/23, for R3 by CMA K, documented she had just got back from her lunch break and was talking with the north unit manager, LN D, when she started hearing yelling coming from the hall. CNA E yelled from R3's room. LN D and CMA K went into the room to see what happened. When she arrived to R3's room she saw R3 lying on the floor, her skin was pale, the sit-to-stand lift was by her feet, and sling was down by her feet. LN D assessed R3, checked her blood sugar, blood pressure, and vitals. CMA K went over by the wheelchair and noticed the oxygen tank was empty. CMA K ran to get a new tank. LN D continued to assess R3. CMA K recorded the vital signs and time for LN D, noted an oxygen mask placed on R3, and CNA E, LN D, and CMA K put R3 in bed. The Witness Statement for the incident on 05/05/23 for R3, by Administrative Nurse B, documented at approximately 01:50 PM several staff at R3's room. Administrative Nurse B went to R3's room and saw R3 lying on the floor, incontinent of bowel. LN D assessed R3, and CNA E was with R3. Administrative Nurse B called the provider at 01:55 PM to advise of condition and orders. R3 was responsive while she was present in the room. CNA E explained she had her up in the sit-to-stand (lift), needed wipes, and left the room. CNA E came back and R3's condition was deteriorating. They asked CNA E if R3 fell, and CNA E reported no. Administrative Nurse B understood R3 was in the wheelchair when the episode occurred. Staff asked R3 if she hurt anywhere, and she denied pain. CNA E and Administrative Nurse B cleaned her up, R3 denied pain while moving her. Staff retrieved a pillow for under R3's head and rolled blankets for under her knees for comfort. R3 was encouraged to take deep breaths while having oxygen mask on at three liters per minute (L/min). While Administrative Nurse B was in the room R3's oxygen saturation fluctuated between 85% and 87%. R3's family member was in the room during the incident and had no verbal communication with staff, he sat in the recliner with his arms crossed. Staff had to work around him to care for R3. The Witness Statement for the incident on 05/05/23 for R3, by LN H, documented at the time she was notified she was in the conference room completing clinical. LN H rushed to the room, when she arrived R3 was on the floor, several staff were with R3, so she felt she was not needed so she exited the room. The Witness Statement for the incident on 05/05/23 for R3, by Administrative Staff N, documented they assisted with investigation regarding R3, phone call was made to CNA E. CNA E verbalized acknowledgement of the incident, while Administrative Staff N inquired of the lowering of R3 with the sit-to-stand lift, CNA E stated she came back to R3's room, found her in her wheelchair, still attached with the sling to the lift. CNA E stated R3 was unresponsive so CNA E bear hugged R3 and lowered her to the ground. This statement did not match what was reported to any nursing staff or her witness statement. The facility and supervisory determination made to terminate employment agreement due to not following the care plan, or company policy. The 05/16/23 Physician Orders lacked documentation of an order for acetaminophen or bio freeze ointment. On 06/15/23 at 02:05 PM, R3 was in bed with the head of the bed elevated, oxygen cannula in her nose, running at three liters per minute (L/min). R3 was alert and awake and wore an immobilizer on her right arm. On 06/15/23 at 02:05 PM, R3 revealed she remembered the fall and stated she had called for assistance with changing. CNA E came in and got her on the mechanical lift and had a hospitality aide with her. CNA E noticed there were no wipes, so she sent the hospitality aide out to get some. When he did not return, CNA E went out of the room, and left R3 hooked to the mechanical lift, to get the wipes. R3 revealed all she really remembered was coming too and her head was close to the radiator. On 06/15/23 at 02:05 PM, R3's family member revealed he was there in the room when CNA E entered alone and called for the hospitality aides assistance. R3's family member stated the hospitality aide left to get supplies, and then CNA E left. He stated R3 lost consciousness because she ran out of oxygen in the tank. R3 fell and broke her arm, she told them she was in pain, and her shoulder hurt. The staff gave her acetaminophen one time, a cream one time, and then they started ignoring it. They finally got an x-ray, and it was broken, and she had to go the hospital. On 06/19/23 at 03:26 PM, Administrative Nurse B revealed she and LN D went into R3's room and she was lying on the floor, she had been incontinent of bowel. LN D took care of assessing and the oxygen. Administrative Nurse B and CNA E cleaned R3 up, R3's family member sat in the recliner with no expression on his face, and staff had to basically crawl over him to assist R3. Administrative Nurse B revealed R3 had no complaints of pain and was stable, so the provider told them to get R3 up. Administrative Nurse B revealed there were no reports to her of pain in the following days. Administrative Nurse B revealed she expected all staff to know and follow the guidelines of two staff assistance with the use of a mechanical lift. Administrative Nurse B stated the facility terminated employment of CNA E, they educated all nursing staff on having two certified and/or licensed staff present with the use of a mechanical lift, and the facility nursing management team was auditing all lift usage weekly. On 06/20/23 at 09:06 AM, Certified Medication Aide (CMA) K revealed on 05/05/23 she had just finished lunch and was sitting in the unit managers office. They heard CNA E yelling, so they went down the hall following the sound to R3's room. R3 was on the floor and other staff were cleaning her up. CMA K kept record of what the nurse was doing. CMA K noticed the oxygen tank was empty, she did not assist with the cleaning of R3 but did assist with getting her into bed. CMA K revealed at the time of the fall R3 was out of it and could not really tell them if she was in pain. On 06/20/23 at 12:42 PM, LN D revealed she was sitting in her office when she heard, I need a nurse, she went to the room. R3 was lying on the floor, the wheelchair was almost in the closet, the lift was on the side of R3. LN D's first thought was R3's blood glucose was out of parameters, so CMA K got the glucometer (instrument used to calculate blood glucose), the reading was within normal limits. LN D noticed the oxygen tubing was off R3, so she placed it on her and connected it to the concentrator. LN D stated R3's family member sat in the recliner with a stoic (a person who can endure pain or hardship without showing their feelings or complaining) expression. R3 was not unresponsive but not coherent, LN D obtained vital signs and R3's oxygen saturation was coming back up, so LN D stepped out to call the provider. LN D revealed R3 stated no pain, during rolling back and forth to place sling under her, or with back and forth to clean her up, R3 complained of no pain. LN D revealed for at least three to four days after the fall R3 did not complain of pain. LN D stated she was present when R3 got the Xray and all she noticed was R3 took a deep breath at one point. LN D revealed CNA E told LN D R3 became unresponsive, so CNA E lowered her to the floor from the wheelchair The facility's reviewed 08/2022 Abuse Prevention Program policy, documented the residents have the right to be free from neglect. The facility failed to provide a safe environment, free from neglect for R3 when a CNA used a lift alone, left R3 alone, suspended in the lift, and with lack of sufficient oxygen, and R3 fell and fractured her humerus. On 06/19/23 at 05:25 PM, Administrative Staff A was provided the Immediate Jeopardy Template and notified the failure to provide a safe environment free from neglect, placed R3 in immediate jeopardy. The facility identified and implemented the following corrective actions completed 05/11/23: 1. Administrator received verbal concern for R3's family member pertaining to shoulder pain following an incident while utilizing a facility lift in the late afternoon of 05/10/23. Investigation into the alleged incident began with education to staff members in the areas pertaining to abuse, neglect, facility lift use, and completed at approximately 11:30 PM on 05/10/23. Staff members on shift of incident 05/05/23 interviewed and statements obtained. Immediate alert of education of mechanical lift use, abuse, and neglect delivered to all staff on 05/11/23 at 09:15 AM. Review of the incident determined immediate suspension of staff member CNA E due to the concern of leaving the resident room while positioned in a sit to lift which led to termination of employment on 05/11/23. 2. Audits initiated for areas pertaining to neglect and lift use concerns on 05/11/23. Social Services Designee interviewed all residents with a BIMS of ten or higher to investigate any potential abuse, neglect, or lift safety concerns of other residents. 3. Education of policies, facility lift procedures and the following completed: A) Abuse, Neglect, and Exploitation Policy completed with staff members on 05/10/23 B) Falls, fall risk, and managing falls completed at approximately 11:30 PM on 05/10/23 with staff members. C) Safe lifting including facility protocol with staff members and mechanical lifts education completed at approximately 11:30 PM on 05/10/23. D) Using the resident care plan policy education completed at approximately 11:30 PM on 05/10/23. E) Instant alert notification sent to all certified staff members at 05/11/23 at 09:15 AM. 4. Audits consisting of abuse, neglect, and lift use will monitor for potential areas of concern until lesser frequency is determined during Quality Assurance Meeting. A) Abuse, Neglect, and Exploitation will be reviewed three times a week for two weeks, then one time a week for four weeks. a. A random sample of five residents of BIMS ten or higher to be completed on scheduled audit. b. Abnormal findings to be reported with immediate action plan as needed. B) Lift use audit to ensure enforcement of facility protocol to be completed five times a week for one week, three times a week for one week, and once a week for four weeks. a. Care plan audit to review all resident transfer status and mechanical lift use 05/11/23. b. To review consistency of staff education of mechanical lift use, audits began 05/16/23 following the resident care plan review to ensure accuracy of use, per schedule with randomized sample. C) All certified staff members received immediate alert via electronic notification of education of mechanical lift use, abuse, and neglect on 05/11/23 at 09:15 AM. 5. Plan of correction and education reviewed with Administrator, DON, and Medical Director in an ad hoc Quality Assurance Meeting 05/11/23. Results of audit findings will be brought to the quality assurance meeting on 06/22/23. The surveyor verified the implemented corrective actions while onsite on 06/20/23. Due to the implemented corrective actions prior to the surveyor entrance, the deficient practice was deemed past noncompliance at a J scope and severity.