Based on interview, record review, hospital record review, and facility policy review, it was determined the facility failed to ensure the person centered comprehensive care plan was implemented for one (1) of four (4) sampled residents (Resident #1). The facility care planned Resident #1 as a choking risk due to behaviors of reaching and grabbing food not on his/her diet, The resident required a pureed diet. In addition, one to one (1:1) supervision, when out of bed. The facility failed to implement the nursing care plan interventions to prevent Resident #1 from getting food not on his/her diet, nor the 1:1 supervision when out of bed. On 08/07/2020, Resident #1 obtained a peanut butter sandwich from the snack tray on the medication cart. Resident #1 grabbed and consumed half of the half of peanut butter sandwich before staff intervention and choked. Staff performed the Heimlich maneuver (abdominal thrusts to remove object causing to choke) and Resident #1 coded with staff initiating Cardiopulmonary Resuscitation (CPR) (chest compressions often with artificial ventilation). Resident #1 was transferred to an acute care facility where he/she was intubated, placed on a ventilator (machine that provides mechanical ventilation {air/breaths}), and a (Nasogastric tube) feeding tube was placed. The facility's failure to implement the care plan has caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/04/2020 and determined to exist on 08/07/2020. The facility was notified of the Immediate Jeopardy on 09/04/2020. An acceptable Credible Allegation of Compliance (AoC), related to the Immediate Jeopardy was received on 09/10/2020 alleging the Immediate Jeopardy was removed on 09/10/2020. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on 09/10/2020. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of facility policy titled, Comprehensive Care Plan, revealed the Comprehensive Care Plan was developed to promote communication of the resident's needs, goal, and interventions to promote successful goal attainment. Each residents care plan was designed to incorporate identified problem areas, and identify the professional services that were responsible for each element of care. Record review revealed the facility readmitted Resident #1, on 03/04/2020 with diagnoses which included Dementia, Encephalopathy, Unspecified Psychosis, Anoxic Brain Damage, Altered Mental Status (AMS), Aphasia, and Dysphagia. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 05/19/2020, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3), which indicated the resident was not interviewable. Further review revealed the resident required supervision with meal setup. Review of Resident #1's Comprehensive Care Plan, dated 11/18/19, revealed the resident was at risk for Nutritional Decline. The Care Plan stated the resident exhibited alterations in mood/behavior of attempting to bite, grab, and scratch staff and other residents. The interventions directed staff to provide 1:1 supervision until further notice, when out of bed (dated 11/26/19), and to supervise meals as indicated for reaching in and getting food not on his/her diet. However, interview with Licensed Practical Nurse (LPN) #1, on 08/20/2020 at 9:46 AM and 11:45 AM; and on 09/03/2020 at 2:25 PM, revealed Resident #1 was supposed to be on 1:1 supervision and she tried to call a Certified Nurse Aide (CNA) into work to provide the 1:1 supervision, but was unsuccessful. LPN #1 stated she did not have enough staff to assign a 1:1, so she tried to keep the resident by the medication cart while she administered medications and handed out snacks. She stated she had the tray of snacks on top of the medication cart. She revealed while she was pouring water to administer a resident's medications, Resident #1 grabbed a half peanut butter sandwich off the snack tray and ate half of it before she could get it away from the resident. She stated the resident choked and she provided the Heimlich maneuver unsuccessfully and Resident #1 coded requiring CPR. She stated Emergency Medical System was called and Resident #1 was transferred to hospital. Further interview with LPN #1 revealed she was aware Resident #1 was care planned for 1:1 supervision and was on the list of residents who grab food in the nurses book at the nursing station. LPN #1 stated it was the nurse who determined staff assignment of the 1:1, but when doing 1:1 staff still had other duties. She stated she did not think the resident could reach the top of the med cart to grab the sandwich off the snack tray. Review of hospital records dated 08/07/2020, revealed Resident #1 was admitted to hospital via the emergency room (ER) after choking on a peanut butter sandwich. Resident #1 was intubated at 10:07 PM on 08/07/2020. Interview with Administrator, on 09/15/2020 at 3:45 PM revealed the resident was still in the hospital and remained intubated with a tracheotomy, on a ventilator, and a nasogastric tube for feeding. Interviews with CNA #1, on 08/20/2020 at 7:41 AM; and, CNA #2 on 08/21/2020 at 9:27 AM, and 08/31/2020 at 3:31 PM, revealed they were attending to other duties and not really paying any attention to Resident #1 sitting on the hallway. The CNA's stated they were aware that Resident #1 was care planned to be on 1:1 when out of bed and someone was to be with him/her at all times and within touching distance, but there was not enough staff to provide the required 1:1 supervision. The CNA's revealed there was not enough staff to sit with the resident 1:1, so no one does 1:1, we just watch resident while doing care on the hall and sometimes the nurse watched the resident. The CNA's stated Resident #1 would grab anything in reach. Interview with Director of Nursing (DON), on 09/15/2020 at 12:00 PM, revealed care plans were to be followed related to dietary needs and supervision. Interview with Administrator, on 09/01/2020 at 4:12 PM, and 09/03/2020 at 4:42 PM, revealed 1:1 supervision was provided depending on why the resident was placed on 1:1. She stated Resident #1 was care planned for 1:1 supervision due to grabbing and scratching other residents; so the staff only had to keep the resident in line of sight to ensure the resident was not within reaching distance of another resident. She further revealed she was not aware Resident #1 would grab at everything and was care planned for reaching in and getting food not on his/her diet. The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #1 was transferred from the facility on 08/07/2020 and has not returned to the facility. 2. The Dietary Manager provided a list of all current residents on mechanical altered diets (17 residents) on 09/08/2020. The Administrator completed a review of the care plans of residents with mechanical soft and pureed diets in regard for the potential for reaching for food not on their meal tray. 3. The Administrator, Social Service Director, and/or licensed nurse completed a review of psychosocial/behavior care plans for any resident currently identified as requiring 1:1 supervision, on 09/08/2020. There were no additional residents at this time requiring 1:1 supervision. This was completed on 09/08/2020. 4. The Regional Director of Operations provided education to the Administrator on 09/04/2020 regarding: One-to-one supervision regarding one staff member dedicated to the supervision of one resident with no other assigned duties during the time. 5. The Regional Quality Manager (RQM) provided education to the Director of Nursing (DON) on 09/04/2020 regarding: One to one supervision requires one staff member dedicated to the supervision of one resident with no other assigned duties during this time. Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. Dietary would provide a list of mechanically altered diets and thickened liquids with each snack pass delivery. All snacks would be placed in a covered container by the dietary staff prior to handling off to nursing staff. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. 6. The DON provided education to assigned licensed nurses (4) and director of medical records/medication technician (a train the trainer education) on 09/04/2020 through 09/06/2020 regarding: One to one supervision requires one staff member dedicated to the supervision of one resident with no other assigned duties during this time. To notify the Administrator and/or the Director of Nursing when there was a need to add a care plan intervention for 1:1 supervision of a resident. The care plan was to be implemented as indicated for 1:1 supervision. Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. Dietary would provide a list of mechanically altered diets and thickened liquids with each snack pass delivery. All snacks would be placed in a covered container by the dietary staff prior to handling off to nursing staff. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. 7. Education was provided to the facility nursing staff, (licensed nurses and nursing assistants), and facility dietary staff by the DON, Administrator, and Regional Quality Manager beginning 09/04/2020 through 09/09/2020, regarding: Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. Dietary would provide a list of mechanically altered diets and thickened liquids with each snack pass delivery. All snacks would be placed in a covered container by the dietary staff prior to handling off to nursing staff. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. 8. Verbal acknowledgement of understanding along with signed education was obtained after the inservice. The facility employs no agency staff. Employed nursing or contracted dietary staff currently on leave or newly hired to the facility will receive this education from the DON or assigned facility manager before assuming duties. 9. The Regional Quality Manager provided education to the DON on 09/08/2020 regarding: To notify the Administrator and/or the DON when there was a need to add a care plan intervention for 1:1 supervision of a resident. The care plan was to be implemented as indicated for 1:1 supervision. 10. The DON provided education (train the trainer) to the staff development Coordinator on 09/08/2020 regarding: One to one supervision requires one staff member dedicated to the supervision of one resident with no other assigned duties during this time. To notify the Administrator and/or the DON when there was a need to add a care plan intervention for 1:1 supervision of a resident. The care plan was to be implemented as indicated for 1:1 supervision. Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. Dietary would provide a list of mechanically altered diets and thickened liquids with each snack pass delivery. All snacks would be placed in a covered container by the dietary staff prior to handling off to nursing staff. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. 11. The Regional Quality Manager, the DON and or Staff Development Coordinator (SDC) provided education to the licensed nursing staff on 09/08/2020 regarding: One to one supervision requires one staff member dedicated to the supervision of one resident with no other assigned duties during this time. To notify the Administrator and/or the DON when there was a need to add a care plan intervention for 1:1 supervision of a resident. The care plan was to be implemented as indicated for 1:1 supervision. 12. Verbal acknowledgement of understanding along with signed education was obtained after the inservices. The facility employs no agency staff. Employed nursing or contracted dietary staff currently on leave or newly hired to the facility will receive this education from the DON or assigned facility manager before assuming duties. 13. An ad-hoc meeting was held on 09/04/2020 to review the summary of Immediate Jeopardy findings and discuss the development of the action items to be completed. This meeting included the Administrator, DON, Social Services, Activities, Dietary, Therapy, and MDS. This information was reviewed with the facility Medical Director by the Administrator via the phone on 09/04/2020. 14. The Administrator, Assistant Administrator, DON, and/or Weekend Department Manager Supervisor would observe five (5) times (X) a week on various shifts to include weekends for two (2) weeks, then three (3) X week for two (2) weeks, then two (2) X week for four (4) weeks for the following: All snacks would be placed in a covered container by dietary staff. Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. The nursing staff member would place the container on the ice chest cart and begin snack pass to the residents. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. Any identified concern will be addressed at the time of discovery by the monitor. The audit began on 09/04/2020. 15. In the morning clinical meeting beginning 09/08/2020, the Administrator, the DON, and/or assigned licensed nursing staff would review the plan of care for all residents requiring 1:1 supervision. 16. The Administrator or the DON would review and sign off on the staffing assignments sheets daily in regards to potential need for any 1:1 supervision. A review of the weekend staffing sheet would be completed on Fridays. The Administrator, the DON was to be notified at any time a resident required a 1:1 supervision. 17. Beginning 09/08/2020, the DON and/or assigned licensed staff would audit five (5) residents requiring 1:1 supervision, risk for diet non-compliance, and/or (if no 1:1 supervision) with mechanically altered diets weekly times four (4) weeks for: Care plans interventions in place and observe the resident for care plan implementation as written in the plan of care 18. The results of the monitoring would be reviewed at a minimum of weekly in the QAPI meetings being held to track the facility's progress toward regulatory compliance. 19. A second ad hoc QAPI meeting was held on 09/08/2020, to review the initial audit findings of the list of residents with mechanically altered diets and subsequent care plan review. This meeting included the Administrator, DON, Social Services, Dietary, Activities, and MDS. This information was reviewed with the facility Medical Director by the Administrator via the phone, on 09/08/2020. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of Notice of Emergency Transfer and Nurses Progress, dated 08/07/2020 at 8:20 PM, revealed Resident #1 was sent to hospital via EMS (emergency management services) related to choking incident. Interview with Administrator, on 09/15/2020 at 3:45 PM, revealed Resident #1 had not returned from the hospital. 2. Interview with Dietary Manager on 09/15/2020 at 11:40 AM revealed she provided a list of residents who were on a mechanically altered diet to the Administrator. Review of care plans of residents that were identified as on mechanically altered diets revealed the Administrator reviewed the care plans, on 09/08/2020 to ensure if resident was known to grab food; it was addressed on the resident's care plan. Interview on 09/15/2020 at 3:45 PM, with Administrator revealed she had reviewed dietary needs of residents with mechanical soft and pureed diets in regard for the potential for reaching for food not on their meal tray. 3. Interviews on 09/15/2020 with Administrator at 3:45 PM, Social Service Director at 10:15 AM, and Director of Nursing (DON) at 12:00 PM revealed there were no additional residents at this time requiring 1:1 supervision. 4. Interview on 09/15/2020 at 3:05 PM, with Regional Quality Manager, revealed the Regional Director of Operations provided education to the Administrator, on 09/04/2020. Interview with Administrator, on 09/15/2020 at 3:45 PM, revealed she was educated by the Regional Director of Operations to ensure staffing would be provided for 1:1 supervised residents with no other duties assigned to that staff member. Review of education documentation revealed the Administrator signed the form indicating she had received education related to one staff member dedicated to the supervision of one resident with no other assigned duties during the time provided on 09/04/2020 5. Interview with the Regional Quality Manager (RQM) revealed she provided education to the Director of Nursing (DON), on 09/04/2020. Interview with DON, on 09/15/2020 at 12:00 PM, revealed she was educated by RQM to ensure if there was 1:1 supervision of a resident, then a staff member would be assigned and have no other duties. She stated in addition she was educated on the new process of dietary delivering, and nursing storing and delivering dietary snacks. 6. Interview with DON, on 09/15/2020 at 12:00 PM, revealed she provided education to SDC, LPN #4 and weekend staff, on 09/04/2020 through 09/06/2020, to ensure they knew the requirements for the 1:1 supervision and snack pass process. Interviews on 09/15/2020 with LPN #1 at 11:20 AM, LPN #2 at 3:11 PM, CNA #1 at 2:25 PM, and CNA #2 at 3:28 PM, revealed they were educated on 1:1 supervision, the new snack pass process and snack requirement, and care plan implementation. They also stated they were educated to call DON and/or Administrator when a resident was placed on 1:1. 7. Interviews on 09/14/2020 with LPN #5 at 4:20 PM, LPN #7 at 4:27 PM, and LPN #3 at 4:30 PM; on 09/15/2020 with Dietary Manager at 11:40 AM, Dietary Aide #1 at 2:30 PM, Dietary Aide #2 at 2:50 PM, SDC at 10:15 AM, SSD at 10:15 AM, KMA#1/Director of Medical Records/Central Supply at 11:00 AM, LPN #1 at 11:20 AM, DON at 12:00 PM, UM #2 at 2:50 PM, RQM at 3:05 PM, LPN #2 at 3:11 PM, CNA #1 at 2:25 PM, CNA #2 at 3:28 PM, and CNA #4 at 1:58 PM revealed they were educated on the new process for resident snack delivery and storage. Observation on 09/14/2020 at 2:10 PM, revealed staff followed the new snack pass guidelines. 8. Review of education documentation revealed all nursing staff and dietary staff signed the education to acknowledge understanding of education. Additionally, interview with LPN #7 (new hire), on 09/14/2020 at 4:27 PM, revealed she was educated on the new process for snacks, 1:1 resident supervision and care plan implementation. 9. Interview on 09/15/2020 at 3:05 PM, with Regional Quality Manager, revealed she provided education to the DON, on 09/08/2020, to ensure she was aware she and/or the Administrator should be notified when a resident was placed on 1:1, and the care plan was to be implemented, as indicated for 1:1 supervision. Interview with DON, on 09/15/2020 at 12:00 PM, revealed she was educated on being notified if a resident was placed on 1:1, and care plan implementation of 1:1 by RQM. Review of education documentation dated 09/08/2020, revealed the DON signed the form indicating she understood the education provided by the RQM. 10. Review of education documentation (train the trainer) provided by DON to the Staff Development Coordinator (SDC), on 09/08/2020, revealed the DON educated the SDC and the SDC signed the form indicating she understood the education. Interview with SDC, on 09/15/2020 at 10:00 AM and 4:00 PM, revealed she was educated by the DON on the new snack process, that the DON and the Administrator must be notified if a resident was placed on 1:1 supervision, and that staff assigned to that resident would have no other duties but the 1:1. 11. Interviews on 09/14/2020 with LPN #7 at 4:27 PM; on 09/15/2020 with LPN #1 at 11:20 AM, LPN #2 at 3:11 PM, LPN #3 at 4:30 PM, and LPN #5 at 4:20 PM, revealed they were educated that staff assigned 1:1 supervision of a resident would not be assigned any other duties, nursing staff were to notify DON and/or the Administrator if a resident was placed on 1:1, and care plan implementation of the 1:1 supervision. Review of education documentation revealed all licensed nursing staff signed they understood the education provided on 09/08/2020 12. Interviews on 09/15/2020 LPN #1 at 11:20 AM, LPN #2 at 3:11 PM, CNA #1 at 2:25 PM, and CNA #2 at 3:28 PM, revealed verbal acknowledgement of provision of education and signing of signature page for verification of education. 13. Interviews on 09/15/2020 with Administrator at 3:45 PM, DON at 12:00 PM, SSD at 10:15 AM, Dietary at 11:40 PM; and Therapy at 2:15 PM revealed an ad-hoc meeting was held on 09/04/2020 to review the summary of Immediate Jeopardy findings with discussion of action plan to address findings of Immediate Jeopardy. Interview with Administrator on 09/15/2020 at 3:45 PM, and with Medical Director on 09/15/2020 at 4:14 PM, revealed the Administrator made the Medical Director aware of the action plan and obtained his input. 14. Review of the Monitoring Tools for Snack Pass, revealed monitoring was conducted five times during the week of 09/04-09/11/20 and continued to be completed with no concerns identified. The monitors were signed by the DON/or weekend supervisor. 15. Interviews on 09/15/2020 with Administrator at 3:45 PM, Administrator in Training (AIT) at 9:37 AM and at 3:45 PM, the DON at 12:00 PM, UM #2 at 2:50 PM, and MDS #1 at 4:06 PM revealed there were no residents on 1:1 at this time but were aware they would review care plans for all residents requiring 1:1 supervision. Review of a facility form that was developed to use to review the plans of care revealed a place to document Resident Name, Follow-up needed, Initials, Assigned to, and date. 16. Interview on 09/15/2020 with the DON at 3:45 PM, the AIT at 9:37 AM and 3:45 PM, and the Administrator at 3:45 PM, revealed they were to be notified at any time a resident required a 1:1 supervision, and that the staffing sheets were being reviewed daily and weekend staffing sheets reviewed on Friday, but at this time there were no residents on 1:1 supervision. A list of reviewed staffing sheets was present in the AOC binder for review 17. Interview on 09/15/2020 at 12:00 PM, with DON, revealed she was auditing accuracy of care plans related to supervision of 1:1, dietary needs, and watched a meal of audited resident that day. 18. Review of documented QAPI meetings revealed a review of facility progress with discussion of any issues dealt with immediately upon point of discovery. Interview on 09/15/2020 with DON at 12:00 PM, Administrator at 3:45 PM, AIT at approximately 9:37 AM and 3:45 PM, revealed they were meeting weekly to discuss any issues identified with during monitoring. 19. Interviews on 09/15/2020 with SSD at 10:15 AM, Dietary Manager at 11:40 AM, DON at 12:00 PM, Administrator at 3:45 PM, AIT at 9:37 AM and 3:45 PM, MDS at 4:06 PM and Medical Director at 4:14 PM revealed there were ongoing reviews of facility's progress toward compliance.

Based on observation, interview, record review, hospital record review, review of Nurse's book, Staff Assignment Sheet, and facility education review, it was determined the facility failed to ensure one (1) of four (4) sampled residents (Resident #1) received adequate supervision to prevent accidents. The facility assessed Resident #1 required one to one (1:1) supervision when out of bed; however, the facility did not ensure this assessed need was met. Interviews and record review revealed, on 08/07/2020, there was no staff to provide 1:1 supervision. One Certified Nurse Aide (CNA) was outside providing supervision during the residents' smoke break, one CNA was providing resident care in a resident room, and the nurse was administering medication. Resident #1 was sitting beside the medication cart while the nurse prepared medication to administer to a resident. There was a snack tray on the medication cart. Resident #1 grabbed a half of a peanut butter sandwich off the tray and ate half of the sandwich before the nurse could stop him/her. Resident #1 choked and staff provided Heimlich maneuver (abdominal thrusts to remove object causing to choke). Resident #1 coded and staff initiated Cardiopulmonary Resuscitation (CPR) (chest compressions often with artificial ventilation). Resident #1 was transferred to an acute care facility where he/she was intubated (insertion of a tube into the patient's body) and placed on a ventilator (machine that provides mechanical ventilation (air/breaths) and a feeding tube was placed. The facility's failure to provide adequate supervision to prevent accidents has caused or was likely to cause serious injury, harm, impairment, or death to a resident, Immediate Jeopardy was identified on 09/04/2020 and determined to exist on 08/07/2020. The facility was notified of the Immediate Jeopardy on 09/04/2020. An acceptable Credible Allegation of Compliance (AoC), related to the Immediate Jeopardy was received on 09/10/2020 alleging the Immediate Jeopardy was removed on 09/10/2020. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on 09/10/2020. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Interview with Regional Quality Manager #2 (RQM), Administrator, Administrator in Training (AIT), and Director of Nursing (DON), on 08/19/2020 at approximately 4:25 PM, revealed there was no facility policy that addressed 1:1 supervision. However, review of facility education documentation provided to staff on 06/13/19, 06/14/19, and 06/20/19 titled, Following Care Plans and Resident to Resident Procedure revealed when a resident was on 1:1 staffing, it was because the resident was evaluated as needing continuous supervision. This meant that the resident must always be in the line of sight of the staff member assigned to them and was a care-planned intervention. Further review of the education revealed not to leave the resident sitting, to attend to another resident or any other task unless someone else was watching them. Record review revealed the facility readmitted Resident #1 on 03/04/2020 with diagnoses, which included Dementia, Encephalopathy, Unspecified Psychosis, Anoxic Brain Damage, Altered Mental Status (AMS), Aphasia, and Dysphagia. Review of Resident #1's Comprehensive Care Plan for at risk for nutritional decline dated 11/18/19, revealed the resident was at risk due to Dementia, Behavior Disturbances, Psychosis, Depression, Anxiety, Pseudobulbar Affect, Anoxic Brain Damage, Encephalopathy, Cerebrovascular Disease, Muscle Weakness, Lack of Coordination, Altered Mental Status (AMS), Aphasia, Pain, Convulsions, Adult Failure to Thrive (AFTT), Bipolar, Risk for Malnutrition, Difficulty Chewing/Swallowing, and Edentulous. Further review of the care plan revealed a goal to tolerate diet without chewing or swallowing problems thru next review and an interventions for continual feeding assist at mealtimes, diet as ordered, and supervised meals as indicated for reaching in and getting food not on his/her diet. Review of Resident #1's Comprehensive Care Plan for alterations in mood/behavior and known for attempting to bite, grab, and scratch staff and other residents revealed an intervention dated 11/26/2019 to provide 1:1 until further notice when out of bed. Review of 100 Hall Nurses Book revealed a list of residents that were identified as at risk of taking food. Resident #1 was on this list. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 05/19/2020, revealed the facility assessed Resident #1's cognition as as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Further review of the MDS assessment, revealed the resident required supervision and meal setup, and had behaviors of scratching, hitting, screaming, and disruptive sounds toward others. Review of Speech Therapy Evaluation and Plan of Treatment, dated 07/13/2020, revealed Resident #1 was downgraded to a puree diet in September 2017, secondary to decreased toleration of mechanical soft diet. The evaluation revealed the resident's history included effects of anoxia with aphasia, mental impairments and decreased safety awareness; with background medical assessment to include combative and impulsive behaviors and resident has a habit of reaching out, and grabbing. Further review of the assessment revealed Resident #1 was at risk for aspiration, with recommendations of intake, puree consistencies; and close supervision. Review of 08/07/2020 Physician Orders, revealed Resident #1 was to receive a Dysphagia Pureed Consistency diet, and to provide 1:1 supervision when out of bed. Review of the Staff Assignment Sheet, for 08/07/2020 for 2:30 PM - 10:30 PM shift, revealed there was one nurse and two CNA's assigned to Resident #1's Unit. Review of a 1:1 documentation form, dated 08/07/2020, revealed LPN #1 had initialed she provided 1:1 supervision to Resident #1 from 6:00 PM-8:00 PM. Review of Nursing Progress Note, dated 08/07/2020 at 8:02 PM written by Licensed Practical Nurse (LPN) #1, revealed Resident #1 was in broda chair and was 1:1 with LPN #1, when LPN #1 witnessed resident taking a peanut butter sandwich from snack tray on cart in hallway. Resident #1 would not release sandwich and took a bite before LPN was able to remove from resident. Further review of the note revealed when LPN #1 attempted to redirect the resident, she saw the resident was showing signs of choking. LPN #1 encouraged resident to cough and resident unable to, so LPN attempted sweeping of mouth digitally, and then performed Heimlich maneuver multiple times and called for help. Resident produced small bolus of food from mouth but still showed signs of aspiration. Continued review of the note revealed LPN #2 (from another unit) came to assist LPN #1 with Heimlich; and an Automated External Defibrillator (AED) and Crash Cart were brought with O2 via nasal cannula applied and suction hooked up and provided. The physician was notified with orders received to send to emergency room (ER) and Emergency Medical System (EMS) called. The Nursing Note further revealed Resident became unconscious and cyanotic (bluish discoloration of skin related to an inadequate supply of oxygen being provided to the blood), pulse was not palpable, respirations ceased, and Resident's fingers and face began turning blue. Resident was full code so the LPN's initiated CPR. Resident gasped for air and began vomiting, was rolled to side, and resident color returned. Resident began using accessory muscles to breathe, pulse bounding, resident then began resisting care, kicking at staff while vomitus continued from mouth. Further review revealed at 8:18 PM, EMS was on site and took over care. Resident was kicking, coughing, and yelling while on stretcher and EMS left facility with emergency lights activated. Review of Emergency Department to Hospital admission records, dated 08/07/2020 at 8:30 PM, revealed Resident #1 from LTC (long term facility) apparently ate a peanut butter sandwich and became acutely choked and EMS was called, EMS retrieved a fair amount of peanut butter material out of oropharynx. However, resumption of normal oxygenation could not be accomplished and because of this Resident #1 was transported to hospital for further care. Resident was quite restless, and pulling at all equipment and fighting EMS and their ability to oxygenate resident. The last oxygen saturation EMS able to obtain was 71% and resident had blue lips upon arrival. Resident was intubated at 10:07 PM on 08/07/2020, and placed on a respirator with resident admitted . Interview with LPN #1, on 08/20/2020 at 9:46 AM and 11:45 AM, revealed there were two (2) CNA's and herself assigned to the unit. She stated she was administering medications, and one CNA was outside supervising resident smoke break and one CNA was providing care in a resident's room. She stated Resident #1 smokes but he/she was out of cigarettes so she was sitting to the left of the medication cart while she was administering medications and passing snacks since the two CNA's were busy. She stated while she was pouring a glass of water for another resident to take his/her medications, Resident #1 grabbed a half of a peanut butter sandwich off the snack tray on the med cart and took a bite (half of half of sandwich) before she was able to get the sandwich from him/her. LPN #1 revealed she saw Resident #1 was choking on the sandwich and saw CNA #1 coming up the hall and told her to get LPN #2 from the other hall. She stated they performed the Heimlich maneuver, and initiated CPR and tried to suction the resident because the resident had no pulse. She stated EMS arrived and took over care of the resident. LPN #1 stated Resident #1 was on 1:1 for a prior incident as he/she had grabbed another resident and given them a skin tear. She further revealed Resident #1 does get manic, upset, grabs at everything, and was an elopement risk as the resident tried to go to the door anytime he/she was up. Further interview with LPN #1, on 09/03/2020 at 2:25 PM, revealed she had received training in December 2019 or January 2020, related to Resident #1's being on 1:1 anytime out of bed. She stated a staff member (nurse or aide) had to be present and ensure the resident was out of reach or grabbing distance of other residents. LPN #1 revealed when giving medications and watching the resident on 1:1 that she pulled the resident along in his/her wheelchair (w/c), keeping the resident beside the med cart. She stated most of the time residents would be in their w/c and she gave their meds at their room door but if she had to go into a room it was only for a minute. She stated the nurse determines who does the 1:1, and when staff were doing 1:1, they still have other duties. LPN #1 stated that she was aware Resident #1's care plan stated that resident would grab food from other residents, and the resident's name was in the nurse book at the desk indicating would grab food. She stated she had also seen Resident #1 grab food out of another residents lap. She further stated she did not think the resident could reach the top of the med cart to grab the sandwich off the snack tray. Interview with LPN #2, on 08/20/2020 at 7:43 AM, and on 08/30/2020 at 12:30 AM, revealed he was on another hall and LPN #1 was the nurse on Resident #1's hall. LPN #2 stated CNA #1 screamed to him that Resident #1 was choking and he responded. He stated he saw Resident #1 about midway down the hall, on the floor, on his/her bottom, but slouched over with head falling down. He stated the resident's eyes were shut, lips were pale, and was not breathing, LPN #2 stated they performed the Heimlich maneuver on the resident three (3) times with nothing coming up, so they initiated CPR because the resident did not have a pulse. He revealed when they started compressions the resident tried to cough the food up and they turned him/her to side and got some to come out. He stated he opened the resident's mouth to see if could swipe anything out and could not so he suctioned the resident. He revealed an ambulance was called and the resident was transferred to the hospital. He revealed he thought the incident happened about 8:00 PM, because he was passing meds when called. LPN #2 revealed Resident #1 was on 1:1 and had been for a while. He stated the aides watched him/her or if the aides were busy, the nurse watched the resident. LPN #2 further revealed Resident #1 was on 1:1, because he/she grabbed things, was real mobile and strong. The resident could grab on to things, people and all kinds of things like that. He stated the resident was on a pureed diet. Interview with CNA #1, on 08/20/2020 at 12:17 PM, revealed she brought residents who smoke in from smoke break and was starting to get residents ready for the night when she came out of a resident's room and saw Resident #1 moving around on the hallway close to the medication cart. She stated she did not notice if Resident #1 had anything in his/her hand She revealed she thought LPN #1 was passing medications because the medication cart was at the back of the hallway. CNA #1 stated a little while after that she and CNA #2 were in hall talking about who we had left to take care of and which one would be taking break; when she observed LPN #1 and then heard her say Resident #1 was choking. She revealed she saw LPN #1 grab Resident #1 and do the Heimlich. She stated LPN #1 told her to get LPN #2 and she obtained crash cart and called 911. She stated the licensed staff had to perform CPR. She revealed Resident #1 was supposed to be on 1:1 when out of bed and someone was to be with him/her at all times and within touching distance. CNA #1 stated they do not have enough staff to provide 1:1. Interview with CNA #2, on 08/21/2020 at 9:27 AM and 08/31/2020 at 3:31 PM, revealed Resident #1 was on 1:1 supervision when out of bed but there was not enough staff to provide 1:1 care. CNA #2 stated the last time she saw Resident #1, he/she was roaming hallway. She revealed staff were not allowed to put the brakes on the resident's chair because it was considered a restraint. CNA #2 stated the nurse was in a room administering medication at the back of the hall, Resident #1 was roaming the hall, and she was in the shower room disposing of dirty laundry. CNA #2 stated when she came out of shower room, she saw the nurse place something on the medication cart, push the cart away, grab Resident #1, and perform the Heimlich maneuver on the resident. She stated she did not see the resident grab the sandwich and did not see any remains of peanut butter sandwich or the plastic bag it came in. She revealed LPN #1 told her that Resident #1 had grabbed a peanut butter sandwich. CNA #2 stated the snack tray was on the end of the med cart, because the nurse served the nighttime snacks as she passed meds. CNA #2 stated Resident #1 was acting like he/she was choking and his/her color went from pink to blue. She revealed LPN #2 and LPN #1 provided CPR when Resident #1 coded. She stated EMS was called and arrived to transport Resident #1 to the hospital. CNA #2 stated we do not have the staff to sit with the resident 1:1, so no one does 1:1, we just watch resident while doing care on the hall and sometimes the nurse watched the resident. CNA #2 further stated Resident #1 grabbed staff and residents, and anything else in reach. Interview with hospital Advanced Registered Nurse Practitioner (ARNP), on 08/21/2020 at 10:05 AM, revealed Resident #1 was brought into ER with blue lips, O2 in 70's and restless but alert and altered level of consciousness (ALOC). She stated a video assisted intubation was provided, and the resident was admitted to hospital with acute hypoxic respiratory failure, aspiration, and was put on ventilator for hypoxic respiratory failure at time of intubation. She stated she consulted an ear/nose/throat (ENT) specialist for trach but it has not been done yet, the plan was for 08/21/2020. She revealed she did not know when the resident would be discharged as he/she may have to go to long term acute care at the hospital to get off the ventilator Interview with Registered Nurse (RN) #2, on 08/23/2020 at 12:40 AM, revealed 1:1 meats the resident was at least in eyesight; if not right beside staff. She stated she did not think there was enough staff to provide 1:1 supervision for Resident #1. RN #2 revealed the few times that she provided care for Resident #1 it was a struggle. She stated the resident's behavior was to grab anything off the desk or carts. In addition, the resident would pull things out of staff pockets, and would pull lanyard off of staff's neck. She further revealed the resident would grab anything within reach, even in his/her room, the resident would reach and try to pull his/her TV off the table. Interview on 08/26/2020 at 5:51 PM, with CNA #16, revealed when Resident #1 was out of bed the resident was supposed to be 1:1, because the resident was feisty and would grab people and stuff. Interview with Social Services Director (SSD) #2, on 08/20/2020 at approximately 3:35 PM, revealed Resident #1 had been on 1:1 for quite some time, and was constantly reaching out grabbing residents. She stated the resident had scratched them, was a constant wanderer, and would try to get out the doors. She stated the resident needed staff within arms length of him/her at all times while out of bed (OOB). She stated she was sure Resident #1 grabbed food, as he/she liked to grab just about anything, and she believed Resident #1 was on a mechanical soft or pureed diet. Interview with Staff Development Coordinator (SDC), on 08/20/2020 at 3:36 PM, revealed Resident #1 must be constantly observed when up. She stated the resident was care planned for 1:1 supervision and needed to be constantly observed. She stated staff needed to be pretty close as that was the reason for 1:1 supervision. Interview with Administrator, on 09/01/2020 at 3:20 PM, 09/02/2020 at 9:45 AM and 09/03/2020 at 4:42 PM, revealed when asked what 1:1 entailed for a resident she stated it depended on the reason the resident was on 1:1. She stated Resident #1 was care planned for 1:1 supervision when out of bed due to grabbing and scratching other residents, so the staff only had to keep the resident in line of sight to ensure the resident was not within reaching distance of another resident. She stated she was not aware the resident would constantly grab items and people and was care planned for grabbing food not on his/her diet. Further interview with Administrator, on 09/15/2020 at 3:45 PM, revealed Resident #1 was still in the hospital and remained intubated with a tracheotomy, on a ventilator, and a nasogastric tube for feeding. The Administrator further revealed the facility had identified the snacks were being left on the medication cart while the nurse was passing medications which enabled residents to have access to food that was not on their prescribed diets. She stated staff had been educated to ensure snacks were kept at nursing station and each snack passed out from there by a staff member so snacks were not left unsupervised with residents having access to them. However, observation on 09/04/2020 at 10:02 AM, revealed a dietary staff delivered the snacks to the nurse on the 200 hall. The nurse went down the hall and placed the snack tray on the med cart. Further observation revealed the nurse obtained a snack from the tray then delivered the snack to resident in their room, leaving snack tray on the cart unsupervised. There was a half peanut butter sandwich and peanut butter crackers still on the snack tray. The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #1 was transferred from the facility on 08/07/2020 and has not returned to the facility. 2. The Dietary Manager provided a list of all current residents on mechanical altered diets (17 residents) on 09/08/2020. The Administrator completed a review of the care plans of residents with mechanical soft and pureed diets in regard for the potential for reaching for food not on their meal tray. 3. The Administrator, Social Service Director, and/or licensed nurse completed a review of psychosocial/behavior care plans for any resident currently identified as requiring 1:1 supervision, on 09/08/2020. There were no additional residents at this time requiring 1:1 supervision. This was completed on 09/08/2020. 4. The Regional Director of Operations provided education to the Administrator on 09/04/2020 regarding: One-to-one supervision regarding one staff member dedicated to the supervision of one resident with no other assigned duties during the time. 5. The Regional Quality Manager (RQM) provided education to the Director of Nursing (DON) on 09/04/2020 regarding: One to one supervision requires one staff member dedicated to the supervision of one resident with no other assigned duties during this time. Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. Dietary would provide a list of mechanically altered diets and thickened liquids with each snack pass delivery. All snacks would be placed in a covered container by the dietary staff prior to handling off to nursing staff. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. 6. The DON provided education to assigned licensed nurses (4) and director of medical records/medication technician (a train the trainer education) on 09/04/2020 through 09/06/2020 regarding: One to one supervision requires one staff member dedicated to the supervision of one resident with no other assigned duties during this time. To notify the Administrator and/or the Director of Nursing when there was a need to add a care plan intervention for 1:1 supervision of a resident. The care plan was to be implemented as indicated for 1:1 supervision. Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. Dietary would provide a list of mechanically altered diets and thickened liquids with each snack pass delivery. All snacks would be placed in a covered container by the dietary staff prior to handling off to nursing staff. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. 7. Education was provided to the facility nursing staff, (licensed nurses and nursing assistants), and facility dietary staff by the DON, Administrator, and Regional Quality Manager beginning 09/04/2020 through 09/09/2020, regarding: Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. Dietary would provide a list of mechanically altered diets and thickened liquids with each snack pass delivery. All snacks would be placed in a covered container by the dietary staff prior to handling off to nursing staff. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. 8. Verbal acknowledgement of understanding along with signed education was obtained after the inservice. The facility employs no agency staff. Employed nursing or contracted dietary staff currently on leave or newly hired to the facility will receive this education from the DON or assigned facility manager before assuming duties. 9. The Regional Quality Manager provided education to the DON on 09/08/2020 regarding: To notify the Administrator and/or the DON when there was a need to add a care plan intervention for 1:1 supervision of a resident. The care plan was to be implemented as indicated for 1:1 supervision. 10. The DON provided education (train the trainer) to the staff development Coordinator on 09/08/2020 regarding: One to one supervision requires one staff member dedicated to the supervision of one resident with no other assigned duties during this time. To notify the Administrator and/or the DON when there was a need to add a care plan intervention for 1:1 supervision of a resident. The care plan was to be implemented as indicated for 1:1 supervision. Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. Dietary would provide a list of mechanically altered diets and thickened liquids with each snack pass delivery. All snacks would be placed in a covered container by the dietary staff prior to handling off to nursing staff. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. 11. The Regional Quality Manager, the DON and or Staff Development Coordinator (SDC) provided education to the licensed nursing staff on 09/08/2020 regarding: One to one supervision requires one staff member dedicated to the supervision of one resident with no other assigned duties during this time. To notify the Administrator and/or the DON when there was a need to add a care plan intervention for 1:1 supervision of a resident. The care plan was to be implemented as indicated for 1:1 supervision. 12. Verbal acknowledgement of understanding along with signed education was obtained after the inservices. The facility employs no agency staff. Employed nursing or contracted dietary staff currently on leave or newly hired to the facility will receive this education from the DON or assigned facility manager before assuming duties. 13. An ad-hoc meeting was held on 09/04/2020 to review the summary of Immediate Jeopardy findings and discuss the development of the action items to be completed. This meeting included the Administrator, DON, Social Services, Activities, Dietary, Therapy, and MDS. This information was reviewed with the facility Medical Director by the Administrator via the phone on 09/04/2020. 14. The Administrator, Assistant Administrator, DON, and/or Weekend Department Manager Supervisor would observe five (5) times (X) a week on various shifts to include weekends for two (2) weeks, then three (3) X week for two (2) weeks, then two (2) X week for four (4) weeks for the following: All snacks would be placed in a covered container by dietary staff. Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. The nursing staff member would place the container on the ice chest cart and begin snack pass to the residents. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. Any identified concern will be addressed at the time of discovery by the monitor. The audit began on 09/04/2020. 15. In the morning clinical meeting beginning 09/08/2020, the Administrator, the DON, and/or assigned licensed nursing staff would review the plan of care for all residents requiring 1:1 supervision. 16. The Administrator or the DON would review and sign off on the staffing assignments sheets daily in regards to potential need for any 1:1 supervision. A review of the weekend staffing sheet would be completed on Fridays. The Administrator, the DON was to be notified at any time a resident required a 1:1 supervision. 17. Beginning 09/08/2020, the DON and/or assigned licensed staff would audit five (5) residents requiring 1:1 supervision, risk for diet non-compliance, and/or (if no 1:1 supervision) with mechanically altered diets weekly times four (4) weeks for: Care plans interventions in place and observe the resident for care plan implementation as written in the plan of care 18. The results of the monitoring would be reviewed at a minimum of weekly in the QAPI meetings being held to track the facility's progress toward regulatory compliance. 19. A second ad hoc QAPI meeting was held on 09/08/2020, to review the initial audit findings of the list of residents with mechanically altered diets and subsequent care plan review. This meeting included the Administrator, DON, Social Services, Dietary, Activities, and MDS. This information was reviewed with the facility Medical Director by the Administrator via the phone, on 09/08/2020. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of Notice of Emergency Transfer and Nurses Progress, dated 08/07/2020 at 8:20 PM, revealed Resident #1 was sent to hospital via EMS (emergency management services) related to choking incident. Interview with Administrator, on 09/15/2020 at 3:45 PM, revealed Resident #1 had not returned from the hospital. 2. Interview with Dietary Manager on 09/15/2020 at 11:40 AM revealed she provided a list of residents who were on a mechanically altered diet to the Administrator. Review of care plans of residents that were identified as on mechanically altered diets revealed the Administrator reviewed the care plans, on 09/08/2020 to ensure if resident was known to grab food; it was addressed on the resident's care plan. Interview on 09/15/2020 at 3:45 PM, with Administrator revealed she had reviewed dietary needs of residents with mechanical soft and pureed diets in regard for the potential for reaching for food not on their meal tray. 3. Interviews on 09/15/2020 with Administrator at 3:45 PM, Social Service Director at 10:15 AM, and Director of Nursing (DON) at 12:00 PM revealed there were no additional residents at this time requiring 1:1 supervision. 4. Interview on 09/15/2020 at 3:05 PM, with Regional Quality Manager, revealed the Regional Director of Operations provided education to the Administrator, on 09/04/2020. Interview with Administrator, on 09/15/2020 at 3:45 PM, revealed she was educated by the Regional Director of Operations to ensure staffing would be provided for 1:1 supervised residents with no other duties assigned to that staff member. Review of education documentation revealed the Administrator signed the form indicating she had received education related to one staff member dedicated to the supervision of one resident with no other assigned duties during the time provided on 09/04/2020 5. Interview with the Regional Quality Manager (RQM) revealed she provided education to the Director of Nursing (DON), on 09/04/2020. Interview with DON, on 09/15/2020 at 12:00 PM, revealed she was educated by RQM to ensure if there was 1:1 supervision of a resident, then a staff member would be assigned and have no other duties. She stated in addition she was educated on the new process of dietary delivering, and nursing storing and delivering dietary snacks. 6. Interview with DON, on 09/15/2020 at 12:00 PM, revealed she provided education to SDC, LPN #4 and weekend staff, on 09/04/2020 through 09/06/2020, to ensure they knew the requirements for the 1:1 supervision and snack pass process. Interviews on 09/15/2020 with LPN #1 at 11:20 AM, LPN #2 at 3:11 PM, CNA #1 at 2:25 PM, and CNA #2 at 3:28 PM, revealed they were educated on 1:1 supervision, the new snack pass process and snack requirement, and care plan implementation. They also stated they were educated to call DON and/or Administrator when a resident was placed on 1:1. 7. Interviews on 09/14/2020 with LPN #5 at 4:20 PM, LPN #7 at 4:27 PM, and LPN #3 at 4:30 PM; on 09/15/2020 with Dietary Manager at 11:40 AM, Dietary Aide #1 at 2:30 PM, Dietary Aide #2 at 2:50 PM, SDC at 10:15 AM, SSD at 10:15 AM, KMA#1/Director of Medical Records/Central Supply at 11:00 AM, LPN #1 [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the Staff Assignment Sheet, facility education documentation, hospital records, and facility policy review, it was determined the facility failed to ensure sufficient staff had the appropriate competencies and skill sets to provide nursing and related services to ensure one (1) of four (4) sampled residents (Resident#1) safety as determined by resident assessments and care plans. The facility assessed and care planned Resident #1 with a history of grabbing food off trays, was at risk for choking, and required 1:1 supervision when out of bed. However, on 08/07/2020, the facility did not assign staff to provide 1:1 supervision, due to insufficient staffing. Interview with Licensed Practical Nurse (LPN) #1 revealed Resident #1 was kept within line of sight during medication pass due to not having enough staff to implement the required 1:1 supervision. In addition, LPN #1 stated she placed a tray of snacks on top of the medication cart with Resident #1 near the cart. Resident #1 grabbed a half of a peanut butter sandwich off the tray and consumed half the sandwich before staff intervention. Resident #1 became choked with staff providing Heimlich (abdominal thrusts to remove object causing to choke) and Cardiopulmonary Resuscitation (CPR) (chest compressions with artificial respirations). Resident #1 was transferred to an acute care facility where he/she was intubated, placed on a ventilator and a (Nasogastric tube) feeding tube was placed. The facility's failure to provide sufficient staff to provide nursing and related services has caused or was likely to cause serious injury, harm, impairment, or death to a resident, Immediate Jeopardy was identified on 09/04/2020 and determined to exist on 08/07/2020. The facility was notified of the Immediate Jeopardy on 09/04/2020. An acceptable Credible Allegation of Compliance (AoC), related to the Immediate Jeopardy was received on 09/10/2020 alleging the Immediate Jeopardy was removed on 09/10/2020. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on 09/10/2020. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Interview with the Administrator, on 09/15/2020 at 3:45 PM, revealed the facility did not have a staffing policy. Review of facility policy titled, Facility Assessment Tool Record dated 03/26/2020, revealed care provision was monitored on a daily basis to ensure that each resident received the care and services that were dictated by the plan of care. Staffing patterns were reviewed on a daily basis. The facility worked to cover the needs of residents on a daily basis, including accounting for call-ins, etc. This was an approach to staffing to ensure sufficient staff to meet the needs of the residents at any given time based on resident population and their needs for care and support. Review of facility education documentation provided to staff, on 06/13/19, 06/14/19, and 06/20/19, titled, Following Care Plans and Resident to Resident Procedure, revealed when a resident was on 1:1 staffing it was because they have been evaluated as needing continuous supervision. This meant that these residents must always be in the line of sight of the staff member assigned to them. Staff cannot leave the resident sitting unattended while attending to another resident or any other task unless someone else was watching them. Record review revealed the facility admitted Resident #1 on 03/21/2013 and readmitted on [DATE] with diagnoses, which included Dementia, Encephalopathy, Unspecified Psychosis, Anoxic Brain Damage, Altered Mental Status (AMS), Aphasia, and Dysphagia. Review of a Speech Therapy Evaluation dated 07/13/2020; a Comprehensive Care Plan for at risk for nutritional decline, dated 11/18/19; and a Comprehensive Care Plan for alterations in mood/behavior revealed, Resident #1 was was assessed and care planned to require 1:1 Supervision due to grabbing food not on his/her diet, and having behaviors of scratching, hitting, and grabbing others. Review of Daily Staffing Sheet, dated 08/07/2020, revealed there was one nurse and two Certified Nurse Aides (CNA's) assigned to Resident #1's unit on the 2:30 PM-10:30 PM shift. Further review revealed there was no one assigned for 1:1 supervision of Resident #1. Review of Nurses Note, dated 08/07/2020 at 8:02 PM by LPN #1, revealed LPN #1 witnessed Resident #1 take a peanut butter sandwich from snack tray on medication cart in hallway and take a large bite of sandwich before LPN #1 could get sandwich from resident. The Resident choked and licensed staff performed the Heimlich maneuver multiple times, and the resident coded with staff providing CPR with success. EMS arrived and took over care of Resident #1 and transported resident to hospital. Review of Emergency Department to Hospital admission Records dated 08/07/2020 at 8:30 PM and interview with hospital Advanced Registered Nurse Practitioner (ARNP), on 08/21/2020 at 10:05 AM, revealed Resident #1 had to be intubated and placed on respirator and admitted to hospital with acute hypoxic respiratory failure and aspiration. An ear/nose/throat (ENT) specialist was consulted for a tracheotomy and it was planned for 08/21/2020. Resident may have to be discharged to go to long-term acute care at the hospital to get off the vent. Interview with Administrator, on 09/15/2020 at 3:45 PM, revealed the resident was still in the hospital and remained intubated with a tracheotomy, on a ventilator, and a nasogastric tube for feeding. Interview with LPN #1, on 08/20/2020 at 9:46 AM, 11:45 AM and on 09/03/2020 at 2:25 PM, revealed, Resident #1 required 1:1 supervision and she did not have enough staff to provide 1:1. She stated she tried to call another CNA into work to provide the 1:1, with no success. She stated one CNA was supervising resident smoke break outside, one CNA was providing resident care in room, and she was administering medications and had placed the snack tray on the medication cart, so she could administer snacks at the same time. She revealed Resident #1 smoked but was out of cigarettes so she had no choice but to try to keep Resident #1 by the medication cart while she administered the medications and passed snacks. She stated as she was pouring a cup of water to administer another resident's medications, Resident #1 grabbed a half of a peanut butter sandwich off of med cart and had eaten half of it before she could stop the resident. LPN #1 stated the facility had sitters for Resident #1, but the sitters were done away with, and the routine scheduled staff had to provide 1:1 supervision along with the duties they already had. Interview with CNA #1, on 08/20/2020 at 7:41 AM, and CNA #2 on 08/21/2020 at 9:27 AM and 08/31/2020 at 3:31 PM, revealed CNA #1 was outside providing supervision for residents' smoke break and CNA #2 was in a resident's room providing resident care. The CNA's stated Resident #1 was sitting in the hallway but they were not paying attention to Resident #1. The CNA's revealed Resident #1 was supposed to be on 1:1 when out of bed and someone was to be with him/her at all times and within touching distance. The CNA's stated they did not have enough staff to provide 1:1 to the resident so the resident wandered up and down the hall and the staff on the hall tried to keep an eye on the resident. CNA #2 revealed the facility used to have a sitter for Resident #1, but now staff have to watch the resident but there was no one to assign to watch the resident on their shift. Interview with Registered Nurse (RN) #2, on 08/23/2020 at 12:40 AM, revealed she did not think there was enough staff to do 1:1 with Resident #1. RN #2 stated the few times that she provided care for Resident #1 it was a struggle. She revealed the resident's behavior was to grab anything off the desk or a cart. She stated the resident would pull things out of staff pockets, and would pull lanyard off staff's neck. She stated the resident would even reach from the bedside to grab the television and try to pull it off the table in his/her room. Interview with Unit Manager (UM) #1, on 09/03/2020 at 2:10 PM, revealed the staff for each hall stayed the same on the Day Shift (6AM-6:00 PM), with one nurse and three aides for halls 100 and 200; and one nurse and two aides on 300 hall. She stated when there was a resident that required 1:1 supervision they were able to pull the Hospitality Aide, Restorative Aide or transportation aide when needed. She stated on Night Shift (6:00 PM-6:00 PM) there were five (5) CNA's and three nurses in building and a Kentucky Medication Assistant, four nights a week. She stated the hospitality aide, restorative aide, and transportation aide would not be available on night shift. She further revealed if there is not enough staff to provide 1:1, the nurse could call a CNA into work. She stated staff were not necessarily assigned to do 1:1 with other duties, but if able to watch the resident and keep in view, it would be okay. She stated Resident #1 was mobile in his/her broda chair and would grab staff, residents and other items when saw them. She was not aware the resident would grab food. Interview with the Director of Nursing (DON) (hired 08/10/2020) and Administrator, on 09/03/2020 at 11:20 AM, revealed the Unit Managers and Staff Development Coordinator do the daily staffing sheets. The DON stated staffing was determined by the amount of activity going on. The DON revealed staff had been moved around since COVID, as all three (3) halls used to have the same amount of staff. She stated since the 300 hall was now used mainly for new admits and possible COVID residents, there were less residents on the hall and the 300 hall had less staff. She stated when there was a resident on 1:1, it was handled with staff throughout the building not just that unit. The Administrator and DON both were not able to describe exactly how they determined the number of staff that were required on each unit. The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #1 was transferred from the facility on 08/07/2020 and has not returned to the facility. 2. The Dietary Manager provided a list of all current residents on mechanical altered diets (17 residents) on 09/08/2020. The Administrator completed a review of the care plans of residents with mechanical soft and pureed diets in regard for the potential for reaching for food not on their meal tray. 3. The Administrator, Social Service Director, and/or licensed nurse completed a review of psychosocial/behavior care plans for any resident currently identified as requiring 1:1 supervision, on 09/08/2020. There were no additional residents at this time requiring 1:1 supervision. This was completed on 09/08/2020. 4. The Regional Director of Operations provided education to the Administrator on 09/04/2020 regarding: One-to-one supervision regarding one staff member dedicated to the supervision of one resident with no other assigned duties during the time. 5. The Regional Quality Manager (RQM) provided education to the Director of Nursing (DON) on 09/04/2020 regarding: One to one supervision requires one staff member dedicated to the supervision of one resident with no other assigned duties during this time. Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. Dietary would provide a list of mechanically altered diets and thickened liquids with each snack pass delivery. All snacks would be placed in a covered container by the dietary staff prior to handling off to nursing staff. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. 6. The DON provided education to assigned licensed nurses (4) and director of medical records/medication technician (a train the trainer education) on 09/04/2020 through 09/06/2020 regarding: One to one supervision requires one staff member dedicated to the supervision of one resident with no other assigned duties during this time. To notify the Administrator and/or the Director of Nursing when there was a need to add a care plan intervention for 1:1 supervision of a resident. The care plan was to be implemented as indicated for 1:1 supervision. Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. Dietary would provide a list of mechanically altered diets and thickened liquids with each snack pass delivery. All snacks would be placed in a covered container by the dietary staff prior to handling off to nursing staff. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. 7. Education was provided to the facility nursing staff, (licensed nurses and nursing assistants), and facility dietary staff by the DON, Administrator, and Regional Quality Manager beginning 09/04/2020 through 09/09/2020, regarding: Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. Dietary would provide a list of mechanically altered diets and thickened liquids with each snack pass delivery. All snacks would be placed in a covered container by the dietary staff prior to handling off to nursing staff. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. 8. Verbal acknowledgement of understanding along with signed education was obtained after the inservice. The facility employs no agency staff. Employed nursing or contracted dietary staff currently on leave or newly hired to the facility will receive this education from the DON or assigned facility manager before assuming duties. 9. The Regional Quality Manager provided education to the DON on 09/08/2020 regarding: To notify the Administrator and/or the DON when there was a need to add a care plan intervention for 1:1 supervision of a resident. The care plan was to be implemented as indicated for 1:1 supervision. 10. The DON provided education (train the trainer) to the staff development Coordinator on 09/08/2020 regarding: One to one supervision requires one staff member dedicated to the supervision of one resident with no other assigned duties during this time. To notify the Administrator and/or the DON when there was a need to add a care plan intervention for 1:1 supervision of a resident. The care plan was to be implemented as indicated for 1:1 supervision. Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. Dietary would provide a list of mechanically altered diets and thickened liquids with each snack pass delivery. All snacks would be placed in a covered container by the dietary staff prior to handling off to nursing staff. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. 11. The Regional Quality Manager, the DON and or Staff Development Coordinator (SDC) provided education to the licensed nursing staff on 09/08/2020 regarding: One to one supervision requires one staff member dedicated to the supervision of one resident with no other assigned duties during this time. To notify the Administrator and/or the DON when there was a need to add a care plan intervention for 1:1 supervision of a resident. The care plan was to be implemented as indicated for 1:1 supervision. 12. Verbal acknowledgement of understanding along with signed education was obtained after the inservices. The facility employs no agency staff. Employed nursing or contracted dietary staff currently on leave or newly hired to the facility will receive this education from the DON or assigned facility manager before assuming duties. 13. An ad-hoc meeting was held on 09/04/2020 to review the summary of Immediate Jeopardy findings and discuss the development of the action items to be completed. This meeting included the Administrator, DON, Social Services, Activities, Dietary, Therapy, and MDS. This information was reviewed with the facility Medical Director by the Administrator via the phone on 09/04/2020. 14. The Administrator, Assistant Administrator, DON, and/or Weekend Department Manager Supervisor would observe five (5) times (X) a week on various shifts to include weekends for two (2) weeks, then three (3) X week for two (2) weeks, then two (2) X week for four (4) weeks for the following: All snacks would be placed in a covered container by dietary staff. Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. The nursing staff member would place the container on the ice chest cart and begin snack pass to the residents. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. Any identified concern will be addressed at the time of discovery by the monitor. The audit began on 09/04/2020. 15. In the morning clinical meeting beginning 09/08/2020, the Administrator, the DON, and/or assigned licensed nursing staff would review the plan of care for all residents requiring 1:1 supervision. 16. The Administrator or the DON would review and sign off on the staffing assignments sheets daily in regards to potential need for any 1:1 supervision. A review of the weekend staffing sheet would be completed on Fridays. The Administrator, the DON was to be notified at any time a resident required a 1:1 supervision. 17. Beginning 09/08/2020, the DON and/or assigned licensed staff would audit five (5) residents requiring 1:1 supervision, risk for diet non-compliance, and/or (if no 1:1 supervision) with mechanically altered diets weekly times four (4) weeks for: Care plans interventions in place and observe the resident for care plan implementation as written in the plan of care 18. The results of the monitoring would be reviewed at a minimum of weekly in the QAPI meetings being held to track the facility's progress toward regulatory compliance. 19. A second ad hoc QAPI meeting was held on 09/08/2020, to review the initial audit findings of the list of residents with mechanically altered diets and subsequent care plan review. This meeting included the Administrator, DON, Social Services, Dietary, Activities, and MDS. This information was reviewed with the facility Medical Director by the Administrator via the phone, on 09/08/2020. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of Notice of Emergency Transfer and Nurses Progress, dated 08/07/2020 at 8:20 PM, revealed Resident #1 was sent to hospital via EMS (emergency management services) related to choking incident. Interview with Administrator, on 09/15/2020 at 3:45 PM, revealed Resident #1 had not returned from the hospital. 2. Interview with Dietary Manager on 09/15/2020 at 11:40 AM revealed she provided a list of residents who were on a mechanically altered diet to the Administrator. Review of care plans of residents that were identified as on mechanically altered diets revealed the Administrator reviewed the care plans, on 09/08/2020 to ensure if resident was known to grab food; it was addressed on the resident's care plan. Interview on 09/15/2020 at 3:45 PM, with Administrator revealed she had reviewed dietary needs of residents with mechanical soft and pureed diets in regard for the potential for reaching for food not on their meal tray. 3. Interviews on 09/15/2020 with Administrator at 3:45 PM, Social Service Director at 10:15 AM, and Director of Nursing (DON) at 12:00 PM revealed there were no additional residents at this time requiring 1:1 supervision. 4. Interview on 09/15/2020 at 3:05 PM, with Regional Quality Manager, revealed the Regional Director of Operations provided education to the Administrator, on 09/04/2020. Interview with Administrator, on 09/15/2020 at 3:45 PM, revealed she was educated by the Regional Director of Operations to ensure staffing would be provided for 1:1 supervised residents with no other duties assigned to that staff member. Review of education documentation revealed the Administrator signed the form indicating she had received education related to one staff member dedicated to the supervision of one resident with no other assigned duties during the time provided on 09/04/2020 5. Interview with the Regional Quality Manager (RQM) revealed she provided education to the Director of Nursing (DON), on 09/04/2020. Interview with DON, on 09/15/2020 at 12:00 PM, revealed she was educated by RQM to ensure if there was 1:1 supervision of a resident, then a staff member would be assigned and have no other duties. She stated in addition she was educated on the new process of dietary delivering, and nursing storing and delivering dietary snacks. 6. Interview with DON, on 09/15/2020 at 12:00 PM, revealed she provided education to SDC, LPN #4 and weekend staff, on 09/04/2020 through 09/06/2020, to ensure they knew the requirements for the 1:1 supervision and snack pass process. Interviews on 09/15/2020 with LPN #1 at 11:20 AM, LPN #2 at 3:11 PM, CNA #1 at 2:25 PM, and CNA #2 at 3:28 PM, revealed they were educated on 1:1 supervision, the new snack pass process and snack requirement, and care plan implementation. They also stated they were educated to call DON and/or Administrator when a resident was placed on 1:1. 7. Interviews on 09/14/2020 with LPN #5 at 4:20 PM, LPN #7 at 4:27 PM, and LPN #3 at 4:30 PM; on 09/15/2020 with Dietary Manager at 11:40 AM, Dietary Aide #1 at 2:30 PM, Dietary Aide #2 at 2:50 PM, SDC at 10:15 AM, SSD at 10:15 AM, KMA#1/Director of Medical Records/Central Supply at 11:00 AM, LPN #1 at 11:20 AM, DON at 12:00 PM, UM #2 at 2:50 PM, RQM at 3:05 PM, LPN #2 at 3:11 PM, CNA #1 at 2:25 PM, CNA #2 at 3:28 PM, and CNA #4 at 1:58 PM revealed they were educated on the new process for resident snack delivery and storage. Observation on 09/14/2020 at 2:10 PM, revealed staff followed the new snack pass guidelines. 8. Review of education documentation revealed all nursing staff and dietary staff signed the education to acknowledge understanding of education. Additionally, interview with LPN #7 (new hire), on 09/14/2020 at 4:27 PM, revealed she was educated on the new process for snacks, 1:1 resident supervision and care plan implementation. 9. Interview on 09/15/2020 at 3:05 PM, with Regional Quality Manager, revealed she provided education to the DON, on 09/08/2020, to ensure she was aware she and/or the Administrator should be notified when a resident was placed on 1:1, and the care plan was to be implemented, as indicated for 1:1 supervision. Interview with DON, on 09/15/2020 at 12:00 PM, revealed she was educated on being notified if a resident was placed on 1:1, and care plan implementation of 1:1 by RQM. Review of education documentation dated 09/08/2020, revealed the DON signed the form indicating she understood the education provided by the RQM. 10. Review of education documentation (train the trainer) provided by DON to the Staff Development Coordinator (SDC), on 09/08/2020, revealed the DON educated the SDC and the SDC signed the form indicating she understood the education. Interview with SDC, on 09/15/2020 at 10:00 AM and 4:00 PM, revealed she was educated by the DON on the new snack process, that the DON and the Administrator must be notified if a resident was placed on 1:1 supervision, and that staff assigned to that resident would have no other duties but the 1:1. 11. Interviews on 09/14/2020 with LPN #7 at 4:27 PM; on 09/15/2020 with LPN #1 at 11:20 AM, LPN #2 at 3:11 PM, LPN #3 at 4:30 PM, and LPN #5 at 4:20 PM, revealed they were educated that staff assigned 1:1 supervision of a resident would not be assigned any other duties, nursing staff were to notify DON and/or the Administrator if a resident was placed on 1:1, and care plan implementation of the 1:1 supervision. Review of education documentation revealed all licensed nursing staff signed they understood the education provided on 09/08/2020 12. Interviews on 09/15/2020 LPN #1 at 11:20 AM, LPN #2 at 3:11 PM, CNA #1 at 2:25 PM, and CNA #2 at 3:28 PM, revealed verbal acknowledgement of provision of education and signing of signature page for verification of education. 13. Interviews on 09/15/2020 with Administrator at 3:45 PM, DON at 12:00 PM, SSD at 10:15 AM, Dietary at 11:40 PM; and Therapy at 2:15 PM revealed an ad-hoc meeting was held on 09/04/2020 to review the summary of Immediate Jeopardy findings with discussion of action plan to address findings of Immediate Jeopardy. Interview with Administrator on 09/15/2020 at 3:45 PM, and with Medical Director on 09/15/2020 at 4:14 PM, revealed the Administrator made the Medical Director aware of the action plan and obtained his input. 14. Review of the Monitoring Tools for Snack Pass, revealed monitoring was conducted five times during the week of 09/04-09/11/20 and continued to be completed with no concerns identified. The monitors were signed by the DON/or weekend supervisor. 15. Interviews on 09/15/2020 with Administrator at 3:45 PM, Administrator in Training (AIT) at 9:37 AM and at 3:45 PM, the DON at 12:00 PM, UM #2 at 2:50 PM, and MDS #1 at 4:06 PM revealed there were no residents on 1:1 at this time but were aware they would review care plans for all residents requiring 1:1 supervision. Review of a facility form that was developed to use to review the plans of care revealed a place to document Resident Name, Follow-up needed, Initials, Assigned to, and date. 16. Interview on 09/15/2020 with the DON at 3:45 PM, the AIT at 9:37 AM and 3:45 PM, and the Administrator at 3:45 PM, revealed they were to be notified at any time a resident required a 1:1 supervision, and that the staffing sheets were being reviewed daily and weekend staffing sheets reviewed on Friday, but at this time there were no residents on 1:1 supervision. A list of reviewed staffing sheets was present in the AOC binder for review 17. Interview on 09/15/2020 at 12:00 PM, with DON, revealed she was auditing accuracy of care plans related to supervision of 1:1, dietary needs, and watched a meal of audited resident that day. 18. Review of documented QAPI meetings revealed a review of facility progress with discussion of any issues dealt with immediately upon point of discovery. Interview on 09/15/2020 with DON at 12:00 PM, Administrator at 3:45 PM, AIT at approximately 9:37 AM and 3:45 PM, revealed they were meeting weekly to discuss any issues identified with during monitoring. 19. Interviews on 09/15/2020 with SSD at 10:15 AM, Dietary Manager at 11:40 AM, DON at 12:00 PM, Administrator at 3:45 PM, AIT at 9:37 AM and 3:45 PM, MDS at 4:06 PM and Medical Director at 4:14 PM revealed there were ongoing reviews of facility's progress toward compliance.