**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #53 was admitted to the facility in December 2021 with diagnoses including dysphagia, secondary Parkinsonism, and history of falling. Review of Resident #53's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident's cognitive ability was not assessed. The MDS also indicated Resident #53 required extensive assistance from staff for all mobility tasks. On 10/24/23 at 12:15 P.M., Resident #53 was observed eating lunch in the dining room. The Resident's meal tray consisted of pasta not cut up, large broccoli pieces, and a full piece of garlic bread. On 10/25/23 at 12:24 P.M., Resident #53 was observed eating in his/her room with a family friend. The Resident was eating blueberries in yogurt and had a mouthful of blueberries while starting to take another bite. The family friend was not providing the Resident with any cues to slow down and, when asked, could not say if the Resident had any need for assistance with meals. On 10/25/23 at 12:25 P.M., Nurse #5 said he was unaware Resident #53's friend provided him/her with food and did not check the food to see if it followed the Resident's ordered diet. On 10/25/23 at 12:28 P.M., Nurse #1 said she was aware Resident #53's friend [NAME] him/her food and said she did not check the food to ensure it followed the Resident's ordered diet. On 10/26/23 at 8:28 A.M., Resident #53 was given his/her meal in his/her room. Resident #53 was left unsupervised while he/she ate the meal from 8:30 A.M. to 8:42 A.M. During his time, the Resident was observed attempting to drink juice that still had a cellophane covering on it, with the cellophane entering the Resident's mouth. Review of Resident #53's physician orders indicated the following order: *General diet diet (sic), chopped texture, nectar thick liquid consistency, initiated 8/10/23. *Cut up solids into bite sized pieces at the beginning of the meals, initiated 8/10/23. Review of Resident #53's diet slip provided by the Food Service Director indicated the following: *Alerts: cut up food bite size, no bread products. Review of the diet order located in Resident #53's medical record dated 7/26/23 indicated Please Chop Food. Review of the form titled Swallow and Dining Recommendations to Nursing, dated 1/26/22 indicated: *Cut up solids into bite sized pieces (about the size of a fingernail) During an interview on 10/26/23 at 11:16 A.M., Speech Therapist #4 said Resident #53 has a long-standing diagnosis of dysphagia and he/she requires his/her food cut up and should not be provided with any bread products and the pasta and broccoli should have been cut up and served as small pieces. Therapist #4 said she is unsure if Resident #53 is able to have blueberries because even though blueberries are soft and bite size, they have skin on them and that may be difficult to swallow. Speech Therapist #4 said Resident #53's family has been educated on the type of food modifications Resident #53 requires, however nursing should ensure the visitor is providing the correct diet prior to the Resident consuming the food. During an interview on 10/25/23 at 9:04 A.M., the Director of Nursing (DON) said she expects residents to receive the diet as ordered and recommended by the clinical staff. During an interview on 10/25/23 at 1:41 P.M., with the Medical Director he said that he would expect that all resident's be provided with the diet that they are ordered to ensure safety. As well, he said that he defers to the recommendations that a Speech and Language Pathologist (SLP) make regarding resident's care needs because an SLP has a very specific scope of knowledge that he does not have. He said that it is his expectation that staff follow the recommendations of the SLP. 3a. Resident #50 was admitted to the facility in November 2022 with diagnoses including Barrett's esophagus and dysphagia. Review of Resident #50's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 which indicated he/she was cognitively intact. The MDS also indicated Resident #50 required partial/moderate assistance from staff for feeding tasks. Review of the report titled, Physician Evaluation and Management Report, dated 10/26/23 indicate Resident #50 completed a Modified Barium Swallow (MBS) study to evaluate the Resident's level of dysphagia. The MBS indicated the following: *Patient presents with severe oropharyngeal dysphagia, affecting the safety and efficiency of the swallow. Nutrition/hydration as well as the respiratory status may be impacted by the patient's current pathophysiology and swallowing profile. *Based on today's consultation the overall risk of developing an aspiration pneumonia is considered to be high. This risk is based on the radiologic findings as well as risk factors assessed during the physician consultation. The patient is at risk for choking episode or airway obstruction; therefore, adherence to dietary recommendations is encouraged. *Patient completed the Penetration Aspiration Scale which has a rating of 1-8 with 8 being most severe and the Resident scored an 8. Review of Resident #50's physician order initiated on 11/3/23 indicated the following: *Pureed texture, thin liquids consistency related to gastrotomy status (z93.1). Please feeds only provide 2 puree items to tray, frozen ice cream, 5cc provale cup from kitchen with water only. On 11/6/23 at 12:24 P.M., Resident #50 was provided with his/her lunch tray. The tray included yogurt, ice cream, pureed mashed potatoes, pureed meat, pureed vegetables and pureed fruit. During an interview on 11/6/23 at 12:29 P.M., the Assistant Director of Nursing (ADON) said she was unaware of the Resident's physician orders for meals and reviewed the order on the computer. After review, the ADON said the Resident should only be receiving two pureed items on his/her meal trays. The ADON said both the kitchen staff and nurses on the unit should be checking the meal trays to ensure all residents are receiving the diets as ordered. During an interview on 11/6/23 at approximately 12: 50 P.M., the Food Service Director (FSD) said he was unaware Resident #50's lunch tray did not follow the diet as ordered by the physician. The FSD said he was unaware the Resident should only have 2 items on his/her meal tray and said he provided the Resident with a variety of food so he/she could try everything. Based on observations, interviews and policy review the facility failed to follow the correct therapeutic menu (mechanical soft) for four Residents (#62, #53, #50 and #4) out of a total sample of 34 residents. Specifically, 1. Resident #62, who has a known history of choking twice at the facility, requiring the Heimlich maneuver and emergent transfer to the hosital, was observed to be served the incorrect diet, placing the Resident at serious risk of a repeated choking incident and/or death, 2. Resident #53 who has a long-standing history of dysphagia (difficulty chewing and swallowing), was served food not on his/her recommended diet, and 3. two Residents (#50 and #4) were provided a meal not in accordance with the physician's order. Findings include: 1. Resident #62 was admitted to the facility in October 2021 and in June 2023 Resident #62 was diagnosed with Dysphagia (difficulty chewing and swallowing). Review of the most recent Minimum Data Set assessment, dated 9/14/23, indicated Resident #62 had a Brief Interview for Mental Status exam score of 5 out of a possible 15, which indicated severely impaired cognition. The MDS further indicated Resident #62 was independent with 1 person physical assistance with eating . Review of the record indicated Resident #62 choked on chicken in July 2022, requiring the Heimlich maneuver and, at that time, Physician orders were obtained to downgrade the diet to a Mechanical Soft Diet. Review of the record indicated that in July 2023, Resident #62 was found in his/her room alone choking on a donut, requiring the Heimlich maneuver and emergent transfer to the hospital. Review of the most recent Speech Therapy (SLP) Discharge summary, dated [DATE], indicated Resident #62 was evaluated following the second choking incident in July 2023. The SLP documented Patient remains a high risk for aspiration and choking given impulsive self-feeding behaviors, which have resulted in prior and recent choking incidents. He/she will continue to benefit from diet modification with soft/bite-sized foods and supervision at meals to provide verbal cues for safe swallowing strategies. Education provided with 3rd floor staff, who are aware. Written sign taped to wall in patient's room stating he/she must have supervision during meals. The SLP references that Resident #62's diet level at discharge from speech therapy to be IDDSI Soft and Bite Sized SB6 (level 6). Review of the facility's diet manual indicated Mechanical soft (Dental Soft) Diet: -Grains: soft, easily chewed breads. -Vegetables: Cooked, tender, chopped or shredded, vegetable juice. Review of the current International Dysphagia Diet Standardization Initiative (IDDSD) indicated Level 6 Soft and Bite Sized includes: -Soft, tender and moist, but with no thin liquid leaking/dripping from the food; -Ability to bite off a piece of food is not required; -'Bite sized' pieces no bigger than 1.5 cm x 1.5 cm in size; -A knife is not required to cut this food. Review of current Nutrition care plan, last revised 2/8/23, had an interventions: -dated 10/25/21: Provide, serve diet as ordered. Monitor intake and record q (each) meal. On 10/23/23 at 12:19 P.M., the surveyors observed Resident #62 alone in his/her room, in the dark, with his/her back to the door. The following was observed: -There was a lunch tray directly in front of Resident #62 that included large slices of vegetable approximately 1.5 inches in size and dry rice. Review of the facility's therapeutic menu for that day indicated Resident #62 should have received steamed rice covered in gravy or sauce and chopped zucchini. -The meal ticket indicated: cut up food bite size, mechanical soft. On 10/24/23 from 8:07 A.M. to 8:15 A.M., Resident #62 was observed in the unit dining room. A staff person delivered his/her breakfast including an uncut cheese omelet. On 10/24/23 at 12:10 P.M., Resident #62 was observed in the unit dining room with a plate of penne pasta and broccoli and a bowl of large pineapple chunks, approximately 1 cubic inch. The broccoli was cut in half but still larger than bite size pieces, approximately an inch in length. During an interview on 10/24/23 at 9:15 A.M., the Food Service Director (FSD) provided the surveyor with the detail report for Resident #62's diet. He said that the Resident should be served a meal consistent with the specific details on the report. The report includes the following: -Diet: Mechanical soft; -Alerts: Cut up food bite size, no bread products. During an interview on 10/24/23 at 10:22 A.M., with SLP #3, she said that she was consulted after Resident #62's choking episode in July 2023 and evaluated Resident #62 at that time. SLP #3 said that Resident #62 is on a mechanical soft diet, that should be bite sized. SLP #3 said that the facility does not have a chopped diet which would equate to bite sized. She said that she has brought this to the attention of the facility administration and the FSD and therefore she would expect the staff to read the meal ticket and cut up the food to bite-sized. During an interview on 10/24/23 at 12:15 P.M., with the Director of Nursing (DON) she said the following: -It is the expectation that residents receive the correct diet and diet consistency as ordered by the MD and recommended by the SLP. -That it is difficult to ensure plans of care, are carried out because the facility is 95% agency staff; During an interview on 10/24/23 at 1:56 P.M., with the DON, Nursing Home Administrator and Regional Nurse Consultant the surveyors shared the concerns during the survey process regarding Resident #62's meals and the accuracy of required diet being served to maintain safety. They said that they were not aware that there was any issues with meals. During an interview on 10/25/23 at 1:41 P.M., with the Medical Director he said that he would expect that all resident's be provided with the diet that they are ordered to ensure safety. As well, he said that he defers to the recommendations that a Speech and Language Pathologist (SLP) make regarding resident's care needs because an SLP has a very specific scope of knowledge that he does not have. He said that it is his expectation that staff follow the recommendations, particularly for Resident #62 who has choked two times and that he/she be served the accurate diet. During an interview on 10/26/23 at 10:31 A.M., the Food Service Director (FSD) said that there's been no education provided to the Dietary Staff since he started at the facility in September,2023 and that most of his staff has been at the facility less than 6 weeks. 3b. Resident #4 was admitted in 07/2011 with diagnoses including dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #4 was severely cognitively impaired. On 11/6/23 at 8:00 A.M., Resident #4 was in his/her room alone eating breakfast and Resident #4 had a whole banana with the peel on his/her tray. Review of the Resident's tray ticket indicated that he/she should receive ½ each fresh banana. On 11/6/23 at 10:40 A.M., the Food Service Director said that they give residents on mechanical soft diet petite bananas that we give them but we let the resident's peel them. The Food Service Director said that he doesn't know where that order for Resident #4 came from because it was a standing order before he got here. The Food Service Director said that he checks the trays, but did not know the Resident got a full banana. The surveyor pointed out the discrepancy between the mechanical soft therapeutic breakdowns and the tray ticket and the Food Service Director said he would follow up on it.

Based on observations and interviews the facility failed to ensure it was administered in a manner that enabled the facility to use its resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility administration failed to ensure orientation, education and training was provided to all staff to provide competent, safe, and effective resident care as well as ensuring the governance and leadership members sustain a sufficient Quality Assurance Performance Improvement (QAPI) program during transitions in leadership and staffing. Findings include: During the survey process it was identified that the Administration's failure to orient and educate staff on policies and procedures specifically related to resident's care and services resulted in residents who required therapeutic diets and supervision while eating to receive incorrect diets and insufficient supervision during meals which lead to at least one episode of choking for a resident with a history of choking. The Resident required the Heimlich Maneuver and transport to the hospital. During an interview on 10/24/23 at 12:15 P.M., the Director of Nursing (DON) said she did not receive orientation training when she was hired by the facility. The DON said that the Nursing Home Administrator (NHA) is not involved in the day to day running of the facility. The DON said the NHA is present at the facility morning meeting, however he doesn't pay attention and is very removed from clinical aspects of the building. The DON said the NHA doesn't really leave his office and has not held a QAPI (Quality Assurance Performance Improvement) meeting since she started working at the facility in August 2023. In addition, the DON said the NHA has not relayed any clinical concerns or facility issues that need to be worked on since she started. The DON said that the NHA being removed affects the building, but that staff are used to it and there should be a happy medium with an administrator. During an interview on 10/25/23 at 1:12 P.M., the facility's Medical Director said the facility Administration had not notified him that the facility's annual Recertification survey had been underway since 10/22/23. Also, he said that the facility Administration had not notified him that the facility Administrator was provided with the Immediate Jeopardy Templates for F689, F803 and F837 on 10/25/23 at 10:39 A.M. During an interview on 10/26/23 at 9:18 A.M., with the Nursing Home Administrator (NHA) and Business Office Manager (BOM), the NHA said that the facility had not had a staff educator since the previous ownership. The BOM and NHA provided the surveyor with a checklist of the expected orientation items for new hires. The BOM said she was responsible for the first part of orientation that educated on human resource policies and procedure. The NHA said he was responsible for the policies and procedures that related to resident care and safety. The NHA said he did not complete any education or orientation and the Assistant Director of Nursing (ADON) would traditionally do the staff education. The NHA said he did not know if any education had started at the facility yet and did not know if any new hires had been oriented, educated, assessed for competency, or had dementia training since the current company acquired the facility in January 2023. During an interview on 10/26/23 at 9:27 A.M., the ADON said she started working at the facility approximately 7 weeks ago and had not yet received an orientation from the facility administration or a designee. The ADON said in those 7 weeks she had not provided orientation to any staff that had been hired in 2023 and that she instructs staff to let her know if they need anything but that they otherwise learn as they go. The ADON said new hires are given an employee handbook and it is their responsibility to read through it and ask questions, but there is no way to ensure that they look at the handbook. The ADON also said there is no test to determine competency or ensure nursing staff are competent in the nursing skills required to provide competent, safe, and effective resident care. During an interview on 10/31/23 at 9:10 A.M., the Administrator said the Director of Nursing position had changed three times since his arrival to the building in March 2023 and said that he could provide no documentation of clinical concerns brought to the QAPI meetings including infection control measures, accidents and hazards, quality of care or quality of life that was comprehensive and measurable with goals. The Administrator said he needs to take a deeper dive into the QAPI program at the facility to identify issues and get systems into place but to date, had not done that. The Administrator further said the current Medical Director, who has been responsible for the building since the end of July has not been involved in the QAPI program. During an interview on 10/31/23 at 9:00 A.M., the Medical Director said that neither the Administrator or Governing Body has ever invited him to attend a QAPI meeting at the facility because the facility is not having QAPI meetings. The Medical Director added If I had to pick between making up policies that no one is going to follow, or taking care of my patients I will pick taking care of my patients. Despite the Nursing Home Administrator voicing knowledge that there had not been a Staff Educator in the building for all of 2023, and that all 22 new staff hires in that time frame were not provide with orientation, or assessed for competency, the facility's administrative team and governing body failed to develop a plan to ensure the facility could safely provide the services to meet the needs of the residents. Further, the facility Administration failed to make efforts to identify areas of concern, such as accidents and hazards, and make attempts to improve the quality-of-care delivery. See F689, F803, F837, F940

Based on interview and record review including the Facility Assessment and facility policies, the facility failed to ensure that the governing body provided oversight and accountability for: 1. ensuring education and competencies were completed per Facility Assessment on hire for 22 out of 22 employees hired since January 2023; 2. ensuring quality of care related to the safety and hazards in the facility was maintained for one Resident (#62) out of a total sample of 34; and 3. ensuring the governance and leadership members sustain a sufficient QAPI program during transitions in leadership and staffing. As a result of the governing body's failure, the facility failed to develop a plan to ensure the facility could safely provide the services to meet the needs of the residents as well as implement an effective QAPI program. Findings include: Review of the Facility Assessment, dated as reviewed with the QAPI committee, in October 2023, indicated that the Governing Body included, but was not limited to, the Administrator, Director of Nursing (DON), Assistant Director of Nursing, the Chief Operating Officer and the Medical Director. The Facility Assessment indicated the following: New Admissions: The admissions director reviews as needed with the Administrator, DON, Medical Director, Regional Nurse Consultant, and Staff Educator to ensure staff competencies and staffing needs can be met. - Every new hire must meet- the minimum education and training requirements to hold and maintain their professional licensures and certifications. All new hires go through general orientation. At orientation, attendees are educated on the following: organizational structure, mission statement, philosophy of care, the characteristics of our resident population, federal and state regulations, OBRA, quality of care, quality of life, resident rights, resident bill of rights, facility practices, behavior policy, Joint Commission, QAPI process, OSHA, chemical hazards, the Right to Know, all emergency codes; locations of policies and procedures, disaster and evacuation policy and procedures including bomb threats. - All Departments have annual competencies completed by the SDC and their respective Department Manager. Any employee who through their actions or by management oversight is determined to require additional training will be provided the education and new competencies completed. -3.5 The facility, together with the Medical Director work together to devise facility policies and procedures. Policies and procedures are devised based on regulatory guidelines, and standards of practice. Policies are reviewed at least annually by the facility and Medical Director. Review of the facility policy titled QAPI Plan, last reviewed 2/18/22 included, but was not limited to the following: - (The Company) shall ensure that the Governing Body, Administration, Medical Director, Director of Nursing, clinical and non-clinical staff demonstrate a consistent endeavor to deliver safe, effective, optimal resident care services in an environment of minimal risk. - This facility shall develop, implement, and maintain an effective, comprehensive, data-driven Performance Improvement Program that focuses on indicators of the outcomes of care and quality of life. - The organizational program, established by the Medical Director and Director of Nursing and interdisciplinary Performance Improvement Committee, with the support and approval from the Governing Body, shall have the responsibility for monitoring every aspect of resident care and services (including contracted services), from the time the resident enters the facility through diagnosis, treatment, recovery and discharge in order to identify and resolve any breakdowns that may result in sub-optimal resident care and safety, while striving to continuously improve and facilitate positive resident outcomes. 1. During an interview on 10/26/23 at 9:18 A.M., with the Nursing Home Administrator (NHA) and BOM (Business Office Manager), the NHA said that the facility had not had a staff educator since this company acquired the facility in January 2023. During an interview on 10/24/23 at 12:15 P.M., the Director of Nursing (DON) said that she did not receive orientation training when she was hired by the facility. The DON said that she was not educated or oriented to the buildings needs by her Regional Nurse Consultant, who oversees the building. She said that her Regional Nurse Consultant has been to the building once or twice since she started and that she has been left to figure things out by rounding the building and asking the staff, which is difficult as they are 95% agency staff. During an interview on 10/26/23 at 9:27 A.M., the Assistant Director of Nursing (ADON) said she started working at the facility approximately seven weeks ago and had not yet received an orientation from the facility administration or a designee. The ADON said in those seven weeks she had not provided orientation to any staff that had been hired in 2023 and that she instructs staff to let her know if they need anything but that they otherwise learn as they go. The ADON said new hires are given an employee handbook and it is their responsibility to read through it and ask questions, but there is no way to ensure that they look at the handbook. The ADON also said there is no test to determine competency or ensure nursing staff are competent in the nursing skills required to provide competent, safe, and effective resident care. During the recertification survey, newly hired employees and their education records were requested. A total of 22 new employees, including the Director of Nurses and Assistant Director of Nurses, had been identified as being hired since January of 2023. The facility was unable to provide education records for the 22 new employees hired since January of 2023. During a follow-up interview on 10/26/23 at 12:35 P.M., the NHA said the facility had no orientation packets for the 22 staff that were hired in 2023, as no orientation had been provided due to the lack of a staff educator or designee. 2. Resident #62 was admitted to the facility in October 2021 with diagnoses including major depressive disorder. In June 2023, Resident #62 was diagnosed with dysphagia (difficulty chewing and swallowing). Review of the facility policy titled Accidents and Incidents, revised 10/2022, indicated the following: -All incidents and accidents will be evaluated when applicable by the interdisciplinary team. -The team will review the investigation and continue if necessary, discuss and determine from the investigation the root causes, make recommendations for additional interventions, education and conclude the investigation. During an interview on 10/24/23 at 1:15 P.M., the Regional Nurse Consultant (RNC) said he provides clinical oversight to the facility. He said that includes reviewing reportable events such as a resident who had two choking incidents but that he does not track the events for trends. The RNC said that is a QA (Quality Assurance) expectation that falls on the facility. A record review during the survey indicated that one Resident (#62) had two choking events. When asked if the RNC assessed reoccurring events for possible system failures, the RNC said that at the time of the second choking incident he was on vacation and did not review it upon his return. The RNC said the incident was reviewed by another company nurse and that the events were far apart. He could provide no additional information regarding the two incidents. 3. During an interview on 10/31/23 at 9:10 A.M., with the Nursing Home Administrator (NHA), the QAPI program was reviewed. The NHA said he is responsible for overseeing the QAPI program within the building. He said he took the role as the Administrator in March of 2023 and since that time has held two meetings in April and July of 2023. He said a meeting should have been held in October of 2023 but you guys showed up. During an interview on 10/27/23 at 11:13 A.M., the Director of Nurses said she has been in the building for six weeks and has not attended a QAPI meeting since she started. She said she has not seen any QAPI projects specific to nursing or infection control. She said she gets some help from the Regional Nurse if she has questions but it's limited. During an interview on 10/31/23 at 9:10 A.M., the Administrator said the Director of Nursing position had changed three times since his arrival to the building in March and could provide no documentation of clinical concerns brought to the QAPI meetings including infection control measures, quality of care, quality of life or accidents and hazards (specifically for Resident #62 who choked for a second time at the facility and required the Heimlich maneuver both times) that was comprehensive and measurable with goals. During an interview on 10/24/23 at 1:15 P.M., the Regional Nurse Consultant said he provides clinical oversight to the facility and is in the building every three to four weeks. He said he reviews charts remotely as well as reportable incidents. He said he is not responsible for tracking incidents and that the QAPI expectation falls on the facility. During an interview on 10/31/23 at 9:00 A.M., the Medical Director said that neither the Administrator or Governing Body has ever invited him to attend a QAPI meeting at the facility because the facility is not having QAPI meetings. The Medical Director added If I had to pick between making up policies that no one is going to follow, or taking care of my patients I will pick taking care of my patients. The facility could provide no further documentation of concerns brought to the QAPI meetings, See F689, F803, F835, F940

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. For Resident #63, the facility failed to complete post fall assessments and implement interventions after a fall. Review of the facility policy titled, Fall Prevention, dated 1/23. Indicated the following: * fall risk assessments will be completed for all residents initially on admission, readmission, quarterly, significant change and after an identified fall. Resident #63 was admitted to the facility in January 2023 with diagnoses including history of falling, Alzheimer's disease. Review of Resident #63 most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident has severe cognition and requires limited assist for personal care. Review of Resident #63's medical record indicated the Resident had a fall on the following dates: 6/15/23, 7/14/23, 9/8/23 and 9/27/23. Further review of medical record failed to indicate a post fall assessment and interventions were put in place after these falls. During an interview on 10/26/23 at 9:36 A.M., the Assistant Director of Nursing (ADON) said after each fall the nurses should complete an incident report, neuro checks should be done on all unwitnessed falls, a fall assessment should be completed after each fall, care plan should be followed and updated after each fall with interventions. 1b. Resident #53 was admitted to the facility in December 2021 with diagnoses including dysphagia, secondary Parkinsonism, and history of falling. Review of Resident #53's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident's cognitive ability was not assessed. The MDS also indicated Resident #53 required extensive assistance from staff for all mobility tasks. On 10/24/23 at 12:15 P.M., Resident #53 was observed eating lunch in the dining room. A Certified Nursing Assistant (CNA) was present in the room but not providing cues to the Resident. The Resident was not alternating between liquids and solids and was not clearing his/her mouth of food prior to taking another bite of food. On 10/25/23 at 8:29 A.M., Nurse #1 brought Resident #53 his/her breakfast in his/her room. The Resident was sitting up in his/her wheelchair when provided breakfast. Nurse #1 left the room after giving the Resident his/her meal and did not return to provide supervision. On 10/25/23 at approximately 12:20 P.M., Resident #53 was observed eating in his/her room with a family friend. The Resident was eating blueberries in yogurt and had a mouthful of blueberries while starting to take another bite. The family friend was not providing the Resident with any cues to slow down and, when asked, could not say if the Resident had any need for assistance with meals. On 10/26/23 at 8:28 A.M., Resident #53 was given his/her meal in his/her room. Resident #53 was left unsupervised while he/she ate the meal from 8:30 A.M. to 8:42 A.M. During his time, the Resident was observed to spill food onto him/herself and did not alternate liquids and solids. Resident #53 was also observed attempting to drink juice that still had a cellophane covering on it, with the cellophane entering the Resident's mouth. Review of Resident #53's activity of daily living care plan last revised 9/21/23, indicated the following: *Eating: 1:1 or supervised dining room. Position upright 90*, preferably sitting in w/c. Alternate liquids and solids, small bites, slow rate, chin tuck. Resident is impulsive and requires verbal and tactile cues to slow rate and implement strategies. Review of Resident #53's Kardex (a form indicating the level of assistance a resident requires) indicated the following: * Eating: 1:1 or supervised dining room. Position upright 90*, preferably sitting in w/c. Alternate liquids and solids, small bites, slow rate, chin tuck. Resident is impulsive and requires verbal and tactile cues to slow rate and implement strategies. Review of the speech language Discharge summary dated [DATE], indicated the following recommendations post discharge: *Strategies: small bites/sips, slow case, swallow each bite/sips before taking more. *Functional Maintenance: Reviewed with nursing see strategies above. Ideally, patient would benefit from 1:1 supervision during meals though this has never been implemented despite previous recs. Therefore, RN encouraged to periodically check in during meals to ensure safe swallowing strategies are being implemented. During an interview on 10/26/23 at 11:16 A.M., Speech Therapist #4 said Resident #53 has a long-standing diagnosis of dysphagia and he/she requires supervision and cueing throughout meals. Speech Therapist #4 said Resident #53's family has been educated on the level of assistance Resident #53 requires and nursing should ensure the visitor is able to provide that during meals if nursing is not in the room. During an interview on 10/25/23 at 9:04 A.M., the Director of Nursing (DON) said she expects residents to receive the level of assistance care planned and recommended by the clinical staff. The DON said staff should refer to the Kardex or care plan to know what level of assistance each resident requires. 1c. Resident #50 was admitted to the facility in November 2022 with diagnoses including Barrett's esophagus and dysphagia. Review of Resident #50's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 which indicated he/she was cognitively intact. The MDS also indicated Resident #50 required partial/moderate assistance from staff for feeding tasks. The surveyor was provided with the facility's audit tool indicating the level of assistance residents in the facility require on 11/6/23 at 8:05 A.M. The audit tool identified Resident #50 as a resident who required assistance with meals. Review of the report titled, Physician Evaluation and Management Report, dated 10/26/23 indicated Resident #50 completed a Modified Barium Swallow (MBS) study to evaluate the Resident's level of dysphagia. The MBS indicated the following: *Patient presents with severe oropharyngeal dysphagia, affecting the safety and efficiency of the swallow. Nutrition/hydration as well as the respiratory status may be impacted by the patient's current pathophysiology and swallowing profile. *Based on today's consultation the overall risk of developing an aspiration pneumonia is considered to be high. This risk is based on the radiologic findings as well as risk factors assessed during the physician consultation. The patient is at risk for choking episode or airway obstruction; therefore, adherence to dietary recommendations is encouraged. *Patient completed the Penetration Aspiration Scale which has a rating of 1-8 with 8 being most severe and the Resident scored an 8. Review of Resident #50's activities of daily living care plan last revised 9/21/23, indicated the following intervention: *Eating: Extensive assistance with meals - tube feeding at night. On 11/6/23 at 8:13 A.M., Resident #50 was given a breakfast tray in his/her room. The Resident was lying almost flat in bed and the staff member did not reposition the Resident to be more upright. The staff member left the room at 8:14 A.M., leaving the Resident unsupervised with his/her meal. During an interview on 11/6/23 at 8:18 A.M., Nurse #12 said all staff have been educated on the importance of residents receiving the correct diet and amount of assistance with meals. Nurse #12 said an audit was created with all residents and their level of assistance needed with meals and the audit is available for all staff to review. On 11/6/23 at 12:16 P.M., Nurse #11 was reviewing the lunch trays in the meal cart. Nurse #11 ripped up Resident #50's tray ticket, indicating he/she would not be eating lunch. On 11/6/23 at 12:20 P.M., Nurse #11 said Resident #50 was NPO (nothing by mouth). When asked why the Resident had received a breakfast tray earlier in the day, Nurse #11 said the Resident was able to eat and then obtained his/her lunch tray and provided the Resident with lunch. The Resident was left alone in the room to eat independently. During an interview on 11/6/23 at 12:24 P.M., Resident #50 said (using a white board to write) that said he/she needs to have someone with him/her during meals. The Resident wrote I know it is not good a lot of it stays stuck in my mouth some of it falls out I have no muscle control. During an interview on 11/6/23 at 12:29 P.M., the Assistant Director of Nursing (ADON) said she was unable to remember the residents who required supervision or assistance with meals and would have to refer to the facility audit tool that indicated the level of assistance residents in the facility require for meals. The ADON showed the surveyor the audit tool which listed Resident #50 as requiring supervision for meals, which was different than the audit tool provided in the morning. The ADON said this audit tool was accurate and Resident #50 required supervision for all meals. The ADON observed that Resident #50 was in his/her room alone without supervision while eating and said the facility was not in compliance with the level of care Resident #50 required during meals. 2. For Resident #48, the facility failed to complete elopement assessments as well as incident reports after an elopement from the unit. Review of the facility policy titled; Elopement Preventions, dated 10/22, indicated the following: *The facility maintains a process to assess all residents for a risk of elopement, implement prevention strategies for those identified as an allotment risk, institute measures for resident identification at the time of admission, and conduct a missing resident procedure. *An elopement risk evaluation is completed by nursing staff on all residents on admission, readmission, quarterly, and upon change of condition. The initial resident assessment should be conducted on admission. Resident #48 was admitted to the facility in January 2023 with diagnoses including Parkinson's Disease, muscle weakness, history of falling and dementia. Review of Resident #48's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored 4 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #48 required extensive assistance from staff for functional daily tasks. Review of the nursing note dated 9/14/23 indicated the following: *This writer notes a wheelchair in front of one of the exits to the unit. This write went out to the stair well and noted this resident sitting on the step. The resident stated I need to go downstairs and get out of here. The patient is alert and confused at baseline. Vital signs - Temp 97.6, BP 104/68, HR 84, RR 18, O2 96%. The patient denies s/sx of SOB and pain at this time. Skin assessment has been performed with no new injuries noted. Patient refused to get onto the wheelchair and became combative. After a few attempts the patient was transferred to the third floor via wheelchair. Upon arrival to the third floor patient continued exit seeking. NP informed with no new orders. HCP and spouse have been informed. Review of Resident #48's medical record indicated an elopement evaluation was completed on 1/12/23 and 5/23/23 but failed to indicate an elopement assessment was completed after this incident. Review of Resident #48's elopement care plans last revised 9/21/23 indicated the following interventions: *Complete Elopement Risk Assessment upon admission, quarterly and with significant change in status assessment. *1:1 as needed. During an interview on 10/25/23 at 11:58 A.M., Nurse #3 said she was working on 9/14/23 and she was the nurse that found Resident #48 in the stairwell. Nurse #3 said she is familiar with Resident #48 and that he/she has reoccurring episodes of exit seeking. Nurse #3 said this was not the first time the Resident had made it through the door. Nurse #3 said the Resident had gone through the door a month prior and she is not sure why a note was note written about that incident or why an incident report was not made. During an interview on 10/26/23 at 9:27 A.M., the Assistant Director of Nursing (ADON) said elopement assessments should be completed upon admission, quarterly and if a resident has a change of status. The ADON said a change of status would include a resident having exit seeking behavior or leaving the unit. The ADON said Resident #48 should have had an elopement assessment completed on 9/14/23. The ADON said she was unaware of the Resident leaving the unit a month prior and would have expected a note and incident report to be completed. 3a. For Resident #35, the facility failed to follow the falls care to prevent a fall. Resident #35 was admitted to the facility in December 2021 with diagnoses including dysphagia, secondary Parkinsonism, and history of falling. Review of Resident #35's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident's cognitive ability was not assessed. The MDS also indicated Resident #35 required extensive assistance from staff for all mobility tasks. Review of the nursing note dated 6/13/23 indicated the following: *this writer was called to resident's room where the assigned CNA stated that she lowered resident to the ground after losing their footing during a transfer. stated that the resident did not hit (his/her) head. NO injuries noted at time of note. Skin intact. T:97.6 BP:117/71 P:70 O2:96% RR:18. Denied pain when asked (gestured thumbs down), shows no non-verbal signs of pain. No changes in mental status, no changes in ROM BE. Assisted off of the floor by two staff and pivoted into wheelchair. Plan is to ensure resident is wearing appropriate footwear and reinforce that resident is a two-person extensive assist with transfers. Notified HCP, provider and left message for DON and administrator. Review of the incident report dated 6/13/23 indicated the CNA was transferring the Resident with one staff only and the Resident was barefoot at the time of the transfer. Review of Resident #35's fall care plan last revised on 9/21/23, indicated that at the time of the fall on 6/23/23, the following care plan intervention was in place: *Use appropriate footwear (non-skid socks, non-slip soles on shoes/sneakers) when ambulating or mobilizing in wc. Initiates 12/30/21 and revised 2/8/23. During an interview on 10/26/23 at 9:27 A.M., the Assistant Director of Nursing (ADON) said she expects all care plan interventions to be followed to prevent falls as much as possible. The ADON did not know the circumstances of Resident #35's fall but said the Resident should not have been barefoot during the transfer. 3b. For Resident #48, the facility failed to complete fall incident reports after a fall. Review of the facility policy titled, Fall Prevention, dated 1/23. Indicated the following: *For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. * The interdisciplinary team and physician should continue to collect and evaluate information until causes for falls can be identified. Resident #48 was admitted to the facility in January 2023 with diagnoses including Parkinson's Disease, muscle weakness, history of falling and dementia. Review of Resident #48's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored 4 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #48 required extensive assistance from staff for functional daily tasks. Review of the nursing note dated 1/29/23 indicated the following: *At 0200, patient heard calling from (his/her) room. This nurse found patient lying on the floor in the bathroom entry. Patient was attempting to go to the bathroom unassisted. ROM WNL. Neuros WNL. Patient admitted to striking (his/her) head on floor. No wound or hematoma found. V/S 118/73 P 82 T 97.6 97% RA. On call ordered patient sent to local for CT of head and eval due to patient being on Eliquis. Family aware, daughter notified. DON notified. Message left for administrator. Intervention for patient is to move (him/her) to RM [ROOM NUMBER] due to patient having no safety awareness and getting up often without using call light. The facility was failed to provide and incident report investigating the cause of the fall. Review of the nursing note dated 2/13/23 indicated the following: *This nurse was assisting another pt when this pt started yelling out for someone to help (him/her). This nurse went to see what the pt needed and found (him/her) kneeling on the floor on the side of (his/her) bed with (his/her) upper half on the bed. When this nurse asked pt what had happened and where (he/she) was going pt stated (he/she) was trying to get back to bed.Pt assisted back into bed by CNA. The facility was failed to provide and incident report investigating the cause of the fall. Review of the nursing note dated 3/12/23 indicated the following: *I walked into room [ROOM NUMBER] and observed this resident sitting on the bathroom floor. (he/she) states (he/she) was attempting to go to the bathroom and slipped, (he/she) was wearing slipper socks. Assessed for injuries, no apparent injury occurred. The NP, resident's spouse, supervisor and Administrator were all notified. The facility was failed to provide and incident report investigating the cause of the fall. During an interview on 10/26/23 at 9:27 A.M., the Assistant Director of Nursing (ADON) said an incident report must be completed after a resident sustains a fall in order to investigate the cause of the fall to prevent further falls in the future. The ADON said she was unable to find an incident report for Resident #48's falls on 1/29/23. 2/13/23 and 3/12/23. 3c. For Resident #31, the facility failed to complete a fall incident report after a fall. Review of the facility policy titled, Fall Prevention, dated 1/23. Indicated the following: *For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. * The interdisciplinary team and physician should continue to collect and evaluate information until causes for falls can be identified. Resident #31 was admitted to the facility in March 2022 with diagnoses including hip fracture after a fall. Review of Resident #31's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 5 out of a possible 15, which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #31 requires extensive assistance for mobility tasks. Review of the nursing note dated 1/15/23 indicated the following: *Resident calling out from (his/her) room. The nurse checked on the resident and found resident laying on the floor net to the bed on door side of bed. Resident was alert and communicating appropriately. Resident was attempting to go to the bathroom. Resident was evaluated and found to have no apparent injury. When asked, the facility was unable to provide an incident report investigating the cause of the fall. During an interview on 10/26/23 at 9:27 A.M., the Assistant Director of Nursing (ADON) said an incident report must be completed after a resident sustains a fall in order to investigate the cause of the fall to prevent further falls in the future. The ADON said she was unable to find an incident report for Resident #31's fall in January 2023. Based on observations, interviews and policy review the facility failed to provide adequate supervision and follow the plan of care to prevent accidents for 5 Residents (#62, #53, #50 #48 #31, and #63) out of a total sample of 34 residents. Specifically: 1a. For Resident #62, who has a known history of choking twice at the facility, requiring the Heimlich maneuver, the facility failed to provide supervision and cueing for safe swallowing strategies with meals and failed to provide with the appropriate diet consistency, as recommended by the Speech Language Pathologist (SLP), placing Resident #62 at high risk for a repeated choking incident, injury and/or death. During the second choking incident Resident #62 was found unsupervised with a meal and his/her face and lips were blue, cyanotic, requiring the Heimlich maneuver and transfer by 911 to the hospital. 1b. For Resident #53, who is at high risk for aspiration/choking, the facility failed to provide the appropriate level of assistance/supervision with meals; 1c. For Resident #50, who is at high risk for aspiration/choking, the facility failed to provide the appropriate level of assistance/supervision with meals; 2. For Resident #48, the facility failed to complete elopement assessments as well as incident reports after an elopement from the unit; 3a. For Resident #35, the facility failed to follow a falls care plan to prevent a fall; 3b and 3c. For Residents #48 and #31, the facility failed to complete incident reports investigating the cause of falls; and 4. For Resident #63, the facility failed to complete post fall assessments and implement interventions after a fall. Findings include: 1a. For Resident #62 who has a known history of choking twice at the facility, requiring the Heimlich maneuver, the facility failed to provide supervision and cueing for safe swallowing strategies with meals and failed to provide the appropriate diet consistency, as recommended by the Speech and Language Pathologist (SLP), placing the Resident at high risk for a repeated choking incident, injury and/or death. The facility policy titled Accidents and Incidents, revised 10/2022, indicated the following: -All incidents and accidents will be evaluated when applicable by the interdisciplinary team. -The team will review the investigation and continue if necessary, discuss and determine from the investigation the root causes, make recommendations for additional interventions, education and conclude the investigation. -The team will write an interdisciplinary team note discussing above. -Should the team feel an intervention is a Rehab evaluation please use the Rehabilitation Referral Form. The facility policy titled Safety and Supervision of Residents, dated as revised 1/2023, indicated the following: -Our facility strives to make the environment as free from accidents hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. -The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. -Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training, as necessary; d. Ensuring that interventions are implemented; and e. Documenting interventions. -Monitoring the effectiveness of interventions shall include the following: a. Ensuring that interventions are implemented correctly and consistently. Resident #62 was admitted to the facility in October 2021 with diagnoses including major depressive disorder. In June 2023, Resident #62 was diagnosed with dysphagia (difficulty chewing and swallowing). Review of the most recent Minimum Data Set (MDS) assessment, dated 9/14/23, indicated Resident #62 had a Brief Interview for Mental Status (BIMS) exam score of 5 out of a possible 15, which indicated he/she had severely impaired cognition. The MDS further indicated Resident #62 was independent with one-person physical assistance with eating. Review of Resident #62's medical record indicated he/she choked while eating chicken in July 2022, requiring the Heimlich maneuver (a first aid procedure to treat airway obstructions by a foreign object) and, at that time, physician orders were obtained to downgrade the Resident's diet to a Mechanical Soft Diet (an altered textured diet for individuals with difficulty chewing and swallowing). Review of Resident #62's Activities of Daily Living Care Plan indicated the following: *EATING: Independent after Set up assistance, last revised 10/25/21. - The care plan failed to indicate it was reviewed or updated following the choking incidents in July 2022, and July 2023 or following the recommendations made by the SLP (speech language pathologist) on 8/7/23. Review of the Licensed Nursing Summary, dated 6/30/23, indicated Resident #62 required physical assistance with eating. Review of the clinical progress note, dated 7/23/23 at 10:00 A.M., indicated Resident #62 had another choking episode. The medical record indicated: Nurse from opposite side of the hall requested assistance from this nurse r/t resident presenting with signs of choking. On assessment, 02 @ 62% (Oxygen Saturation (O2 sat) @ 62%; A normal oxygen saturation level is between 95-100%), not able to verbalize needs, face and lips blue, cyanotic. Instructed nurse to call 911. Visual examination of throat with blockage of large amount of cake donut blocking airway. Resident was bent forward in wheelchair while doing back blows then finger sweeps. Food removed piece by piece and opened airway. Resident able to take shallow breaths, 02 improved slowly to 90%. Emergency services arrived @ approx 0905 and care taken over, resident transferred to ER @ local Hospital. (sic) Review of the most recent Speech Therapy (SLP) Discharge summary, dated [DATE], indicated Resident #62 was evaluated following the second choking incident. The SLP documented Patient remains a high risk for aspiration and choking given impulsive self-feeding behaviors, which have resulted in prior and recent choking incidents. He/she will continue to benefit from diet modification with soft/bite-sized foods and supervision at meals to provide verbal cues for safe swallowing strategies. Education provided with 3rd floor staff, who are aware. Written sign taped to wall in patient's room stating he/she must have supervision during meals. The SLP references that Resident #62's diet level at discharge from speech therapy to be IDDSI Soft and Bit Sized SB6 (level 6). Review of the current International Dysphagia Diet Standardization Initiative (IDDSD) indicated Level 6 Soft and Bite Sized includes: -Soft, tender and moist, but with no thin liquid leaking/dripping from the food; -Ability to bite off a piece of food is not required; -'Bite sized' pieces no bigger than 1.5 cm x 1.5 cm in size; -A knife is not required to cut this food. -Examples of food to avoid: Dry cake crumble foods. The Nutrition care plan, last revised 2/8/23, had the following interventions: -dated 2/8/23: Increase initiation cues to help promote independence -dated 10/25/21: Provide, serve diet as ordered. Monitor intake and record q (each) meal. Review of Resident #62's Activities of Daily Living Care Plan failed to indicate the facility updated the care plan after the Resident's second choking episode or to include the SLP recommendations from 8/7/23. The medical record failed to indicate Resident #62 had any behaviors of diet non-compliance or of refusing care. During an interview on 10/24/23 at 10:22 A.M., SLP #3 said that she was consulted after Resident #62's choking episode in July 2023 and evaluated Resident #62 at that time. SLP #3 said for Resident #62, the no bread products mean no donuts. She said that she believes, Resident #62's issues are related to impulsive eating, cognitive impairment and behaviors, as well as the strength of his/her swallow. SLP #3 said she instructed the nursing staff that Resident #62 must eat with supervision and responds well to cueing to take small bites and take small sips. SLP #3 said that she reiterated to nursing staff that she believes the choking issue is likely to occur again, and; therefore, Resident #62 needs to have the supervision and needs verbal cueing for the entirety of all meals. On 10/22/23 at 8:01 A.M., Resident #62 was observed in the unit dining room. There was a plate of food on the table directly in front of him/her. Resident #62's head was bobbing, as if he/she was falling asleep. A Certified Nursing Assistant (CNA) approached Resident #62, placed a towel across his/her chest and walked away. No one was present to assist or cue Resident #62 for safe swallow strategies with the meal. On 10/22/23 at 8:08 A.M., Resident #62 remained without assistance or cueing for safe swallow strategies with the meal. On 10/23/23 at 12:19 P.M., Resident #62 was observed alone in his/her room, in the dark, with his/her back to the door. There was a lunch tray directly in front of Resident #62 that included large slices of vegetable approximately 1.5 inches in size and dry rice. Review of the facility's therapeutic menu for that day indicated Resident #62 should have received steamed rice covered in gravy or sauce and chopped zucchini. A sign on the wall in Resident #62's room indicated the following: -Patient is high risk for aspiration and choking. -Needs supervision with meals. -Please bring to dining area for all meals. On 10/24/23 from 8:07 A.M. to 8:15 A.M., Resident #62 was observed in the unit dining room. A staff person delivered Resident #62 breakfast which included an uncut cheese omelet. Staff did not provide cues for safe swallow strategies. On 10/24/23 at 12:10 P.M., Resident #62 was observed putting food into his/her mouth and not swallowing prior to putting more food into his/her mouth. There was one nurse in the room who was at a different table and was not providing any cues for safe swallow strategies to Resident #62. During an observation on 10/25/23 at 8:20 A.M., Resident #62 and 5 other residents were observed in the unit dining room with no staff supervision, Resident #62's eye were closed, with his/her head facing downward as he/she chewed on eggs without swallowing. Staff walked in and out passing trays, however, no one provided cueing and safe swallow strategies to Resident #62. During an interview on 10/23/23 at 1:59 P.M., the Speech and Language Pathologist (SLP) #1 said that based upon the 8/7/23 SLP recommendations, she would expect Resident #62 to be provided with 1:1 supervision with meals if the meal was in his/her room and that Resident #62 should not be in his/her room for meals. She said Resident #62 should be receiving cues for safe swallow strategies throughout the meal. During an interview on 10/24/23 at 9:49 A.M., SLP #2 said that when a diet slip indicates No bread products that would include no donuts. During an interview on 10/24/23 at 12:15 P.M., with the Director of Nursing (DON) she said the following: -It is the expectation that residents that need supervision and cueing for safe swallowing strategies with meals should be receiving both throughout the entire meal. -That when therapy provides education to the nursing staff regarding new recommendations the education is provided verbally not written education with sign offs from the staff verifying that the education was provided. -That it is difficult to ensure plans of care are carried out because the facility is using 95% agency staff. -That she started working at the facility in August 2023 and was aware that all care plans at the facility had not been updated since 2021 and the staff could not refer to Resident #62's care plan to ensure she was being provided with the required care with meals. During an interview on 10/25/23 on 12:15 P.M., with Nurse (#3) she said that she worked on Resident #62's unit the day of the second choking incident. Nurse #3 said that Resident #62 was alone in his/her[TRUNCATED]

Based on document review and staff interviews, the facility failed to ensure that they implemented and maintained an effective training program for all new hires, consistent with their expected roles, and failed to determine the amount and type of training necessary based on the facility assessment. Specifically, 22 out of 22 new staff hired in 2023 to date, were not provided training, therefore, failing to ensure competent, safe, and effective resident care. Findings include: Review of the Facility Assessment indicated the following: -3.4 Every new hire must meet the minimum education and training requirements to hold and maintain their professional licensures and certifications. All new hires go through general orientation. At orientation, attendees are educated on the following: organizational structure, mission statement, philosophy of care, the characteristics of our resident population, federal and state regulations, OBRA, quality of care, quality of life, resident rights, resident bill of rights, facility practices, behavior policy, Joint Commission, QAPI process, OSHA, chemicals hazard, the Right to Know, all emergency codes; location of policies and procedures, disaster and evacuation policy and procedure including bomb threats. -We also tour the facility and meet the individual departments and explain their function. We discuss elevator use, explain the alarm system, show the emergency, and fire equipment location, and demonstrate the telephone and paging system, the call light system, safety practices including workplace violence, sexual harassment, and ergonomics. Infection control policy and procedure, CDC standard precautions, hand hygiene; disease specific isolation, exposure control plan, bloodborne pathogens including transmission; Hepatitis B vaccine; Persona Protective Equipment (PPE); Tuberculosis Policy and Procedure; Ombudsman program; privacy and confidentiality; HIPAA; Dignity; Resident Rights; Verbal and Physical Abuse, Neglect, Mistreatment, Psychological Harm and Misappropriation of property. Incident reporting policy and procedure, Resident incident reports, Safety and Accident Precautions, resident Safety, Employee Safety, Communication, Annual in-service Education requirements, Dementia Training, and Annual Performance Evaluation. The benefits, employee responsibilities regarding Time Schedule/request time off and time clock, paycheck distribution, parking, breakroom area, Personal Handbook and Job Description. -Competencies by department: All departments have annual competencies completed by the (Staff Development Coordinator) SDC and their respective Department Manager. Any employee who through their actions or by management oversight is determined to require additional training will be provided the education and new competencies completed. -All departments receive an initial 8 hours of dementia training and 4 hours annually. During an interview on 10/26/23 at 8:47 A.M., with the Business Office Manager (BOM), she provided the surveyors with an update regarding a Certified Nursing Assistant (CNA) #10 file that had been requested. The BOM said that CNA #10 started working at the facility the previous week, and although he had worked several shifts, the facility did not have staff available to provide orientation to CNA #10. Also, the BOM said that CNA #10 had told her that he had received 8 hours of dementia training at another nursing facility but that she did not yet have a copy of it on file. She said that there was no one to provide education to the staff since the facility was acquired by a new company in January 2023. The surveyors requested a list of new hires since the company was acquired by the new company in January 2023. During an interview on 10/26/23 at 9:18 A.M., with the Nursing Home Administrator (NHA) and Business Office Manager (BOM), the NHA said that the facility had not had a staff educator since previous ownership. The NHA said that traditionally the Assistant Director of Nursing (ADON) would do the education, but he does not know if that has started yet at the facility and does not know if any new hires have been oriented, educated, assessed for competency, or had dementia training since the current company acquired the facility in January 2023. The BOM said she does general building orientation such as teaching the new hires how to use the time clock, but that the clinical component of new orientation is completed by the Administrator and clinical staff. During an interview on 10/26/23 at 9:27 A.M., the ADON said she started working at the facility approximately 7 weeks ago and had not yet received an orientation from the facility administration or a designee. The ADON said in those 7 weeks she had not provided orientation to any staff that had been hired in 2023 and that she instructs staff to let her know if they need anything but that they otherwise learn as they go. The ADON said new hires are given an employee handbook and it is their responsibility to read through it and ask questions, but there is no way to ensure that they look at the handbook. The ADON also said there is no test to determine competency or ensure nursing staff are competent in the nursing skills required to provide competent, safe, and effective resident care. During a follow-up interview on 10/26/23 at 12:35 P.M., the NHA confirmed that the facility had no orientation packets for the 22 staff that were hired in 2023, as no orientation had been provided due to the lack of a staff educator or designee.