**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and facility policy review, the facility failed to protect the resident's right to be free from neglect as evidenced by: (1) the facility's failure to identify a resident choked on 6/17/23; failure to ensure the resident had supervision and was on a modified diet to prevent choking on 8/20/23; and failure on 10/25/23 to supervise and modify diet which lead to the resident again choking and requiring Cardiopulmonary resuscitation (CPR) and hospitalization with a poor recovery prognosis. Resident #13. (2) the facility's failure to ensure a resident was free from verbal abuse as evidenced by a Certified Nursing Assistant (CNA) threatening to hit a resident for Resident #46 for two (2) of three (3) allegations of abuse and neglect reviewed. The facility neglected to identify or investigate the choking incident on 06/17/23 with required hospitalization for three (3) days and removal of a food bolus from his oropharynx and failed to have knowledge of the 08/20/23 choking incident that required the Heimlich maneuver to remove the food bolus from his oropharynx in the facility. This neglect resulted in the resident not receiving services to possibly prevent choking episodes. The resident's diet was changed on 8/21/23 to Consistent Carbohydrate Diet (CCD) mechanical soft. The Administrator had the resident's diet changed on 8/31/23 to CCD with chopped meats and the Certified Nursing Assistants (CNA)were to chop the resident's meat when the tray was served. The meal tickets were never changed to include the CNA to chop meats. On 10/25/23 in the evening, Resident #13 was served an Italian Sausage link that was five (5) to six (6) 1½ inch chunks of meat and the resident was found in his bed, unable to breath and without a pulse or respirations. Cardiopulmonary Resuscitation (CPR) was performed for over ten (10) minutes and was not successful. Resident #13 was transported to the local hospital where he remains on life support. The facility's negligence to identify the choking incidents and to ensure that staff were aware of the diet needs of Resident #13 and serve the correct diet order to a resident with a known history of choking in the facility and dysphagia resulted in Resident #13 choking on 10/25/23 and required life saving measures and remained in the hospital on the ventilator at the time of the survey. This negligence resulted in harm for Resident #13 and placed other residents at risk in a situation that was likely to cause serious harm, injury, impairment or death. The situation was identified as an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 6/17/23 when the first choking episode occurred and the facility failed to identify the event as choking. On 11/2/23 at 3:35 PM, the State Agency notified the facility's Administrator of the IJ and SQC and provided the Administrator with the IJ templates. The facility submitted an acceptable Removal Plan on 11/3/23, in which the facility alleged all corrective actions were completed to remove the IJ on 11/3/23, and the IJ was removed on 11/4/23. The SA validated the Removal Plan on 11/06/23, prior to exit and the scope and severity for F600 was lowered to an E, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Resident #13 Record review of the facility policy titled, Abuse Prohibition Policy with a revision date of 5/28/2021 revealed, INTENT: This protocol was intended to assist in the prevention of abuse, neglect and misappropriation of property. Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse. POLICY: .2 .The facility will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations. Verbal abuse is defined as the use of, oral, written or gestured language that willfully includes disparaging or derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability .Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness Record review revealed a facility-reportable incident (FRI) that had occurred on 10/25/23 at 7:42 PM, when Resident #13 was noted to be having an active seizure while eating supper in bed. A record review of the Unusual Incident .Staff reported at the supper time, resident was asleep and did not want supper. Night shift Certified Nursing Assistant (CNA) #6 reported that she had assisted the resident to the restroom, and he was eating his supper, while she was caring for roommate. She heard (Resident #13) making a noise, and he was found actively having a seizure. The nurse was called to the room and life-saving measures were began by nursing staff ending in Cardiopulmonary Resuscitation (CPR). The resident was transferred to the hospital. Staff called to check on resident condition on 10/26/23 and was informed that a piece of sausage was extracted from the resident's oropharynx prior to resident being intubated. Medical records were obtained from (hospital) on 10/26/23 and received at 2:33 PM. Resident was intubated and noted to have Pneumonitis on 10/26/23. After investigation, resident had a witnessed seizure causing aspiration of food content. I cannot substantiate abuse or neglect. This investigation was not dated but signed by the Administrator. Record review of Progress Notes, dated 10/25/23 at 19:42 (7:42 PM) revealed, Nurse was alerted by CNA that I was needed in resident's room. Upon arriving in room resident appeared to be having seizure activity. Pulse was faint and respirations noted. Resident had foamy secretions coming from mouth. Resident was pale in color . CNA told this nurse that prior to her alerting me he had been eating . This nurse performed back thrust times 5 and was in process of performing ABD (abdominal) thrust when other help arrived. Thrust was ineffective. Nurse left room and got crash cart and upon returning CPR was in process related to no pulse or respirations. Progress note for 10/25/23 at 19:45 (7:45 PM) Nurse observed resident unresponsive, pale and foaming at the mouth. Nurse called 911 and returned to aid with chest compression until EMS arrived. Record review of the local hospital emergency room report dated 10/25/23 stated, History of Present Illness .Per ambulance run report: Patient was found lying supine in bed upon arrival; nursing home staff stated that the patient was found unresponsive and cyanotic immediately after mealtime. Per ED (Emergency Department) sign out: Patient was exhibiting agonal breathing; a piece of sausage was extracted from his oropharynx prior to intubation . Problem List Plan: . Respiratory: Patient ' s acidosis and elevated lactate is likely attributed to airway obstruction caused by food getting stuck in his oropharynx; although there is clinical and radiographic evidence concerning for potential aspiration pneumonia .Infectious Disease: Radiographic and clinical suspicion for aspiration pneumonia . Feeding: Feeding tube inserted .CPR Exam: Narrative: .Respiratory: Decreased air entry throughout, stridorous respirations, significant accessory muscle use, saturating 49% on nonrebreather .On arrival, it immediately became apparent that the patient was in profound respiratory distress and needed emergent airway management. During the intubation, we visualized a very large piece of food obstructing the patient's airway, using forceps, and removed the foreign body. After the patient was intubated and sedated and placed on the ventilator, his vital signs normalized . An interview on 10/31/23 at 12:50 PM, CNA # 2 revealed on 10/25/23 she was passing the dinner trays and went into Resident #13's room and he was asleep, which is not uncommon for him, she revealed a lot of times he would wake up later and eat. She stated she tried to wake him, and he said he wasn't hungry and covered his head up. She sat the tray down on his side table and never uncovered it. She stated when she came back to work the next day, she found out that Resident #13 had choked. We were told to make sure we chopped his meats from now on. She confirmed she had never been in-serviced on how to chop the resident's meats before and wasn't aware that he was supposed to have his meats chopped because the diet ticket never said to chop his meats. An interview on 10/31/23 at 1:40 PM, with CNA #7 revealed the resident is a heavy eater and snacks in his room all the time. She revealed the day before he choked on 10/25/23, he had a whole piece of chicken that was served on his meal tray. She revealed we never cut his meat up before and the resident can eat by himself, and we don't stay in the room with him while he is eating. An interview on 11/01/23 at 8:10 AM, CNA #8 revealed she was never aware that the resident required his meats to be chopped before he choked on 10/25/23. She revealed we were told after he choked that we needed to make sure and chop his meats, but not before. An interview on 11/01/23 at 8:25 AM with the dietary management group Account Manager revealed she has been at the facility for about two months and stated that when she started, she was told anyone with a chopped meats diet we were to put a whole piece of meat on the plate and put a knife on the tray so that the CNA could cut up the meat. She revealed this was the only place she had ever worked that I had heard that a CNA would cut the meat up. She stated on 10/25/23 she was in the kitchen but didn't cook the dinner meal but did observe the meal which consisted of Italian sausage that was cut into about one (1) to one and one-half (1 ½) inch chunks and each resident got about three or four chunks of the meat on their tray. An interview on 11/01/23 at 8:50 AM with CNA #6 revealed that she was working the night of 10/25/23 and went into Resident #13's room at about 7:15 PM to get his vital signs. She stated he was asleep, and she woke him up and took his vital signs and temperature. The resident said he had to go to the bathroom, and he was hungry. I assisted him to the bathroom and then set up his tray which consisted of noodles, round Polish sausage there were about four large round pieces about ½ inch to one inch long on his tray, and broccoli florets. She revealed she did not cut the sausage up because she was not aware that he required his meat to be chopped or cut. She revealed I went and started getting his roommate's vital signs and then she heard Resident #13 make a sound I never had heard before, she stated she thought he was having a seizure because he had fallen back on his bedrail and was foaming out of the mouth. I went for help immediately. She revealed on his plate he had eaten all the sausages and maybe one of the broccoli florets. She stated that after this incident we were in-serviced to make sure to look on the meal ticket and that CNAs were responsible for chopping meat for residents requiring chopped meats. We were also in-serviced on neglect and abuse. She confirmed before the choking incident they were not told to cut the residents' meats up. She stated she had worked here for about a year and had never been told to chop his meats before and hadn't seen his meats chopped up. In an interview on 11/01/23 at 9:30 AM, the Administrator (ADM) revealed Speech Therapy had ordered a chopped meats diet in August because the resident had a choking episode. She revealed the Dietary Director of Operations told her they were not able to do a chopped meats diet. She revealed we immediately in-serviced the staff that the kitchen would send out the appropriate knife and they would have to chop the meats. She stated, I did not feel comfortable with my staff cutting the meats, but I was told by the Dietary Director of Operations that it was a facility policy but since then I found out that was not true. She confirmed that she found out that was not true through the Corporate Chief Operating Officer (COO) and stated, I didn't say anything to the Dietary Director of Operations after that because that's a corporate-level issue and I was letting them handle it. She stated, I could make it happen today to stop all chop meats and just do a Mechanical soft. I haven't done it yet because Corporate had been working with the dietary management company about the issue. She revealed that since the incident happened on 10/25/23 with Resident #13 the aides are still chopping meat for the residents and stated that we keep a list of residents who require chopped meats at the nurse's station. The Administrator confirmed when she found out on 10/26/23 that the resident had choked, she had not done anything different with the chopped meat diets because corporate was working on that. An interview on 11/01/23 at 10:05 AM with the Director of Operations (DO) for the dietary services management group revealed that dietary services has three diets which are Regular, Mechanical Soft, and Pureed. He stated that Resident #13 was put on a chopped meat diet on 08/21/23, because he had a choking episode. He confirmed that he had asked the Administrator for a diet clarification because dietary does not historically do chopped meats, but could do mechanical soft, and he was told by the Administrator to send out a knife for the residents who were on a chopped meat diet and the aides would chop the meats. He confirmed that this occurred on the Thursday before Labor Day, which would have been 08/31/23. The Director of Operations for Dietary revealed he is over 23 buildings, and this is the only building where they are doing chopped meats and requiring aides to chop the meat when it gets to the resident. He stated, I don't like doing that, but I couldn't get the Administrator to understand that chopped meats is a mechanical soft diet, I just needed them to get the order clarified. An interview on 11/01/2023 at 12:55 PM with the Nurse Consultant, Director of Nurses (DON), and Administrator revealed they were not aware of the choking episode on 6/17/2023. The DON and Nurse Consultant revealed they were not aware of a choking episode on 8/20/23. The Administrator revealed she was aware of the 8/20/23 choking episode and had a conversation with the Dietary because Speech Therapy had evaluated Resident #13 and requested a chopped meat diet. An interview on 11/01/23 at 2:05 PM, with CNA #7 revealed she never saw on the electronic charting guide for Resident #13 that the CNA was to chop meats. She revealed, our tablets are how we know how to chart for the residents and what they are supposed to get. An interview on 11/01/23 at 2:15 PM with CNA #4 revealed, I've never seen chopped meats listed on the tablets that we use to document. An interview on 11/01/23 at 2:25 PM, the Speech Therapist (ST) confirmed Resident #13 was on caseload for dysphagia beginning June 2023 through August 2023 and then again up until he was discharged to the hospital on [DATE]. She revealed the recommendations were for him to be supervised for meals. He was at risk of aspiration because he wanted to lie down and eat. She revealed she would always caution Resident #13 about sitting up and eating and not lying down to eat. An interview on 11/01/23 at 2:35 PM, the Minimum Data Set (MDS) nurse updated the care plan on 8/25/23 to be up in w/c for all meals and stated that she put it in there when he had his quarterly MDS. She revealed I think we also may have talked about it in the morning meeting, but I'm not sure. An interview on 11/01/23 at 2:45 PM, the Medical Records Nurse revealed that when a resident comes back from the hospital the hospital directly uploads any paperwork into our system. She revealed the hospital will notify the Social Worker (SW) that they are uploading paperwork from the residents' hospital stay. She confirmed we usually review the paperwork in our standup meeting the next day or our clinical standards meeting on Friday. She confirmed for those meetings the Director of Nursing (DON), Assistant Director of Nursing (ADON), MDS nurse, Treatment Nurse, Social Worker, and Administrator are in attendance. She stated, I don't know what happened in June when Resident #13 went out to the hospital and when he returned the discharge paperwork revealed he had choked and confirmed that she had apparently overlooked it. A phone interview on 11/01/23 at 3:30 PM with the Medical Director revealed, As far as I know he never had any seizures. He stated he had access to the hospital records and according to the hospital records they are currently treating Resident #13 for pneumonia and encephalopathy and the family is there, and they are talking about putting him on hospice because the prognosis is very poor. An interview on 11/01/23 at 4:00 PM, Registered Nurse (RN) #2 revealed on 8/20/23 was the Nurse Supervisor; she stated the floor nurse hollered for me and said she had done the Heimlich maneuver on Resident #13 and was able to get the food expelled. She revealed we called the doctor to see if there was anything he wanted us to do, and she revealed he wanted us to watch for any signs or symptoms of possible aspiration. She stated they put in a diet order change the next day for chopped meats and confirmed the order put in for care plans for him to be set up in the wheelchair was due to the choking episode on 8/20/23. She revealed she was unaware of the choking episode for Resident #13 in June and stated we have a daily stand-up meeting where all disciplines attend including the Administrator, DON, and ADON. She confirmed I'm not sure if it was discussed in the morning stand-up meeting or the clinical standards meeting about him choking on 8/20/23 but all the nursing knew about it and his care plan to be up in his wheelchair for all meals. An interview on 11/01/23 at 4:10 PM, with the Administrator revealed for the incident on 10/25/23 she was not made aware that Resident #13 was eating dinner until the next day on 10/26/23 around lunch time. She confirmed the nurse told her that he had a seizure and they had to do CPR and he was sent to the hospital. She had seen the hospital paperwork on 10/26/23 that revealed he had the sausage in his oropharynx and revealed for the August 20th incident the staff nurses just reported that he got strangled on his food and that's when he got the order for speech therapy to be evaluated. She confirmed she wasn't aware that Resident #13 required the Heimlich maneuver at that time. An interview at the same time with the DON revealed for the 8/20/23 incident she was made aware that the resident had trouble with taking his medicines and wasn't made aware of him choking. She revealed she is going to start going back and reading the nurse's notes each day so she will know what is going on. She revealed it usually will come out on the 24-hour nurses report and we will discuss it in the morning meeting. The DON and Administrator both revealed they were not sure how the choking episodes got missed. The DON confirmed after the 10/25/23 incident she instructed Resident #13's care plan to be updated to make sure CNA to chop meats was reflected on his meal tickets and that she was the one that put it on his 10/25/23 meal ticket for CNA to chop meats, and confirmed that it was not on there for the CNA to see that day. She confirmed it was not on the care plan before 10/25/23 and it should have been. She confirmed again that she was not aware of Resident #13 having a choking episode in June or August and that she wasn't aware that he had choked on 10/25/23 until the afternoon on 10/26/23. A phone interview on 11/01/23 at 4:25 PM, Licensed Practical Nurse (LPN) #5 confirmed she was working the night shift on 10/25/23 and that the CNA came and said she needed a nurse in Resident #13's room. She revealed the CNA said she thought he was having a seizure because he had foam coming out of his mouth. I took off to the room and when I entered it appeared that Resident #13 was having seizure activity. I put him in a recovery position on the right side and the CNA said he had been sitting up eating so I thought at that time that he was probably choking. She confirmed I did five thrusts to the back, and when I went to turn him over to do the abdominal thrust other help had arrived in the room and he was not breathing. I went and got the crash cart at that time and when I returned to the room CPR was in process. She revealed when EMS arrived, I told them he was having seizure-like activity. She revealed I had never worked with Resident #13 but had heard reports that he had choked before. She confirmed another nurse was on the phone with the DON at that time. And had notified her. I knew that he was on a chopped meats diet but there was no residue of any meat on the plate at that time, just some broccoli. An interview on 11/02/23 at 8:30 AM, the DON stated regarding the incident on 10/25/23, the nurse let me know that night that she thought he was having a seizure and revealed she did not instruct the night shift staff to start an investigation because she thought it was a seizure. She revealed that they didn't have stand-up the next morning, I can't remember why we didn't have it, but I was informed around one or one-thirty that day when we were having a party, when a staff member said they had called over to the ER and had been told that he had something in his throat when they tried to intubate him. She stated that's when we called over and got the medical records. She stated at that time they had started an investigation, but she still wasn't aware of the June and August incidents of choking until the SA told me on 11/01/23that it was located in the medical records and nurses' notes. The DON revealed the staff called her back that night and said the resident was being admitted and had to be intubated. The DON confirmed that she didn't thoroughly investigate the choking because I thought it was a seizure. She revealed that any resident sent out to the hospital, the staff will have to notify the DON or the Administrator right away. An interview on 11/02/23 at 10:00 AM, the Social Worker stated she was aware that he had choking episodes before the recent one on 10/25/23 but could not remember specific dates. She confirmed in the morning meeting we discuss any major issues and choking is an important issue. She revealed the morning meeting is made up of all department heads, which also includes the Administrator and DON. An interview on 11/02/23 at 10:40 AM, the ADON revealed she did an in-service on 8/31/2023 for the CNAs and nursing staff regarding chopped meats. She confirmed the in-service was not attended by all nursing staff including CNA #2 and CNA #6. She revealed that the 7 PM -7 AM shift did not get in-serviced on chopping meats because the meal trays are sent out on the day shift not the night shift. She confirmed that she did not demonstrate how to chop the meat to the in-service staff and that not all staff were in-serviced. An interview on 11/02/23 at 10:50 AM, the Administrator revealed the Registered Dietitian (RD) consult record is made up by the nursing department and given to the RD each week when she comes. She revealed the residents on the consult record and the residents that have had any significant changes are usually listed on the record to be seen that week. She confirmed that Resident #13 had never been put on the list for the RD to see after the choking episodes. Record review of Resident #13's admission Record revealed he was admitted to the facility on [DATE] with diagnoses that included Transient Cerebral Ischemic Attack, Dysphagia, Altered Mental Status, and Unspecified Dementia. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/25/23, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 07, which indicated the resident had a severe cognitive impairment. The assessment further indicated under Section GG that Resident #13 required for eating, supervision, or touching assistance- Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. The assessment further indicated under Section K that Resident #13 had coughing or choking during meals or when swallowing medication and complaints of difficulty or pain with swallowing. Record review of the local hospital emergency room Report dated 6/17/23 revealed chief complaint: Altered Mental Status. Rehab facility was contacted for further information regarding patient's presentation, and they reported that patient had abnormal moaning and jerking-like motions, and that staff had concerns for new onset seizure-like activity. Per chart review, patient has no prior history of seizures but does have a history of Cerebral Vascular Accident (CVA) involving left middle cerebral artery. At the time of my exam, it was noted that a patient had a golf ball sized food bolus extracted from posterior oropharynx. A record review of Progress notes dated 6/20/23 by the Medical Records Nurse, Note Text: Resident discussed in clinical standards, return from hospital on 6/20/23, continues all meds as ordered, new med of levetiracetam 500 mg bid for seizures, alert with periods of confusion, up with assist, CCD diet, will monitor. Record review of Progress notes dated 08/20/23 at 18:20 PM, stated, Resident noted with choking episode this shift at dinner time. LPN reporting that the resident had gotten choked on a piece of meat off his dinner tray. LPN assist resident with dislodging piece of meat. Resident's color returning to normal with O2 (oxygen) saturation of 97% on RA (room air). Resident cont. (continues) to be noted with a cough. Record review of Progress Note dated 08/21/23 at 13:48 PM stated, It was reported to ST (Speech Therapy) that the pt got choked while eating meat the previous day. Also nurse reports pt had difficulty while taking meds today. Record review of Progress Notes, dated 08/23/23 at 10:16 AM stated, Resident is to be gotten up for meals in W/C (wheelchair). Record review of the Diet Requisition Form diet change dated 8/21/23 revealed Resident #13 was changed to a Mechanical soft chopped meat texture diet. Record review meal ticket dated 08/31/23 at 2:34 PM diet order was changed to Chopped Meats; Knife and resident was served whole meats with a knife to cut. Record review of the Order Summary Report Active Orders as of 8/31/23 revealed an order dated 8/21/23, CCD Diet, Chopped Meat texture, thin consistency. Record review of Resident #13's meal ticket dated 8/30/23 all meals CCD-Mechanical Soft. Review of the Dinner meal ticket revealed- Ground Italian Sausage, brown gravy, parmesan noodles, broccoli florets chopped and sliced pears. The same meal was served on 10/25/23 the evening that the resident choked, and review of the dinner meal ticket revealed, Italian Sausage, Parmesan noodles, Broccoli florets, sliced pears . knife .CNA will cut meat Resident #46 An interview with the Administrator on 10/30/23 at 10:55 AM, revealed on 10/20/23, there was a witnessed verbal abuse incident of Resident #46 by Certified Nursing Assistant (CNA) #1. She revealed CNA #1 admitted that she threatened to hit Resident #46 and she was terminated for verbal abuse. The Administrator revealed this incident was reported to the State Agency (SA) and other entities and an investigation was completed. During a phone interview on 10/31/23 at 8:05 AM, Resident #46's brother, his Resident Representative (RR), revealed the facility notified him that CNA #1 threatened to hit his brother and that she was terminated for this. During a phone interview on 10/31/23 at 4:10 PM, CNA #1 revealed Resident #46 was upset and angry and was swinging his arms and trying to hit her. She stated she did not threaten the resident she was going to hit him, but told him, Don't hit people. They are going to want to hit you back. She stated Licensed Practical Nurse (LPN) #1 yelled at her to not talk to residents that way and she then told LPN #1 that if someone hit you, you would want to hit them back. When asked about her written statement, Don't hit me if you hit me I'm going to hit you back, she stated she did write that in her statement and that was what happened, but she did not mean she was going to hit him, she just wanted him to know that he could get hit back if he hit another resident or any other person. When asked if the statement she wrote at the time of the incident was accurate, she confirmed that what she wrote was what happened. She stated, It's fine, I just want to get this over with. She stated she was fired because of this incident. She verified she had been in-serviced on abuse and neglect. During a phone interview on 10/31/23 at 4:30 PM, LPN #1 revealed she was working on the medication cart at the nurse's station, and she saw CNA #1 pushing Resident #46 in his wheelchair and she heard CNA #1 tell the resident, If you hit me, I am going to hit your ass back. She said she confronted the CNA and told her she could not talk to the resident that way and she told me that if nobody does anything about him hitting, then I can tell him that. She stated, I was actually offended hearing her talk to the resident that way and any other resident or family overhearing this would also have been offended. She confirmed this was abusive towards the resident and she reported it immediately. On 10/31/23 at 5:00 PM, during a phone interview, CNA #2 revealed she was a Nurse's Aide when this incident occurred, and since she was not certified, she was working with CNA #1. She stated the resident was in his wheelchair and was trying to get out of the chair, so CNA #1 went to him to take him to the nurse's station. She stated Resident #46 was angry and swung his arms and CNA #1 told him that if he hit her, she was going to hit him back. She stated she told CNA #1 to calm down and that it was not the resident's fault, but CNA #1 responded with Resident #46 should not hit people or he would get hit back. CNA #2 stated LPN #1 was at the nurse's station and heard what was said and reported the incident. She stated she gave her statement during the investigation. During an interview with the Director of Nursing (DON) on 11/2/23 at 9:50 AM, it was revealed that an allegation of verbal abuse of Resident #46 by CNA #1 was reported. She stated this was reported and CNA #1 was told to leave the facility immediately and an investigation was done. She stated CNA #1 was terminated due to her confession and the results of the investigation. The DON confirmed the facility failed to ensure a resident was free from verbal abuse by a staff member. An interview with the Administrator on 11/2/23 at 9:51 AM, revealed that CNA #1 admitted that she told Resident #46 that if he hit her, she would hit him back and she also wrote a statement that verified what occurred during this incident. She stated when this allegation of abuse was made, the facility reported this to the State Agency, Attorney General's office, and to the local police department and CNA #1 was suspended and then terminated. The Administrator confirmed the facility failed to ensure that Resident #46 was free from verbal abuse by a staff member and abuse towards any resident was not acceptable. Record review of CNA #1's statement dated 10/20/23 revealed, Don't hit me if you hit me, I'm going to hit you back. He was swinging and [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and facility policy review the facility failed to implement a care plan for for two (2) of 18 care plans reviewed as evidenced by (1) the facility failed to develop and implement a care plan for a resident with a history of choking on 6/17/23 and 8/20/23 resulting in the resident experiencing a choking episode on 10/25/23 which required Cardiopulmonary Resuscitation and hospitalization with a poor recovery prognosis. Resident #13. (2) the facility also failed to implement a care plan regarding shaving and nail care for a resident that required assistance with ADL's (Activities of Daily Living) for Resident #30. The facility failed to implement care plans for Resident #13 following a choking incident on 06/17/23 with required hospitalization for three (3) days and removal of a food bolus from his oropharynx and on 08/20/23 choking incident that required the Heimlich maneuver to remove the food bolus from his oropharynx in the facility. This failure to implement a care plan resulted in the resident not receiving services to prevent choking episodes. The resident's diet was changed on 8/21/23 to Consistent Carbohydrate Diet (CCD) mechanical soft. The resident's diet changed on 8/31/23 to CCD with chopped meats and the Certified Nursing Assistants (CNA) were to chop the resident's meat when the tray was served. The meal tickets were never changed to include the CNA to chop meats. On 10/25/23 in the evening, Resident #13 was served an Italian Sausage link that was five (5) to six (6) 1 ½ inch chunks of meat and the resident was found in his bed, unable to breath and without a pulse or respirations. The facility performed Cardiopulmonary Resuscitation (CPR) for approximately ten (10) minutes and Resident #13 was transported to the local hospital where he remained on life support. The facilities failure to implement the care plan to sit up at meals, supervision, and to serve the correct diet order to a resident with a known history of choking in the facility and dysphagia resulted in Resident #13 choking on 10/25/23 and required life saving measures and remained in the hospital on the ventilator at the time of the survey. This failure resulted in harm for Resident #13 and placed other residents at risk in a situation that was likely to cause serious harm, injury, impairment or death. The situation was identified as an Immediate Jeopardy (IJ) that began on 6/17/23, when the facility failed to implement care plans for a resident with dyphasia who had a history of choking. On 11/2/23 at 3:35 PM, the State Agency notified the facility's Administrator of the IJ and provided the Administrator with the IJ templates. The facility submitted an acceptable Removal Plan on 11/3/23, in which the facility alleged all corrective actions were completed to remove the IJ on 11/03/23 and the IJ was removed on 11/4/23. The State Agency (SA) validated the removal plan on 11/06/23, prior to exit. and the scope and severity for F656 was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy, titled Care Plans, Comprehensive Person-Centered dated 10-2022: Reviewed [DATE] revealed, Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1 .The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 3. The IDT includes: a. The attending physician; b. A registered nurse who has responsibility for the resident; c. A nurse aide who has responsibility for the resident; a member of the food and nutrition services staff; e. The resident and the resident's legal representative (to the extent practicable); and f. Other appropriate staff or professionals as determined by the resident's needs or as requested by the resident . Resident #13 Cross Reference F600 Record review of Resident #13's care plan revealed Focus: The resident has risk for nutritional problem or potential nutritional problem r/t (related to) .DYSPHAGIA following CVA (cerebrovascular accident) .Interventions . CCD diet, Chopped Meat texture, Thin Consistency (undated) CNA to Chop meats. Date initiated 10/26/23 .Monitor/document/report PRN (as needed) any s/sx (signs/symptoms) of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Date initiated: 06/26/2023 .Provide and serve diet as ordered. Date initiated: 06/26/2023 .Resident to be up in w/c (wheelchair) for all meals d/t (due to) aspiration precautions Date initiated: 08/25/2023 .Staff to assist patient with self-feeding with all meals Date initiated: 06/26/2023 . Record review of Resident #13's care plan Focus: The resident has an ADL (activity of daily living) self-care performance deficit . Interventions .EATING: The resident requires (supervision assistance) by (1) staff to eat. Date initiated 8/25/23 . Record review of Resident #13's care plan Focus: I have alteration in my respiratory status r/t .08/20/23-choking episode noted during meal on meat . Record review of Progress Notes, dated 08/23/23 at 10:16 AM stated, Resident is to be gotten up for meals in W/C (wheelchair). Record review of Progress Note dated 08/21/23 at 13:48 PM revealed, It was reported to ST (Speech Therapy) that the patient got choked while eating meat the previous day. Also nurse reports patient had difficulty while taking meds today. Record review of Resident #13's meal ticket, dated 8/30/23, all meals CCD-Mechanical Soft. Review of the Dinner meal ticket revealed- Ground Italian Sausage, brown gravy, parmesan noodles, broccoli florets chopped and sliced pears. The same meal was served on 10/25/23 the evening that the resident choked, and review of the dinner meal ticket revealed, Italian Sausage, Parmesan noodles, Broccoli florets, sliced pears. During an interview on 11/1/23 at 2:05 PM, with CNA #7 revealed she never saw on the electronic charting guide for Resident #13 that directed the CNA to chop meats. She revealed facility CNA tablets are how CNAs know how to chart for the residents and what they are supposed to get, but that was not showing on the tablets. During an interview, on 11/1/23 at 2:15 PM, with CNA #4 revealed I've never seen chopped meats listed on the tablets that we use to document. During an interview on 11/1/23 at 2:35 PM, the Minimum Data Set (MDS) nurse updated the care plan on 8/25/23 to be up in w/c for all meals and stated that she put it in there when he had his quarterly MDS. She revealed I think we also may have talked about it in the morning meeting, but I'm not sure. During an interview on 11/1/23 at 4:00 PM, Registered Nurse (RN) #2 revealed on 8/20/23 was the Nurse Supervisor when the resident choked that night and stated they put in a diet order change the next day for chopped meats and confirmed the order put in for care plans for him to be set up in the wheelchair was due to the choking episode on 8/20/23. She revealed she was unaware of the choking episode for Resident #13 in June and stated we have a daily stand-up meeting where all disciplines attend including the Administrator, DON, and Assistant Director of Nursing (ADON). She confirmed I'm not sure if it was discussed in the morning stand-up meeting or the clinical standards meeting about him choking on 8/20/23 but all the nursing knew about it and his care plan to be up in his wheelchair for all meals. During an interview on 11/01/23 at 4:15 PM, the DON confirmed after the 10/25/23 incident she instructed Resident #13's care plan to be updated to make sure it read for the CNA to chop meats was reflected on his meal tickets and that she was the one that put it on his 10/25/23 meal ticket for CNA to chop meats, and confirmed that it was not on there for the CNA to see that day. She confirmed it was not on the care plan before 10/25/23 and it should have been. During an interview on 11/2/23 at 8:30 AM, the DON revealed she was not aware that the resident had a choking episode in June or in August and revealed she didn't know that the care plan was updated in June for the staff to assist him with all meals or the care plan updated in August for him to be up in the wheelchair for all meals. She revealed the Interdisciplinary Team (IDT) team is involved in care plan meetings and confirmed the care plan was not being followed. She revealed she is usually informed of any changes during the stand-up meeting each morning and revealed, I don't know how the incident in June and August was missed. The DON stated, I guess it was a breakdown in communication. The DON confirmed she did instruct the staff to update the Resident's care plan on 10/26/23 for the CNA to Chop the meat. She revealed when it is in the care plan it pulls to the CNA's [NAME]. She confirmed it was not in the care plan prior to the incident on 10/25/23 and it should have been. She confirmed that the CNAs would not have any way of knowing how to chop the meats until they corrected it on 10/26/23. During an interview on 11/2/23 at 12:07 PM, the Social Worker revealed they normally keep sign-in sheets for the care plan meeting, but she does not have one for the 8/25/23 quarterly care plan meeting. She stated when she had the care plan meeting with Resident #13, it was just the two of them. She revealed if the family is coming, then all necessary disciplines will meet with the family. During an interview on 11/2/23 at 12:15 PM, the MDS nurse revealed she was not at Resident #13's quarterly care plan meeting on 8/25/23 and revealed she usually does not attend the resident care plan meetings only if she is requested to attend. She revealed she did put in the care plan in August that the resident was to be up in wheelchair (w/c) for all meals related to (d/t) aspiration precautions and that was probably because we discussed it in the morning meeting about his choking episode in August. She stated the morning meetings consist of all department heads, including the DON and the Administrator, we discuss anything from the 24-hour report that is significant. She stated, I'm sure everyone was aware of him choking which was a significant issue. Record review of Resident #13's admission Record revealed he was admitted to the facility on [DATE] with diagnoses that included Transient Cerebral Ischemic Attack, Dysphagia, Altered Mental Status, and Unspecified Dementia. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 07, which indicated the resident had a severe cognitive impairment. The assessment further indicated under Section GG that Resident #13 required for eating, supervision, or touching assistance- Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. The assessment further indicated under Section K that Resident #13 had Coughing or choking during meals or when swallowing medication and complaints of difficulty or pain with swallowing. Resident #30 Record review of Resident #30's care plans revealed the resident had a care plan that indicated the resident has an ADL self-care deficit related to a CVA (Cerebrovascular Accident) and left sided weakness, encephalopathy and dementia with an initiation date of 3/15/22. The interventions for this care plan included that the resident required total assistance by one staff with bathing/showering and extensive assistance by one staff with personal hygiene. During an observation and interview on 10/30/23 at 11:30 AM, revealed Resident #30 had facial hair that was approximately 3/4 inch long on the resident's chin and sides of his face. Bilateral fingernails were approximately 1/2 inch long and had a brown substance under 4 nails. Resident #30 stated that he was not sure when he was last shaved or when his nails were last trimmed. During an observation and interview on 10/31/23 at 9:15 AM, revealed Resident #30 with no change in appearance from the previous day. He stated he is supposed to be shaved when he is showered but it doesn't always happen. He revealed he likes his nails trimmed and has tried to cut them himself with a pair of toenail clippers. He revealed the treatment nurse trimmed them once before. During an observation and interview on 10/31/23 at 9:25 AM, with Certified Nurse Assistant (CNA) #2 revealed she is assigned to Resident #30 today. She confirmed that the resident looked like he had not been shaved in a while and that his fingernails were long and needed to be trimmed. During an interview on 11/1/23 at 3:50 PM with Licensed Practical Nurse (LPN) #4 revealed the purpose of the care plans were to see what is needed to care for the residents and to make sure those needs are met. He stated that all staff have access to the care plans including the CNA's. He revealed that if a resident was supposed to be shaved and was not then their care plan was not implemented. During an interview on 11/1/23 at 4:00 PM with CNA #5 revealed the CNA's have access to the care plans and the resident care plans are to be followed for care needed and to make sure everything goes as it is supposed to. She confirmed that if a resident was not shaved and needed assistance then the resident's care plan would not have been implemented. Record review of Resident #30's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Major Depressive Disorder and Need for Assistance with Personal Care. Record review of Resident #30's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/28/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident is moderately cognitively intact and in Section GG that the resident needs substantial/maximal assistance with showers/bathe self. The Facility submitted the following Removal Plan: 1. On 10/26/2023 at 3:00pm, the Minimum Date Set (MDS) Nurse audited diet orders for residents that require chop meats and ensured that it is on the [NAME] and Care Plan. Results noted five residents on chopped meats and five corrections were made to pull to the [NAME] and Care Plan by the MDS Nurse. 2. On 10/26/2023 at 3:00pm, Nurse Educator initiated an in-service to nursing staff to supervise residents who require a chopped diet. 3. On 10/26/2023 at 7:30pm, Staff Development Coordinator initiated an in-service to all staff on Abuse/Neglect, Vulnerable Adults Act and Resident Rights. 4. On 10/27/2023 at 8:00am, Nurse Educator initiated in-services with nursing staff on verify a meal ticket, identify diet textures, fluid consistencies, Choking/Relief of foreign body obstructing airway, Heimlich Maneuver Competency, Crash Carts (location and how they are stocked). 5. On 10/27/2023 at 1:00pm, Speech Therapy evaluation was requested on residents that remain in facility on chopped meats by Administration and Medical Director. 6. On 10/28/2023 at 8:00am, Speech Therapy evaluated four residents with chopped meats with no change noted in each residents Care Plan. Each resident was found to be safe on a chopped meat diet. Residents that are in hospital will be evaluated per Speech on return to facility. 7. On 11/1/2023 at 11:22am, Medical Director gave orders to change all chopped meat diets to Mechanical Soft. Orders were changed on residents remaining in the facility with a chopped meat order, Responsible Parties of residents were notified, and dietary recommendations were turned into dietary department. 8. On 11/1/2023 at 1:00pm, Minimum Date Set (MDS) Nurse updated diets for all residents in facility on Mechanical Soft diet on [NAME] and Care Plan. 9. On 11/1/2023 at 1:00pm, Nurse Educator initiated in-services to nursing staff to notify Director of Nurses of all transfers out of facility, giving a resident full assessment and documenting on each resident transferred out, making sure when passing trays, the meal ticket matches what is on the tray, chopped meat will no longer be provided it will be ground meat consistency (Mechanical Soft), and choking verses seizure (similarity and differences). 10. On 11/1/2023 at 5:00pm, Emergency AD HOC Quality Assurance Meeting was held. Administrator in-serviced that paperwork on all transfers will be obtained and reviewed by the Interdisciplinary Team in morning stand up meeting. Those present were the Administrator, Director of Nurses, Assistant Social Services, Medical Records Clerk, Wound Nurse, Business office Managers, Housekeeping Supervisor, Nurse Educator, Social Services Director, Maintenance Director, Minimum Data Set (MDS) Nurse, Assistant Director of Nurses, Activity Director, Staff Development Coordinator, Human Resources, Respiratory Therapy, Regional Dietary Manager, Infection Preventionist, and the Medical Director. 11. On 11/2/2023 at 4:00pm, Regional Clinical Services Nurse and Director of Nursing initiated an audit to review twenty-four-hour report from 6/1/2023 to 11/1/2023 to ensure no other incidents of choking or harm were documented and unreported to Administration. 12. The Regional Clinical Services Nurse in-serviced Administrator, Director of Nursing, and Assistant Director of Nursing on proper use of the twenty-four-hour report, Proper Reporting, and Proper Investigation on 11/3/2023 at 10:00am. The twenty-four-hour report will be printed each morning and taken to the daily stand-up meeting for review for all discipline documentation effective 11/3/2023. 13. The weekend Registered Nurse was in-serviced on 11/1/2023 at 1:00pm to notify Director of Nurses with all transfers and incidents by the Nurse educator. 14. The Regional Clinical Services counseled the Administrator, Director or Nurses and Assistant Director of Nursing on investigation being timely and thorough on 11/3/2023 at 10:00am. 15. The Regional Clinical Services Nurse and Regional Case Mix Nurse in-serviced Administrator, Director of Nurses, Assistant Director of Nurses, Staff Development, Minimum Data Set (MDS) Nurses, Medical Records, Wound Nurse, Nurse Educator, Social Services Director, Assistant Social Services Director, Business Office Managers and Therapy on reviewing care plans in Care Plan Meeting on 11/3/2023 at 4:00pm. 16. All in-services that have been initiated will have 100% completion by 11/3/2023. NO employees will be allowed to work until in-serviced. The facility alleges that all corrective actions were completed as of 11/3/2023 and the Immediate Jeopardy removed on 11/4/2023. The state Survey Agency (SA) validated the removal of the immediacy. 1. The State Agency (SA) validated through record review and interview on 11/06/23 at 9:12 AM with the Minimum Date Set (MDS) Nurse that the diet orders were audited for residents that require chop meats and ensured that it is on the [NAME] and Care Plan. Results noted five residents on chopped meats and five corrections were made to pull to the [NAME] and Care Plan by the MDS Nurse. 2. The SA validated on 11/06/23 at 9:24 AM through record review and interview that the Nurse Educator initiated an in-service to nursing staff to supervise residents who require a chopped diet. 3. The SA validated on 11/06/23 at 9:24 AM through interview and record review that the Staff Development Coordinator initiated an in-service to all staff on Abuse/Neglect, Vulnerable Adults Act and Resident Rights. 4. The SA validated on 11/06/23 at 9:27 AM through interview that the Nurse Educator initiated in-services with nursing staff on verify a meal ticket, identify diet textures, fluid consistencies, Choking/Relief of foreign body obstructing airway, Heimlich Maneuver Competency, Crash Carts (location and how they are stocked). Record review of these in-services were validated by the SA. 5. The SA validated Speech Therapy evaluation was requested on residents that remain in facility on chopped meats by Administration and Medical Director. 6. The SA validated through interviews and record review on 11/06/23 that Speech Therapy evaluated four residents with chopped meats with no change noted in each residents Care Plan. Each resident was found to be safe on a chopped meat diet. Residents that are in hospital will be evaluated per Speech on return to facility. 7. The SA validated through interview and record review on 11/06/23 with the Medical Director that he gave orders to change all chopped meat diets to Mechanical Soft. Orders were changed on residents remaining in the facility with a chopped meat order, Responsible Parties of residents were notified, and dietary recommendations were turned into dietary department. 8. The SA validated through record review and interview on 11/06/23 with the Minimum Date Set (MDS) Nurse that updated diets for all residents in facility on Mechanical Soft diet are on [NAME] and Care Plan. 9. The SA validated that the Nurse Educator initiated in-services to nursing staff to notify Director of Nurses of all transfers out of facility, giving a resident full assessment and documenting on each resident transferred out, making sure when passing trays, the meal ticket matches what is on the tray, chopped meat will no longer be provided it will be ground meat consistency (Mechanical Soft), and choking verses seizure (similarity and differences). 10. The SA validated through record review and interviews on 11/06/23 that an Emergency AD HOC Quality Assurance Meeting was held. Administrator in-serviced that paperwork on all transfers will be obtained and reviewed by the Interdisciplinary Team in morning stand up meeting. Those present were the Administrator, Director of Nurses, Assistant Social Services, Medical Records Clerk, Wound Nurse, Business office Managers, Housekeeping Supervisor, Nurse Educator, Social Services Director, Maintenance Director, Minimum Data Set (MDS) Nurse, Assistant Director of Nurses, Activity Director, Staff Development Coordinator, Human Resources, Respiratory Therapy, Regional Dietary Manager, Infection Preventionist and Medical Director. 11. The SA validated through interview on 11/06/23 with the Regional Clinical Services Nurse and Director of Nursing initiated an audit to review twenty-four-hour report from 6/1/2023 to 11/1/2023 to ensure no other incidents of choking or harm were documented and unreported to Administration. 12. The SA validated through record review and interview on 11/06/23 that the Regional Clinical Services Nurse in-serviced Administrator, Director of Nursing, and Assistant Director of Nursing on proper use of the twenty-four-hour report, Proper Reporting, and Proper Investigation on 11/3/2023 at 10:00am. The twenty-four-hour report will be printed each morning and taken to the daily stand-up meeting for review for all discipline documentation effective 11/3/2023. 13. The SA validated through record review and interview on 11/06/23 that the weekend Registered Nurse was in-serviced on 11/1/2023 at 1:00pm to notify Director of Nurses with all transfers and incidents by the Nurse educator. 14. The SA validated through record review and interview on 11/06/23 with the Regional Clinical Services that she counseled the Administrator, Director or Nurses and Assistant Director of Nursing on investigation being timely and thorough on 11/3/2023 at 10:00am. 15. The SA validated through record review and interview on 11/06/23 that the Regional Clinical Services Nurse and Regional Case Mix Nurse in-serviced Administrator, Director of Nurses, Assistant Director of Nurses, Staff Development, Minimum Data Set (MDS) Nurses, Medical Records, Wound Nurse, Nurse Educator, Social Services Director, Assistant Social Services Director, Business Office Managers and Therapy on reviewing care plans in Care Plan Meeting on 11/3/2023 at 4:00pm. 16. All in-services that have been initiated will have 100% completion by 11/3/2023. NO employees will be allowed to work until in-service is completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and facility policy review the facility failed to ensure a resident with a history of choking on 06/17/23 was ordered a therapeutic diet to prevented a choking incident on 8/20/23 and again on 10/25/23 which required Cardiopulmonary resuscitation, and hospitalization with a poor recovery prognosis for one (1) of six (6) residents reviewed for diets. The facility failed to identify a choking incident on 06/17/23 with required hospitalization for three (3) days and removal of a food bolus from his oropharynx and failed to identify an 08/20/23 choking incident that required the Heimlich maneuver to remove the food bolus from his oropharynx in the facility. This failure resulted in the resident not receiving services to prevent choking episodes. The resident's diet was changed on 8/21/23 to Consistent Carbohydrate Diet (CCD) mechanical soft. The resident's diet changed on 8/31/23 to CCD with chopped meats and the Certified Nursing Assistants (CNA) were to chop the resident's meat when the tray was served. The meal tickets were never changed to include the CNA to chop meats. On 10/25/23 in the evening, Resident #13 was served an Italian Sausage link that was five (5) to six (6) 1 ½ inch chunks of meat and the resident was found in his bed, unable to breath and without a pulse or respirations. Cardiopulmonary Resuscitation (CPR) was performed for over ten (10) minutes and Resident #13 was transported to the local hospital where the resident was placed on life support. The facility's failure to ensure that staff were aware of the diet needs of Resident #13 and to clarify and serve the correct diet order to a resident with a history of choking and dysphagia resulted in Resident #13 choking on 10/25/23 and required life saving measures The resident remained in the hospital on the ventilator at the time of the survey. The situation was identified as an Immediate Jeopardy (IJ) that began on 6/17/23 when the facility failed to ensure Resident #13 received a modified diet after a choking episode. On 11/2/23 at 3:35 PM, the State Agency notified the facility's Administrator of the IJ and provided the Administrator with the IJ templates. The facility submitted an acceptable Removal Plan on 11/3/23, in which the facility alleged all corrective actions were completed to remove the IJ on 11/03/23, and the IJ was removed on 11/04/23. The State Agency (SA) validated the removal plan on 11/06/23, prior to exit. and the scope and severity for F803 was lowered to a 'D while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Cross Reference F600 Review of the facility policy titled, Food and Nutrition Services dated October 2022, revealed, Policy Statement Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident Policy Interpretation and Implementation: 7 .Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident . Review of the facility policy titled, Diet and Nutrition Care Manual Dysphagia Advanced (level 3) or Mechanical (Dental) soft diet dated 2019 revealed, This diet is used for individuals with mild oral and/or pharyngeal phase dysphagia. Foods that are difficult to chew are chopped, ground, shredded, cooked, or altered to make them easier to chew and swallow . Review of the facility policy titled, Therapeutic Diets dated October 2022 revealed, the diet order should match the terminology used by the food and nutrition services department. Record review of the Diet Requisition Form New admission dated 5/16/22 revealed Resident #13 had a regular consistent carbohydrate (CCD) regular texture, thin liquids diet. Record review of the local hospital emergency room Report, dated 6/17/23, read chief complaint: Altered Mental Status. Rehab facility was contacted for further information regarding patient's presentation, and they reported that patient had abnormal moaning and jerking-like motions, and that staff had concerns for new onset seizure-like activity. Per chart review, patient has no prior history of seizures but does have a history of Cerebral Vascular Accident (CVA) involving left middle cerebral artery. At the time of exam, it was noted that the patient had a golf ball sized food bolus extracted from posterior oropharynx. Record review of Progress notes dated 08/20/23 at 18:20 PM, revealed, Resident noted with choking episode this shift at dinner time. Licensed Practical Nurse (LPN) reporting that the resident had gotten choked on a piece of meat off his dinner tray. LPN assist resident with dislodging piece of meat. Resident's color returning to normal with O2 (oxygen) saturation of 97% on RA (room air). Resident continued to be noted with a cough. Record review of the Diet Requisition Form Diet Change, dated 8/21/23, revealed Resident #13 was changed to a Mechanical soft chopped meat texture diet. Record review of a Meal Ticket, dated 08/31/23 at 2:34 PM, revealed diet order was changed to Chopped Meats; Knife and resident was served whole meats with a knife to cut. Record review of Progress Note dated 08/21/23 at 13:48 PM read, It was reported to ST (Speech Therapy) that the pt got choked while eating meat the previous day. Also nurse reports pt had difficulty while taking meds today. Record review of Resident #13's meal ticket dated 8/30/23 all meals CCD-Mechanical Soft. Review of the Dinner meal ticket revealed- Ground Italian Sausage, brown gravy, parmesan noodles, broccoli florets chopped and sliced pears. The same meal was served on 10/25/23, the evening that the resident choked, and review of the dinner meal ticket revealed, Italian Sausage, Parmesan noodles, Broccoli florets, sliced pears. Record review of Progress Notes, dated 10/25/23 at 19:42 PM stated, Nurse was alerted by CNA that I was needed in resident's room. Upon arriving in room resident appeared to be having seizure activity. Pulse was faint and respirations noted. Resident had foamy secretions coming from mouth. Resident was pale in color. CNA told this nurse that prior to her alerting me he had been eating. This nurse performed back thrust times 5 and was in process of performing ABD (abdominal) thrust when other help arrived. Thrust was ineffective. Nurse left room and got crash cart and upon returning CPR was in process related to no pulse or respirations. Progress note for 10/25/23 at 19:45 PM Nurse observed resident unresponsive, pale and foaming at the mouth. Nurse called 911 and returned to aid with chest compression until EMS arrived. Record review of the local hospital emergency room report dated 10/25/23 stated, History of Present Illness .Per ambulance run report: Patient was found lying supine in bed upon arrival; nursing home staff stated that the patient was found unresponsive and cyanotic immediately after mealtime. Per ED (Emergency Department) sign out: Patient was exhibiting agonal breathing; a piece of sausage was extracted from his oropharynx prior to intubation . During the intubation, we visualized a very large piece of food obstructing the patient's airway, using forceps, and removed the foreign body. After the patient was intubated and sedated and placed on the ventilator, his vital signs normalized . In an interview on 10/31/23 at 12:50 PM CNA # 2 revealed she had never been in-serviced on how to chop the resident's meats before and wasn't aware that he was supposed to have his meats chopped because the diet ticket never said to chop his meats. In an interview on 10/31/23 at 1:40 PM with CNA #7 revealed the day before he choked on 10/25/23, he had a whole piece of chicken that was served on his meal tray. She stated we never cut his meat up before and the resident can eat by himself, and we don't stay in the room with him while he is eating. In an interview on 11/01/23 at 8:10 AM, CNA #8 revealed she was never aware that the resident required his meats to be chopped before he choked on 10/25/23. She revealed we were told after he choked that we needed to make sure and chop his meats, but not before. In an interview on 11/01/23 at 8:25 AM with Dietary management Service Account Manager revealed she has been here for about two months and stated that when she started, she was told anyone with a chopped meats diet we were to put a whole piece of meat on the plate and put a knife on the tray so that the CNA could cut up the meat. She revealed this was the only place she had ever worked that a CNA would cut the meat up. She stated on 10/25/23 she was in the kitchen and did observe the meal which consisted of Italian sausage that was cut into about one (1) to one and one-half (1½) inch chunks and each resident got about three or four chunks of the meat on their tray. An interview, on 11/01/23 at 8:50 AM, with CNA #6 revealed that she was working the night of 10/25/23 and went into Resident #13's room at about 7:15 PM to get his vital signs. The resident said he was hungry. CNA #6 stated she assisted him to the bathroom and then set up his tray which consisted of noodles, round Polish sausage there were about four large round pieces about ½ inch to one inch long on his tray, and broccoli florets. She revealed she didn't cut the sausage up because she was not aware that he required his meat to be chopped or cut. She revealed I went and started getting his roommate's vital signs and then she heard Resident #13 make a sound I never had heard before. She stated she thought he was having a seizure because he had fallen back on his bed rail and was foaming out of the mouth. I went for help immediately. She revealed on his plate he had eaten all the sausages and maybe one of the broccoli florets. She stated that after this incident we were in-serviced to make sure to look on the meal ticket and that CNAs were responsible for chopping meat for residents requiring chopped meats. She confirmed before the choking incident they were not told to cut the residents' meats up. She stated she had worked here for about a year and had never been told to chop his meats before and hadn't seen his meats chopped up. In an interview on 11/01/23 at 9:30 AM, the Administrator (ADM) revealed Speech Therapy had ordered a chopped meats diet in August because the resident had a choking episode. She revealed the Dietary Director of Operations told her they were not able to do a chopped meats diet. She revealed we immediately in-serviced the staff that the kitchen would send out the appropriate knife and they would have to chop the meats. She stated, I did not feel comfortable with my staff cutting the meats, but I was told by the Dietary Director of Operations that it was a facility policy but since then I found out that wasn't true. She confirmed that she found out that wasn't true through my Corporate Chief Operating Officer and stated, I didn't say anything to the Dietary Director of Operations after that because that's a corporate-level issue and I was letting them handle it. She stated, I could make it happen today to stop all chop meats and just do a Mechanical soft. I haven't done it yet because Corporate had been working with Dietary Management about the issue. She revealed that since the incident that happened on 10/25/23 with Resident #13 the aides are still chopping meat for the residents and stated that we keep a list of residents who require chopped meats at the nurse's station. She confirmed when she found out on 10/26/23 that the resident had choked, she hadn't done anything different with the chopped meat diets because corporate is working on that. In an interview on 11/01/23 at 10:05 AM, with the Director of Operations (DO) for the dietary services management company revealed that the management company has three diets which are Regular, Mechanical Soft, and Pureed. He stated that Resident #13 was put on a chopped meat diet on 08/21/23, because he had a choking episode. He confirmed that he had asked the Administrator for a diet clarification because we do not historically do chopped meats, we could do mechanical soft, and he was told by the Administrator to send out a knife for the residents who were on a chopped meat diet and the aides would chop the meats. He confirmed that this occurred on the Thursday before Labor Day, which would have been 08/31/23. The Director of Operations revealed he is over 23 buildings, and this is the only building where they are doing chopped meats and requiring aides to chop the meat when it gets to the resident. In an interview on 11/01/2023 at 12:55 PM, with the Nurse Consultant, Director of Nurses (DON), and Administrator revealed they were not aware of the choking episode on 6/17/2023. The DON and Nurse Consultant revealed they were not aware of a choking episode on 8/20/23. The Administrator revealed she was aware of the 8/20/23 choking episode and had a conversation with the Dietary because Speech Therapy had evaluated Resident #13 and requested a chopped meat diet. In an interview on 11/01/23 at 2:05 PM with CNA #7 revealed she never saw on the electronic charting guide for Resident #13 that the CNA was to chop meats. She revealed our tablets are how we know how to chart for the residents and what they are supposed to get. In an interview on 11/01/23 at 4:00 PM, Registered Nurse (RN) #2 revealed on 8/20/23 was the Nurse Supervisor; she stated the floor nurse hollered for me and said she had done the Heimlich maneuver on Resident #13 and was able to get the food expelled. She stated they put in a diet order change the next day for chopped meats. Record review of Resident #13's admission Record revealed he was admitted to the facility on [DATE] with diagnoses that included Transient Cerebral Ischemic Attack, Dysphagia, Altered Mental Status, and Unspecified Dementia. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 07, which indicated the resident had a severe cognitive impairment. The assessment further indicated under Section GG that Resident #13 required for eating, supervision, or touching assistance- Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. The assessment further indicated under Section K that Resident #13 had coughing or choking during meals or when swallowing medication and complaints of difficulty or pain with swallowing. Removal Plan: On 11/02/23 at 3:35 PM, the Facility Administrator was notified that the situation of neglect for Resident #13 was deemed an Immediate Jeopardy (IJ). The Facility submitted the following Removal Plan: 1. On 10/26/2023 at 3:00pm, the Minimum Date Set (MDS) Nurse audited diet orders for residents that require chop meats and ensured that it is on the [NAME] and Care Plan. Results noted five residents on chopped meats and five corrections were made to pull to the [NAME] and Care Plan by the MDS Nurse. 2. On 10/26/2023 at 3:00pm, Nurse Educator initiated an in-service to nursing staff to supervise residents who require a chopped diet. 3. On 10/26/2023 at 7:30pm, Staff Development Coordinator initiated an in-service to all staff on Abuse/Neglect, Vulnerable Adults Act and Resident Rights. 4. On 10/27/2023 at 8:00am, Nurse Educator initiated in-services with nursing staff on verify a meal ticket, identify diet textures, fluid consistencies, Choking/Relief of foreign body obstructing airway, Heimlich Maneuver Competency, Crash Carts (location and how they are stocked). 5. On 10/27/2023 at 1:00pm, Speech Therapy evaluation was requested on residents that remain in facility on chopped meats by Administration and Medical Director. 6. On 10/28/2023 at 8:00 am, Speech Therapy evaluated four residents with chopped meats with no change noted in each residents Care Plan. Each resident was found to be safe on a chopped meat diet. Residents that are in hospital will be evaluated per Speech on return to facility. 7. On 11/1/2023 at 11:22 am, Medical Director gave orders to change all chopped meat diets to Mechanical Soft. Orders were changed on residents remaining in the facility with a chopped meat order, Responsible Parties of residents were notified, and dietary recommendations were turned into dietary department. 8. On 11/1/2023 at 1:00pm, Minimum Date Set (MDS) Nurse updated diets for all residents in facility on Mechanical Soft diet on [NAME] and Care Plan. 9. On 11/1/2023 at 1:00pm, Nurse Educator initiated in-services to nursing staff to notify Director of Nurses of all transfers out of facility, giving a resident full assessment and documenting on each resident transferred out, making sure when passing trays, the meal ticket matches what is on the tray, chopped meat will no longer be provided it will be ground meat consistency (Mechanical Soft), and choking verses seizure (similarity and differences). 10. On 11/1/2023 at 5:00pm, Emergency AD HOC Quality Assurance Meeting was held. Administrator in-serviced that paperwork on all transfers will be obtained and reviewed by the Interdisciplinary Team in morning stand up meeting. Those present were the Administrator, Director of Nurses, Assistant Social Services, Medical Records Clerk, Wound Nurse, Business office Managers, Housekeeping Supervisor, Nurse Educator, Social Services Director, Maintenance Director, Minimum Data Set (MDS) Nurse, Assistant Director of Nurses, Activity Director, Staff Development Coordinator, Human Resources, Respiratory Therapy, Regional Dietary Manager, Infection Preventionist and the Medical Director. 11. On 11/2/2023 at 4:00pm, Regional Clinical Services Nurse and Director of Nursing initiated an audit to review twenty-four-hour report from 6/1/2023 to 11/1/2023 to ensure no other incidents of choking or harm were documented and unreported to Administration. 12. The Regional Clinical Services Nurse in-serviced Administrator, Director of Nursing, and Assistant Director of Nursing on proper use of the twenty-four-hour report, Proper Reporting, and Proper Investigation on 11/3/2023 at 10:00 am. The twenty-four-hour report will be printed each morning and taken to the daily stand-up meeting for review for all discipline documentation effective 11/3/2023. 13. The weekend Registered Nurse was in-serviced on 11/1/2023 at 1:00pm to notify Director of Nurses with all transfers and incidents by the Nurse educator. 14. The Regional Clinical Services counseled the Administrator, Director or Nurses and Assistant Director of Nursing on investigation being timely and thorough on 11/3/2023 at 10:00 am. 15. The Regional Clinical Services Nurse and Regional Case Mix Nurse in-serviced Administrator, Director of Nurses, Assistant Director of Nurses, Staff Development, Minimum Data Set (MDS) Nurses, Medical Records, Wound Nurse, Nurse Educator, Social Services Director, Assistant Social Services Director, Business Office Managers and Therapy on reviewing care plans in Care Plan Meeting on 11/3/2023 at 4:00pm. 16. All in-services that have been initiated will have 100% completion by 11/3/2023. NO employees will be allowed to work until in-serviced. The facility alleges that all corrective actions were completed as of 11/3/2023 and the Immediate Jeopardy removed on 11/4/2023. 1. The State Agency (SA) validated through record review and interview on 11/06/23 at 9:12 AM with the Minimum Date Set (MDS) Nurse that the diet orders were audited for residents that require chop meats and ensured that it is on the [NAME] and Care Plan. Results noted five residents on chopped meats and five corrections were made to pull to the [NAME] and Care Plan by the MDS Nurse. 2. The SA validated on 11/06/23 at 9:24 AM through record review and interview that the Nurse Educator initiated an in-service to nursing staff to supervise residents who require a chopped diet. 3. The SA validated on 11/06/23 at 9:24 AM through interview and record review that the Staff Development Coordinator initiated an in-service to all staff on Abuse/Neglect, Vulnerable Adults Act and Resident Rights. 4. The SA validated on 11/06/23 at 9:27 AM through interview that the Nurse Educator initiated in-services with nursing staff on verify a meal ticket, identify diet textures, fluid consistencies, Choking/Relief of foreign body obstructing airway, Heimlich Maneuver Competency, Crash Carts (location and how they are stocked). Record review of these in-services were validated by the SA. 5. The SA validated Speech Therapy evaluation was requested on residents that remain in facility on chopped meats by Administration and Medical Director. 6. The SA validated through interviews and record review on 11/06/23 that Speech Therapy evaluated four residents with chopped meats with no change noted in each residents Care Plan. Each resident was found to be safe on a chopped meat diet. Residents that are in hospital will be evaluated per Speech on return to facility. 7. The SA validated through interview and record review on 11/06/23 with the Medical Director that he gave orders to change all chopped meat diets to Mechanical Soft. Orders were changed on residents remaining in the facility with a chopped meat order, Responsible Parties of residents were notified, and dietary recommendations were turned into dietary department. 8. The SA validated through record review and interview on 11/06/23 with the Minimum Date Set (MDS) Nurse that updated diets for all residents in facility on Mechanical Soft diet are on [NAME] and Care Plan. 9. The SA validated that the Nurse Educator initiated in-services to nursing staff to notify Director of Nurses of all transfers out of facility, giving a resident full assessment and documenting on each resident transferred out, making sure when passing trays, the meal ticket matches what is on the tray, chopped meat will no longer be provided it will be ground meat consistency (Mechanical Soft), and choking verses seizure (similarity and differences). 10. The SA validated through record review and interviews on 11/06/23 that an Emergency AD HOC Quality Assurance Meeting was held. Administrator in-serviced that paperwork on all transfers will be obtained and reviewed by the Interdisciplinary Team in morning stand up meeting. Those present were the Administrator, Director of Nurses, Assistant Social Services, Medical Records Clerk, Wound Nurse, Business office Managers, Housekeeping Supervisor, Nurse Educator, Social Services Director, Maintenance Director, Minimum Data Set (MDS) Nurse, Assistant Director of Nurses, Activity Director, Staff Development Coordinator, Human Resources, Respiratory Therapy, Regional Dietary Manager, Infection Preventionist and Medical Director. 11. The SA validated through interview on 11/06/23 with the Regional Clinical Services Nurse and Director of Nursing initiated an audit to review twenty-four-hour report from 6/1/2023 to 11/1/2023 to ensure no other incidents of choking or harm were documented and unreported to Administration. 12. The SA validated through record review and interview on 11/06/23 that the Regional Clinical Services Nurse in-serviced Administrator, Director of Nursing, and Assistant Director of Nursing on proper use of the twenty-four-hour report, Proper Reporting, and Proper Investigation on 11/3/2023 at 10:00am. The twenty-four-hour report will be printed each morning and taken to the daily stand-up meeting for review for all discipline documentation effective 11/3/2023. 13. The SA validated through record review and interview on 11/06/23 that the weekend Registered Nurse was in-serviced on 11/1/2023 at 1:00pm to notify Director of Nurses with all transfers and incidents by the Nurse educator. 14. The SA validated through record review and interview on 11/06/23 with the Regional Clinical Services that she counseled the Administrator, Director or Nurses and Assistant Director of Nursing on investigation being timely and thorough on 11/3/2023 at 10:00 am. 15. The SA validated through record review and interview on 11/06/23 that the Regional Clinical Services Nurse and Regional Case Mix Nurse in-serviced Administrator, Director of Nurses, Assistant Director of Nurses, Staff Development, Minimum Data Set (MDS) Nurses, Medical Records, Wound Nurse, Nurse Educator, Social Services Director, Assistant Social Services Director, Business Office Managers and Therapy on reviewing care plans in Care Plan Meeting on 11/3/2023 at 4:00pm. 16. All in-services that have been initiated will have 100% completion by 11/3/2023. NO employees will be allowed to work until in-service is completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and facility policy review, the facility failed to be administered in a manner to prevent negligent care to a resident and to ensure staff were made aware of significant incidents and the dietary needs of Resident #13 for one (1) of three (3) residents reviewed for abuse/neglect. Resident #13 Resident #13 had choking episodes on 6/20/23 which resulted in the hospitalization where a golf ball size meat bolus was removed in the Emergency Room. Resident #13 choked on meat again on 8/20/23 which was removed in the facility with the Heimlich Maneuver. The resident's diet was changed on 8/21/23 to Consistent Carbohydrate Diet (CCD) mechanical soft. The Administrator requested the resident's diet changed on 8/31/23 to CCD with chopped meats and the Certified Nursing Assistants (CNA) were to chop the resident's meat when the tray was served. The meal tickets were never changed to include the directions for CNA to chop meats. On 10/25/23 in the evening, Resident #13 was served an Italian Sausage link that was five (5) to six (6) 1½ inch chunks of meat and the resident was found in his bed, unable to breath and without a pulse or respirations. Cardiopulmonary Resuscitation (CPR) was performed for over ten (10) minutes and was not successful. Resident #13 was transported to the local hospital where he remained on life support. The hospital report revealed the resident had choked again. This situation was identified as an Immediate Jeopardy (IJ) that began on 6/17/23 when the Administration failed ensure measures were put into place to prevent further choking episodes. The facility's failure to be administered in a way to ensure a resident was protected from further choking incidents resulted in harm to Resident #13 and the likelihood of serious harm, impairment, or death to other residents. On 11/2/23 at 3:35 PM, the State Agency notified the facility's Administrator of the IJ and provided the Administrator with the IJ templates. The facility submitted an acceptable Removal Plan on 11/3/23, in which the facility alleged all corrective actions were completed to remove the IJ on 11/3/23, and the IJ was removed on 11/4/23. The State Agency (SA) validated the removal plan on 11/06/23, prior to exit. and the scope and severity for F835 was lowered to a 'D while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Cross Reference F600 Record review of facility policy, dated March 2017, Job Description Position Title: Facility Administrator revealed, Basic Function- Responsible for the overall management, leadership, growth, and profitability of the facility . Essential Functions and Responsibilities: .Maintain and guide the implementation of facility policies and procedures in compliance with corporate, state, federal, and other regulatory guidelines . Ensures that the quality and appropriateness of resident care meets or exceeds company and industry standards and ensures that all services are in compliance with state and federal legal, regulatory, accreditation and reimbursement guidelines . Report incident reports to proper company and agency authorities in accordance with regulatory guidelines. Attend and/or conduct facility meetings, as required to carry out responsibilities. Promotes optimal communication among staff members, facility staff, referral sources physicians and residents. Record review of facility policy, dated April 2017, titled, Job Description Position Title: Director of Nursing revealed, Function: Plans, coordinates and manages the nursing department. Responsible for the overall direction, coordination and evaluation of nursing care and services provided to the Residents .Care and Services: Responsible for the overall direction, coordination and evaluation of the nursing department . Schedules and performs Resident rounds to monitor and evaluate the quality and appropriateness of nursing care. Maintains administrative authority, responsibility and accountability for the proper charting and documentation of care and of medications and treatments. Record review of facility policy, dated 05/2017, titled, Position Description Position Title: Assistant Director of Nursing revealed, The primary purpose of your job position is to assist the Director of Nursing Services in planning organizing, developing, and directing the day-to-day functions of the Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator, the Medical Director, and/or Director of Nursing Services, to ensure that the highest degree of quality care is maintained at all times . Review nurses' notes to ensure that they are informative and descriptive of the nursing care being provided . Participate in developing, planning, conducting, and scheduling in-service training classes that provide instructions on how to do the job, and ensure a well-educated nursing service department . The Administrator (ADM) in an interview on 11/01/23 at 9:30 AM, revealed Speech Therapy had ordered a chopped meats diet in August because the resident had a choking episode. She revealed the dietary management company's Dietary Director of Operations told her they were not able to do a chopped meats diet. She revealed we immediately in-serviced the staff that the kitchen would send out the appropriate knife and they would have to chop the meats. She stated, I didn't feel comfortable with my staff cutting the meats, but I was told by the Dietary Director of Operations that it was a facility policy but since then I found out that wasn't true. She confirmed that she found out that wasn't true through Corporate and stated, I didn't say anything to the Dietary Director of Operations after that because that's a corporate-level issue, and I was letting them handle it. She stated, I could make it happen today to stop all chop meats and just do a Mechanical soft. I haven't done it yet because Corporate had been working with the dietary company about the issue. She revealed that since the incident that happened on 10/25 with Resident #13 the aides are still chopping meat for the residents and stated that we keep a list of residents who require chopped meats at the nurse's station. She confirmed when she found out on 10/26/23 that the resident had choked, she had not done anything different with the chopped meat diets because corporate is working on that. The Director of Operations (DO) for Dietary with the dietary management company stated in an interview on 11/01/23 at 10:05 AM, that the company has three diets which are Regular, Mechanical Soft, and Pureed. He stated that Resident #13 was put on a chopped meat diet on 08/21/23, because he had a choking episode. He confirmed that he had asked the Administrator for a diet clarification because dietary does not historically do chopped meats, but could do mechanical soft, and he was told by the Administrator to send out a knife for the residents who were on a chopped meat diet and the aides would chop the meats. He confirmed that this occurred on the Thursday before Labor Day, which would have been 08/31/23. The Director of Operations for Dietary revealed he is over 23 buildings, and this is the only building where they are doing chopped meats and requiring aides to chop the meat when it gets to the resident. He stated that he did not like sending knives out for CNAs to cut up meat but he was unable to get the Administrator to understand that chopped meats is considered a mechanical soft diet. The Director of Operations (DO) for Dietary stated he just needed the Administration to get the diet order clarified. The Nurse Consultant, Director of Nurses, and Administrator revealed during an interview on 11/01/2023 at 12:55 PM, they were not aware of the choking episode on 6/17/2023. The DON and Nurse Consultant revealed they were not aware of a choking episode on 8/20/23. The Administrator revealed she was aware of the 8/20/23 choking episode and had a conversation with the Dietary because Speech Therapy had evaluated Resident #13 and requested a chopped meat diet. Registered Nurse (RN) #2, in an interview on 11/01/23 at 4:00 PM, revealed she was unaware of the choking episode for Resident #13 in June and stated we have a daily stand-up meeting where all disciplines attend including the Administrator, DON, and Assistant Director of Nursing (ADON). She confirmed I'm not sure if it was discussed in the morning stand-up meeting or the clinical standards meeting about him choking on 8/20/23. The Administrator revealed during an interview on 11/01/23 at 4:10 PM, for the incident on 10/25/23 she was not made aware that Resident #13 was eating dinner when the episode occurred, until the next day, on 10/26/23, around lunch time. She confirmed the nurse told her that he had a seizure and the facility had to do CPR and send Resident #13 to the hospital. She had seen the hospital paperwork on 10/26/23 that revealed he had the sausage in his oropharynx and revealed for the 8/20/23 incident the staff nurses just reported that he got strangled on his food and that's when he got the order for speech to be evaluated. She confirmed she was not aware that Resident #13 required the Heimlich maneuver at that time. The DON revealed in an interview, at the same time, on 11/01/23 at 4:10 PM, that for the 8/20/23 incident she was made aware that the resident had trouble with taking his medicines and was not made aware of him choking. She revealed she is going to start going back and reading the nurse's notes each day so she will know what is going on. She revealed it usually will come out on the 24-hour nurses report and we will discuss it in the morning meeting. The DON and Administrator both revealed they were not sure how the choking episodes got missed. The DON confirmed after the 10/25/23 incident she instructed Resident #13's care plan to be updated to make sure CNA to chop meats was reflected on his meal tickets and that she was the one that put it on his 10/25/23 meal ticket for CNA to chop meats, and confirmed that it was not on there for the CNA to see that day. She confirmed it was not on the care plan before 10/25/23 and it should have been. She confirmed again that she was not aware of Resident #13 having a choking episode in June or August and that she wasn't aware that he had choked on 10/25/23 until the afternoon on 10/26/23. An interview on 11/02/23 at 8:30 AM, the DON revealed she did not know that the care plan was updated in June for the staff to assist him with all meals or the care plan updated in August for him to be up in the wheelchair for all meals. She revealed Resident #13 has a history of wanting to lie down in bed and eat. That's his preference. SA asked the DON why she thought the care plan was put in on 6/26/23. The DON revealed I didn't put it in, and I wasn't aware of that care plan or a choking incident. The DON stated, I wasn't aware of this incident until it was brought to my attention yesterday. I can't review every piece of paper that comes through. She revealed she is usually informed of any changes during the stand-up meeting each morning and revealed I do not know how the incident in June and August was missed, she confirmed I guess it was a breakdown in communication. She stated that for the incident on 10/25/23, the nurse let me know that night that she thought he was having a seizure and revealed she did not instruct the night shift staff to start an investigation because I thought it was a seizure. The DON revealed the staff called her back that night and said the resident was being admitted and had to be intubated. She revealed that they did not have stand-up the next morning. She stated, I can not remember why we didn't have it, but I was informed around one or one-thirty that day when we were having a party, she revealed a staff member said they had called over to the ER and had been told that he had something in his throat when they tried to intubate him. She stated, that's when we called over and got the medical records. She stated at that time they had started an investigation, but she still wasn't aware of the June and August incidents of choking until the State Agency (SA) had told her they had discovered documentation of choking in the medical records and nurses' notes. The DON confirmed that she didn't thoroughly investigate the choking because she thought it was a seizure. The DON confirmed she did instruct the staff to update the Resident's care plan on 10/26/23 for the CNA to Chop the meat. She revealed when it is in the care plan it pulls to the CNA's [NAME]. She confirmed it was not in the care plan prior to the incident on 10/25/23 and it should have been. She confirmed that the CNAs would not have any way of knowing how to chop the meats until they corrected it on 10/26/23. An interview on 11/02/23 at 10:40 AM the ADON revealed she did an in-service on 8/31/2023 for the CNAs and nursing staff regarding Chopped meats. She confirmed the in-service was not attended by all nursing staff including CNA #2 and CNA #6. She revealed that the 7 p.m.-7 a.m. shift did not get the in-service on chopping meats because the meal trays are sent out on the day shift not the night shift. She confirmed that she did not demonstrate how to chop the meat to the in-service staff. Record review of the Diet requisition form Diet change dated 8/21/23 revealed Resident #13 was changed to a Mechanical soft chopped meat texture diet. Record review Meal ticket dated 08/31/23 at 2:34 PM diet order was changed to Chopped Meats; Knife and resident was served whole meats with a knife to cut. Record review of Resident #13's meal ticket, dated 8/30/23, all meals CCD-Mechanical Soft. Review of the Dinner meal ticket revealed- Ground Italian Sausage, brown gravy, parmesan noodles, broccoli florets chopped and sliced pears. The same meal was served on 10/25/23 the evening that the resident choked. Record review of the dinner meal ticket revealed, Italian Sausage, Parmesan noodles, Broccoli florets, sliced pears. Record review of Progress notes dated 08/20/23 at 18:20 PM, stated, Resident noted with choking episode this shift at dinner time. LPN reporting that the resident had gotten choked on a piece of meat off his dinner tray. LPN assist resident with dislodging piece of meat. Resident's color returning to normal with O2 (oxygen) saturation of 97% on RA (room air). Resident continued. to be noted with a cough. Record review of Progress Note dated 08/21/23 at 13:48 PM stated, It was reported to ST (Speech Therapy) that the pt got choked while eating meat the previous day. Also nurse reports pt had difficulty while taking meds today. Record review of Progress Notes, dated 08/23/23 at 10:16 AM stated, Resident is to be gotten up for meals in W/C (wheelchair). The Facility submitted the following Removal Plan, on 11/03/23, alleging removal of the immediacy as of 11/04/23. 1. On 10/26/2023 at 3:00pm, the Minimum Date Set (MDS) Nurse audited diet orders for residents that require chop meats and ensured that it is on the [NAME] and Care Plan. Results noted five residents on chopped meats and five corrections were made to pull to the [NAME] and Care Plan by the MDS Nurse. 2. On 10/26/2023 at 3:00pm, Nurse Educator initiated an in-service to nursing staff to supervise residents who require a chopped diet. 3. On 10/26/2023 at 7:30 pm, Staff Development Coordinator initiated an in-service to all staff on Abuse/Neglect, Vulnerable Adults Act and Resident Rights. 4. On 10/27/2023 at 8:00 am, Nurse Educator initiated in-services with nursing staff on verify a meal ticket, identify diet textures, fluid consistencies, Choking/Relief of foreign body obstructing airway, Heimlich Maneuver Competency, Crash Carts (location and how they are stocked). 5. On 10/27/2023 at 1:00pm, Speech Therapy evaluation was requested on residents that remain in facility on chopped meats by Administration and Medical Director. 6. On 10/28/2023 at 8:00 am, Speech Therapy evaluated four residents with chopped meats with no change noted in each residents Care Plan. Each resident was found to be safe on a chopped meat diet. Residents that are in hospital will be evaluated per Speech on return to facility. 7. On 11/1/2023 at 11:22 am, Medical Director gave orders to change all chopped meat diets to Mechanical Soft. Orders were changed on residents remaining in the facility with a chopped meat order, Responsible Parties of residents were notified, and dietary recommendations were turned into dietary department. 8. On 11/1/2023 at 1:00pm, Minimum Date Set (MDS) Nurse updated diets for all residents in facility on Mechanical Soft diet on [NAME] and Care Plan. 9. On 11/1/2023 at 1:00pm, Nurse Educator initiated in-services to nursing staff to notify Director of Nurses of all transfers out of facility, giving a resident full assessment and documenting on each resident transferred out, making sure when passing trays, the meal ticket matches what is on the tray, chopped meat will no longer be provided it will be ground meat consistency (Mechanical Soft), and choking verses seizure (similarity and differences). 10. On 11/1/2023 at 5:00pm, Emergency AD HOC Quality Assurance Meeting was held. Administrator in-serviced that paperwork on all transfers will be obtained and reviewed by the Interdisciplinary Team in morning stand up meeting. Those present were the Administrator, Director of Nurses, Assistant Social Services, Medical Records Clerk, Wound Nurse, Business office Managers, Housekeeping Supervisor, Nurse Educator, Social Services Director, Maintenance Director, Minimum Data Set (MDS) Nurse, Assistant Director of Nurses, Activity Director, Staff Development Coordinator, Human Resources, Respiratory Therapy, Regional Dietary Manager, Infection Preventionist, and Medical Director. 11. On 11/2/2023 at 4:00pm, Regional Clinical Services Nurse and Director of Nursing initiated an audit to review twenty-four-hour report from 6/1/2023 to 11/1/2023 to ensure no other incidents of choking or harm were documented and unreported to Administration. 12. The Regional Clinical Services Nurse in-serviced Administrator, Director of Nursing, and Assistant Director of Nursing on proper use of the twenty-four-hour report, Proper Reporting, and Proper Investigation on 11/3/2023 at 10:00 am. The twenty-four-hour report will be printed each morning and taken to the daily stand-up meeting for review for all discipline documentation effective 11/3/2023. 13. The weekend Registered Nurse was in-serviced on 11/1/2023 at 1:00pm to notify Director of Nurses with all transfers and incidents by the Nurse educator. 14. The Regional Clinical Services counseled the Administrator, Director or Nurses and Assistant Director of Nursing on investigation being timely and thorough on 11/3/2023 at 10:00 am. 15. The Regional Clinical Services Nurse and Regional Case Mix Nurse in-serviced Administrator, Director of Nurses, Assistant Director of Nurses, Staff Development, Minimum Data Set (MDS) Nurses, Medical Records, Wound Nurse, Nurse Educator, Social Services Director, Assistant Social Services Director, Business Office Managers and Therapy on reviewing care plans in Care Plan Meeting on 11/3/2023 at 4:00pm. 16. All in-services that have been initiated will have 100% completion by 11/3/2023. NO employees will be allowed to work until in-serviced. The facility alleges that all corrective actions were completed as of 11/3/2023 and the Immediate Jeopardy removed on 11/4/2023. 1. The State Agency (SA) validated through record review and interview on 11/06/23 at 9:12 AM with the Minimum Date Set (MDS) Nurse that the diet orders were audited for residents that require chop meats and ensured that it is on the [NAME] and Care Plan. Results noted five residents on chopped meats and five corrections were made to pull to the [NAME] and Care Plan by the MDS Nurse. 2. The SA validated on 11/06/23 at 9:24 AM through record review and interview that the Nurse Educator initiated an in-service to nursing staff to supervise residents who require a chopped diet. 3. The SA validated on 11/06/23 at 9:24 AM through interview and record review that the Staff Development Coordinator initiated an in-service to all staff on Abuse/Neglect, Vulnerable Adults Act and Resident Rights. 4. The SA validated on 11/06/23 at 9:27 AM through interview that the Nurse Educator initiated in-services with nursing staff on verify a meal ticket, identify diet textures, fluid consistencies, Choking/Relief of foreign body obstructing airway, Heimlich Maneuver Competency, Crash Carts (location and how they are stocked). Record review of these in-services were validated by the SA. 5. The SA validated Speech Therapy evaluation was requested on residents that remain in facility on chopped meats by Administration and Medical Director. 6. The SA validated through interviews and record review on 11/06/23 that Speech Therapy evaluated four residents with chopped meats with no change noted in each residents Care Plan. Each resident was found to be safe on a chopped meat diet. Residents that are in hospital will be evaluated per Speech on return to facility. 7. The SA validated through interview and record review on 11/06/23 with the Medical Director that he gave orders to change all chopped meat diets to Mechanical Soft. Orders were changed on residents remaining in the facility with a chopped meat order, Responsible Parties of residents were notified, and dietary recommendations were turned into dietary department. 8. The SA validated through record review and interview on 11/06/23 with the Minimum Date Set (MDS) Nurse that updated diets for all residents in facility on Mechanical Soft diet are on [NAME] and Care Plan. 9. The SA validated that the Nurse Educator initiated in-services to nursing staff to notify Director of Nurses of all transfers out of facility, giving a resident full assessment and documenting on each resident transferred out, making sure when passing trays, the meal ticket matches what is on the tray, chopped meat will no longer be provided it will be ground meat consistency (Mechanical Soft), and choking verses seizure (similarity and differences). 10. The SA validated through record review and interviews on 11/06/23 that an Emergency AD HOC Quality Assurance Meeting was held. Administrator in-serviced that paperwork on all transfers will be obtained and reviewed by the Interdisciplinary Team in morning stand up meeting. Those present were the Administrator, Director of Nurses, Assistant Social Services, Medical Records Clerk, Wound Nurse, Business office Managers, Housekeeping Supervisor, Nurse Educator, Social Services Director, Maintenance Director, Minimum Data Set (MDS) Nurse, Assistant Director of Nurses, Activity Director, Staff Development Coordinator, Human Resources, Respiratory Therapy, Regional Dietary Manager, Infection Preventionist and Medical Director. 11. The SA validated through interview on 11/06/23 with the Regional Clinical Services Nurse and Director of Nursing initiated an audit to review twenty-four-hour report from 6/1/2023 to 11/1/2023 to ensure no other incidents of choking or harm were documented and unreported to Administration. 12. The SA validated through record review and interview on 11/06/23 that the Regional Clinical Services Nurse in-serviced Administrator, Director of Nursing, and Assistant Director of Nursing on proper use of the twenty-four-hour report, Proper Reporting, and Proper Investigation on 11/3/2023 at 10:00 am. The twenty-four-hour report will be printed each morning and taken to the daily stand-up meeting for review for all discipline documentation effective 11/3/2023. 13. The SA validated through record review and interview on 11/06/23 that the weekend Registered Nurse was in-serviced on 11/1/2023 at 1:00pm to notify Director of Nurses with all transfers and incidents by the Nurse educator. 14. The SA validated through record review and interview on 11/06/23 with the Regional Clinical Services that she counseled the Administrator, Director or Nurses and Assistant Director of Nursing on investigation being timely and thorough on 11/3/2023 at 10:00 am. 15. The SA validated through record review and interview on 11/06/23 that the Regional Clinical Services Nurse and Regional Case Mix Nurse in-serviced Administrator, Director of Nurses, Assistant Director of Nurses, Staff Development, Minimum Data Set (MDS) Nurses, Medical Records, Wound Nurse, Nurse Educator, Social Services Director, Assistant Social Services Director, Business Office Managers and Therapy on reviewing care plans in Care Plan Meeting on 11/3/2023 at 4:00pm. 16. All in-services that have been initiated will have 100% completion by 11/3/2023. NO employees will be allowed to work until in-service is completed.