Complaint, #NJ157771, #NJ157773, #NJ157831 Based on observations, interviews, record review, and review of other pertinent facility documentation, it was determined that on 09/21/22, the facility failed to ensure: a.) a resident with moderate cognitive impairment, who was at risk for elopement, and had a known history of wandering and exit seeking behavior was appropriately supervised and monitored to ensure safety, prevent elopement, or exiting of the building, and staff failed to follow their facility's policy and procedure on Wandering/Elopement. This deficient practice was identified for one of five residents, (Resident #206) reviewed, who had moderate cognitive impairment, and were at risk for elopement. This placed Resident #206 as well as all other residents with moderate cognitive impairment, who were at risk for or had a known history of wandering and/or elopement in Immediate Jeopardy (IJ). On 09/03/22, Resident #206 was able to exit the building unsupervised through an unlocked door at 10:12 AM, was found by the police, and subsequently expired on 09/03/22 at 4:19 PM. The IJ for Resident #206, occurred on 09/03/22, and was identified on 09/07/22 at 4:20 PM, when the Facility's Administrator (Admin) and the Director of Nursing (DON) were notified of the IJ situation. The survey team provided the facility with an IJ template on 09/07/22. The facility provided an acceptable Removal Plan (RP), on 09/08/22 at 10:16 AM to remove the immediacy. The facility further failed to ensure: b.) staff provided a resident who was at risk for aspiration (when food, drink, or a foreign object is breathed into the lungs) with the correct liquid consistency to prevent aspiration pneumonia (an infection caused by a foreign substance entering the lungs), and staff failed to follow the facility's policy and procedure for the administration of thickened liquids. This deficient practice was identified for one of three residents, (Resident #191) reviewed for accidents related to mechanically altered diets. On 05/27/22, Resident #191 was provided with thin liquids when the resident had a physician's order for thickened liquids. This placed Resident #191 as well as all other residents who received a mechanically altered diet at risk for Immediate Jeopardy (IJ). The IJ for Resident #191 started on 05/27/22, and was identified by the survey team on 09/13/22. The survey team provided the facility with an IJ template on 09/13/22. The IJ was identified as past non-compliance from 05/27/22 through 05/31/22 when the facility provided the survey team with an acceptable Plan of Correction. This deficient practice was further evidenced by the following: Part A The surveyor reviewed the medical record for Resident #206. The surveyor reviewed the admission Record (AR), Resident #206 was admitted to the Facility with diagnoses which included but were not limited to: epilepsy, dementia, hyperlipidemia, hypothyroidism, protein-calorie malnutrition, atherosclerotic heart disease, injury of the head, anxiety disorder, mood disorder, anemia, depression, dysphasia, rhabdomyolysis, thrombocytopenia, and essential hypertension. Review of the quarterly Minimum Data Set (MDS), an assessment tool dated 08/04/22, revealed that Resident #206 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated that Resident #206 had moderate cognitive impairment. Further review of the MDS in Section G for functional status, indicated that Resident #206 was independent with transfers, locomotion on the unit, and ambulation. Review of the Care Plan (CP), with a documented resolved date of 03/29/22, revealed a focus area that Resident #206 was at risk for elopement due to wandering related to cognitive impairment, confusion, and dementia. The goal was that Resident #206 would not leave the facility unsupervised. The interventions included: to assess for change in behavior, to observe for unsafe behaviors, to provide with a program of activities that minimize the potential for wandering, wander guard in place left ankle, observe for placement, and proper functioning each shift. This CP was resolved and discontinued with the date of 03/29/22, which indicated that Resident #206 was no longer at risk for elopement. Review of the Physician's Progress Note (PN) dated 8/2/2022 at 03:48 PM, revealed the resident was on the Psychotropic medication, Depakote 125 milligrams two times daily and had dementia with behavioral issues/wandering behavior with gait instability. Review of the Medication Administration Record (MAR) dated 09/2022, revealed the nurses were monitoring Resident #206's behaviors to include; itching, picking at skin, restlessness, hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, and refusing care. During a review of a Facility Reportable Event (FRE) form dated 09/05/22 at 09:13 AM, sent into NJ Department of Health (DOH) from the DON. On 09/03/22, the Certified Nursing Assistant (CNA #1) assigned to Resident #206 left unit 1A where he/she resided and went on break without giving report or asking someone to monitor their residents. During the break, Resident #206 was able to independently exit the facility unattended, without the staff's knowledge, through an unlocked door in unit 1D, and wandered off the facility grounds onto the main road. Resident #206 made it across the main road and was later found by police at 3:52 PM, laying on the ground at the 9/11 Memorial. The policeman immediately performed Cardiac Pulmonary Resuscitation (CPR) and Resident #206 was later reported to have expired at 4:16 PM. The last time Resident #206 was observed within the facility was at 10:12 AM on video surveillance walking the hallway and exited through an unlocked door on unit 1D. The Licensed Practical Nurse/Unit Manager (LPN/UM #1) observed an empty wheelchair in the hallway of 1D which had a tag with Resident #206's name on it. This initiated a CODE GREY and all staff started a search of the interior of the facility then moved to the exterior of the facility. When Resident #206 was not found within the facility's grounds, the LPN/UM #2 initiated a call to the police at 12:14 PM on 09/03/22, to report Resident #206 missing. The facility searched for Resident #206, but was unaware of the whereabouts of Resident #206 until he/she was found by police on 09/03/22 at 03:52 PM. On 09/06/22 at 11:53 AM, the surveyors observed Stairwell #4 on the 1st floor in the presence of the facility's Admin, Assistant Admin, and Maintenance Director (MD). The Admin stated this was the door that Resident #206 exited the facility from at approximately 10:10 AM on 09/03/22, and Resident #206 was not wearing a wander guard. The surveyors observed a horizontal metal bar on the top of the door and a keypad next to the door. The door was observed to be locked. The MD waved a tool by the keypad and an alarm sounded which indicated that the wander guard keypad system was functioning. The Admin stated the door was a delayed egress maglock and either the maglock system malfunctioned or the keypad itself malfunctioned when Resident #206 exited the building. The Admin told the surveyors that since Resident #206 exited the facility, the keypad, and the maglock were both replaced and were now, new. The surveyors exited the door that Resident #206 exited from and observed a parking lot with woods surrounding. The Admin told the surveyors that the office next to the door Resident #206 exited from was closed because it was a Saturday, and no cars were in the parking lot because no one was in the area that day. The Admin further stated that a Dietary Aide (DA) observed Resident #206 trying to open the patio door. Resident #206 had asked the DA to open the door and the DA stated that he/she could not open the door. On 09/06/22 at 12:53 PM, the surveyors interviewed the DA, who stated that he/she worked at the facility since April 2022, and worked in the kitchen, the day Resident #206 left the facility. The DA stated that when he/she left the kitchen, it was to drop off and pick up meal trays. The DA stated that he/she had observed Resident #206 by the patio trying to open the door. Resident #206 asked the DA to open the door. The DA told Resident #206 that he/she could not, so the resident continued walking toward the unit. The DA told the surveyors that it was not the first time that DA had seen Resident #206 and had observed the resident on 1A when he/she dropped off the meal trays. The DA stated that he/she did not think it was an odd behavior for Resident #206 to ask the DA to open the door because he/she figured Resident #206 wanted to sit outside. The surveyors asked the DA approxiamtely what time he/she saw Resident #206 trying to exit onto the patio. The DA stated that it had to be before 12:00 PM because that was when he/she left the facility for the day. The DA stated that a nurse asked when he/she last saw Resident #206, so the DA provided the nurse with their observation and a statement. The surveyors asked when the DA was last educated on elopement and the DA said they learned about elopement in orientation, but was unable to speak to specifics, and stated that it was common sense to go look for the person, if they went missing. On 09/06/22 at 1:22 PM, the surveyors reviewed the video surveillance from 09/03/22 from 10:07 AM to 10:10 AM. There were two cameras which provided the video surveillance. Both cameras were located on the first floor. One of the cameras was in hallway 1D with views of the hallway and patio entrance. The second camera faced the adjoining hallway between the facility and another outside organization. The Admin stated that there were no cameras outside of the facility. On 09/03/22 at 10:07 AM, the video showed the DA walked to 1D unit. At 10:08 AM, the surveyors observed Resident #206 self-ambulate from 1D unit, pointed at the patio area, observed the DA walk past Resident #206, and then observed Resident #206 ambulate toward the adjoining hallway. At 10:08, the surveyors observed the DA walk towards the kitchen and returned food trays to the kitchen. At 10:09 AM, the surveyors observed the DA leave the dietary area. At 10:10 AM, the surveyors observed Resident #206 walk down the adjoining hallway when the DA was no longer in view of the camera. Resident #206 was observed in the video surveillance, walking toward the double doors that entered the adjoining area. The video ended when Resident #206 exited the door, and was no longer visible on the surveillance video. On 09/06/22 at 1:55 PM, the survey team interviewed the Admin in the presence of the DON and asked, What should be done if the resident has wandering behavior and was confused? The Admin stated that residents had wandering behaviors, but it did not indicate that the resident was exit seeking. On 09/06/22 at 1:56 PM, the survey team interviewed the DON in the presence of the Admin and asked, What does it mean when a resident wanders? The DON stated that a definition of wandering meant that a resident did not always remain in one space. The DON further stated that interventions to decrease wandering behavior included; to re-direct the resident, provide diversional activities, provide time in day room, provide the resident with verbal cues as to where they are. The DON told the survey team that if the resident had a history of wandering and displayed that behavior, it should be included in the resident's CP. The DON further stated that a wander guard assessment should be completed for a resident upon admission, quarterly, and annually. On 09/06/22 at 3:52 PM, the surveyors interviewed the Admin who stated that the cameras were accurately time stamped, could not be edited, and the cameras captured live time. On 09/06/22 at 3:56 PM, the survey team interviewed Resident #206 's Primary Care Physician (PCP), who stated that they had taken care of Resident #206 while he/she resided at the facility. The PCP did not take care of Resident #206 when he/she lived at home. The survey team asked the PCP to describe Resident #206. The PCP stated Resident #206 had a fair amount of confusion with day-to-day tasks, but was easily re-directed when Resident #206 was confused. The PCP stated that they never knew Resident #206 to have exit seeking behaviors at the facility, however, during the COVID-19 Pandemic there were a lot of room changes and Resident #206 would get confused and needed to be re-directed back to the location of their room, so staff placed a wander guard on Resident #206. The surveyors asked if the PCP knew when the wander guard was discontinued and the PCP could not recall specific dates, however, stated when PO's were discontinued, the nurse performed an assessment and PCP based the determination of discontinuing orders, off the nurse's assessment. The PCP stated that Resident #206 never expressed that he/she wanted to leave the facility. The PCP knew Resident #206's history prior to admission to the nursing facility. The PCP told the surveyors that Resident #206 was the primary caretaker of his/her spouse, the spouse became ill, and went to the hospital, and when the spouse was in the hospital, Resident #206 stayed at home and wandered around their home. The PCP stated that they never observed Resident #206 wandering and did not hear from staff that Resident #206 wandered and would assume that was why the wander guard was discontinued, because for the most part Resident #206 stayed in their room. The PCP stated that Resident #206's behavior of wandering was not exactly a chronic issue, it was an issue Resident #206 had in the past. The PCP gave the example of high blood pressure and stated that if wandering was in a resident's history, just like high blood pressure, that would always be something that should be monitored. The PCP further stated that they thought Resident #206's wandering should have been included in their plan of care because it would make Resident #206 challenging to go home without 24/7 supervision. On 09/07/22 at 11:07 AM, LPN/UM #2 unit 1A stated that he/she was working on Saturday when Resident #206 eloped. LPN/UM #2 stated that Resident #206 did not have behaviors. Resident #206 would come out of the room and sit in the doorway and sometimes Resident #206 liked to sit in atrium. The atrium was closed a few weeks ago because it was under construction. Resident #206 would go to the atrium because he/she saw other people there and would just come back to the unit. The LPN/UM #2 stated Resident #206 was confused and could not put a complete sentence together. The LPN/UM #2 stated they had known Resident #206 for about a year and had never observed Resident #206 self-ambulate without an assistive device. The LPN/UM #2 saw Physical Therapist (PT) work with Resident #206 to use a rolling walker and Resident #206 was also assessed for use of a wheelchair. Even when Resident #206 stood in the room, he/she had an unsteady gait. Assistance of one person with care, would always need help. The LPN/UM #2 added that the Psychiatric Nurse Practitioner (PNP) recently decreased Resident #206's Depakote because he/she was not having behaviors. There were no noted changes in Resident #206's behavior or mood. At one point, Resident #206 did have a wander guard in place, although LPN/UM #2 did not recall when it was removed but stated that they put the wander guard on Resident #206 when he/she was getting acclimated to the facility. Resident #206 and their spouse lived at the facility. Resident #206's spouse always expressed that they wanted to go home. That was why the facility put the wander guard on Resident #206. After Resident #206 was oriented to the facility and had a history of going to different areas on the first floor, Resident #206 never tried to exit the elevator, and was not exit seeking to the LPN/UM #2's knowledge. When asked about Resident #206's confusion, LPN/UM #2 stated when they asked Resident #206 something, he/she had a hard time to gather the words to answer the questions. Resident #206 knew the mealtimes, med times, staff, and other residents, but the resident would not have been safe to live in community based on their cognitive status. Resident #206 needed oversite- direction for showers and from the LPN/UM #2's experience, they did not identify Resident #206 as an elopement risk. On 09/07/22 at 11:21 AM, the surveyor interviewed the Security Supervisor (SS) who stated that he/she was the head of the security for the facility and was employed by a security company that was subcontracted by the facility. The SS stated that there was no keypad to the left of the stairwell #4 door prior to 09/05/22, the day the repairs were done. The SS stated that There was not a keypad on that exit door prior to Monday. The SS also stated that The facility had just installed that keypad on Monday. The SS added that prior to 09/05/22, there was no lock on the door, and you could just walk out. The SS added that the security guards that were assigned to work at the facility had no responsibility of monitoring cameras and thought that the cameras were county property and unsure if they were working. The SS stated that the county personnel and visitors to the county clinic entered the adjoining hallway and used that same exit door to freely access the clinic, which was located on the second floor. On 09/07/22 at 12:15 PM, the surveyor interviewed Resident #206's PNP who stated that he/she saw Resident #206 last week to follow up on their psychotropic medications and laboratory review. The PNP further stated that Resident #206 was first placed under psychiatric care because he/she had behaviors of refusing medications and care. The PNP told the surveyor that Resident #206 had diagnoses of depression, dementia, and mood disorders and was absolutely confused. The surveyor asked the PNP if Resident #206 had cognitive awareness of where they lived. The PNP stated that Resident #206 had periods of knowing where he/she was and at times did not. The PNP stated that he/she remembered that Resident #206 had a past history of wearing a wander guard, but they never verbalized or displayed behavior indicating that Resident #206 wanted to leave the facility. The PNP stated that they were surprised that Resident #206 walked out of the wheelchair because PNP always observed Resident #206 in their wheelchair. On 09/07/22 at 02:32 PM, the surveyor interviewed the technician (tech) via telephone who stated that he/she provided a service on Monday Labor Day, 09/05/22. The tech stated he/she was called on Sunday, 09/04/22, but could not come and told the facility to call someone else but then he/she was called back and was able to come on Monday. The tech stated he/she was told that the wanderguard keypad was not working meaning that the wanderguard keypad was not keeping the door locked at all times. The tech added he/she was not an expert on wanderguards but had worked with them and knew they had more than one function and confirmed that the wanderguard was not keeping the door locked. The wanderguard was working when a wanderguard was in the vicinity because it would lock the door, but the relay to keep the door locked was not working. The tech referred to the new keypad he/she installed, on the left wall of the door, and a code had to be put in to unlock it. The tech added that there was no keypad on the left wall of the door before they put one in. When asked by the surveyor why the invoice had replaced keypad, the tech stated, I sort of replaced it, you say new and I say replaced, because I sort of replaced the keypad because they had a wanderguard keypad. The wanderguard keypad was on the opposite wall before the door. Review of the document titled Police Department Investigation Report, dated 09/04/22, revealed that the police were called at 12:20 PM on 09/03/22. Once the police received a description of Resident #206, the police requested mutual aid from the sheriff's office, K-9 unit, as well as the utilization of the drone unit. After review of the facility's video, the police concluded that Resident #206 was last seen at approximately 10:12 AM walking down the dietary hallway of the facility, on the first floor, and walking through the exit door but it was undetermined from the video surveillance, which direction Resident #206 continued to walk. The police found Resident #206 on 09/03/22 at 3:52 PM, and Resident #206 expired at 4:19 PM on the same day. A review of the facility's policy titled; Wandering/Elopement Policy with the revised dated of 01/2022, included; It is the objective of this facility to ensure the safety and protection of wandering residents by preventing their exit from the building. Under Policy Interpretation and Implementation; Section 1. Upon admission, annually, and when there is a significant change in status, resident will be assessed for wandering/elopement using the Elopement risk form. Any resident identified to be a risk for wandering either by preadmission history and/or observed behavior will be provided with a wander-guard and an appropriate plan of care will be developed. Section 6- The Admin or in his/her absence the DON will notify Department of Health (DOH) if the resident is NOT FOUND as per DOH guidelines. The facility's policy also did not indicate a specific time frame to notify DOH after a search for a missing resident that had not been found within the facility or on the facility's grounds. This deficient practice placed Resident #206 and all other residents with moderate cognitive impairment who were at risk for or had a known history of wandering and/or exit seeking behavior, in an Immediate Jeopardy (IJ) situation. The IJ was identified on 09/07/22 at 4:15 p.m., when the Admin and DON were notified of the IJ situation, which ran from 09/03/22 until 09/05/22, when the door was monitored and repaired. The facility provided an acceptable removal plan on 09/08/22 at 10:16 AM, to remove the Immediacy. The Removal Plan was verified by the survey team on 09/08/21 at 10:40 AM, the sixth day of the survey. This deficient practice continues at a lower S/S for no actual harm with the potential for more than minimal harm. Part B Refer to F609 On 09/01/22 at 11:32 AM, the surveyor observed Resident #191 reclining back in his/her reclining chair in their room. The surveyor attempted to interview the resident. The resident was able to communicate his/her name to the surveyor. The surveyor reviewed the medical record for Resident #191. A review of the resident's admission Record, reflected that the resident had resided at the facility for about a year and had diagnoses which included but were not limited to; cerebral palsy (a congenital disorder that affects movement, muscle tone and posture due to abnormal brain development before birth), lobar pneumonia, unspecified organism, unspecified severe protein calorie malnutrition, schizophrenia, major depressive disorder, anxiety, unspecified intellectual disabilities, essential hypertension, and gastro-esophageal reflux disease without esophagitis (inflammation that damages the tube running from the throat to the stomach). A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 03/24/22, reflected that the resident had a Brief Interview for Mental Status score of 6 out of 15, which indicated the resident had moderately impaired cognition. A further review of the resident's MDS, Section G - Functional Status for activities of daily living reflected that the resident required supervision and setup for eating and drinking. A review of the resident's Order Audit Report, throughout Resident's #191's stays at the facility, revealed a Physicians Order (PO) dated 05/27/2022, and timed at 10:37 AM, for regular diet puree texture, honey thickened liquid consistency. According to a review of an incident investigation dated 06/08/22, completed by the facility's DON indicated on 05/27/22 at 2:30 PM Resident #191 was in the 2D dayroom during snack time. The resident's (Licensed Practical Nurse) LPN was informed by an activity aide that Resident #191 was choking and vomiting. The resident had a PO for honey thickened liquids and was provided thin whole milk by his/her primary CNA2. The resident was immediately evaluated by the LPN. Upon evaluation, the LPN heard crackles throughout the resident's lungs and determined the resident's vital signs were abnormal. The LPN notified the residents (Primary Care Physician) PCP who gave physician orders for the administration of oxygen and nebulizer treatments, quickly came to the unit, assessed the resident, and sent the resident to the hospital for an evaluation. Resident #191 was admitted with aspiration pneumonia and required placement of a peg-tube (a creation of an artificial external opening in the stomach for nutritional support) in the hospital. A further review of the incident investigation dated 06/08/22, revealed Resident #191 was incorrectly provided regular thin liquids during snack time when his/her current diet order indicated honey thick liquids. The DON further concluded that the incident most likely occurred due to lack of knowledge regarding proper protocols in verifying fluid consistencies. A review of a Progress Note (PN) dated 5/27/22, and timed at 14:30 (2:30 PM), indicated that while Resident #191 was in the dayroom during snack time, staff informed nursing that the resident was choking and vomiting. The PN further explained that the resident had a PO for honey thickened liquids and was given thin milk by an unknown staff member. The PN revealed that the resident was evaluated by the LPN. Upon evaluation, the LPN heard crackles throughout the resident's lungs, the resident's vital signs were abnormal, and the resident's physician was notified immediately. Upon notification of the physician, the physician provided the LPN with physician orders for the resident to be administered oxygen and a nebulizer treatment. The PN further indicated that the physician came to the unit, assessed the resident, and decided to send the resident to the hospital. A further review of the resident's PN, dated 5/27/22, and timed at 22:35 (10:25 PM), reflected that the resident was admitted to the hospital with possible aspiration pneumonia. A review of the resident's hospital discharge paperwork from 05/27/22 through 06/09/22, reflected a discharge diagnosis of aspiration which was identified on a chest x-ray. A further review of the resident's hospital paperwork indicated that the resident required placement of a peg-tube. The hospital discharge paperwork dated 06/08/22, by the Speech Language Pathologist (SLP) at the hospital indicated, [Resident arrives via ambulance from [facility] with [blood pressure] 70/40. The hospital discharge paperwork further indicated as per Emergency Medical Services the resident was normally on a thickened liquid but was administered unthickened milk at some point, aspirated on it. A review of the facility's Investigation of the incident that took place on 05/27/22 was dated, 06/08/22 and signed by the DON. The investigation indicated that video surveillance dated 05/27/22 and timed at 1426 (2:26 PM), shows [CNA2] passing out snacks in the dayroom. He opens and places what appears to be a milk carton in from of [Resident #191]. [Resident #191] is seen sitting at the table drinking milk. Three other employees are present in the dayroom. [Activity aide] appears to be checking on [Resident #191], leaves the dayroom and returns with [LPN] (pulling the vital sign machine). The Investigation revealed that the DON interviewed the staff members that were present in the dayroom. A review of the interview with the resident's LPN revealed that a staff member saw the resident drinking milk and then start coughing. The LPN went into the dayroom, evaluated the resident, and observed that the resident was coughing and spitting up. The LPN told the DON that she auscultated (listened to the resident's lungs with a stethoscope) and heard crackles. The LPN then notified the resident's PCP who gave her physician orders for oxygen and nebulizer treatments. The LPN interview indicated that the resident's PCP came to the unit and decided to call 911 because the resident's vital signs were abnormal. A review of the interview with the resident's CNA2 indicated that he did not recall passing out the milk to Resident #191 but recalled seeing the resident drinking the milk and being surprised that the resident was on regular milk fluid consistency. The investigative report revealed that the DON asked the CNA2 the process for identifying residents on alternative fluid consistencies, the CNA2 responded that he knew by the dots by the resident's bedroom doors. A review of the interview with the activity aide indicated that she saw the resident drinking milk out of a red carton. The activity aide told the DON that she did not know who gave the resident the milk and the resident was spitting up liquid and coughing. When the DON asked the activity aide the process for identifying residents on alternative fluid consistencies the activity aide stated that she did not know. A review of the interview with the facility's Corporate Food Service Director revealed that on 05/27/22 at 10:31AM, the kitchen received a PO for honey thick liquids for the resident. A review of the Investigation conclusion indicated the resident was provided regular thin liquids when his/her current diet indicated honey thickened liquids. A further review of the Investigation revealed the DON concluded Resident #191 received the incorrect fluid consistency during snack time and the incident most likely occurred due to lack of knowledge by staff regarding proper protocols in verifying fluid consistencies. A review of Nurse Staffing for the 2D unit on 05/27/22, revealed that the CNA2 that provided Resident #191 with the thin whole milk was the resident's primary care CNA for that day. A review of the CNA2's personnel file revealed that on 05/27/22, the CNA2 who provided the resident with thin whole milk received a verbal warning by the facility's DON. The verbal warning indicated that the CNA2 failed to follow instructions. Incorrect Diet was documented on the verbal warning work rule violation. Additionally, a Dietary Inservice was provided to the CNA2 by the DON. The Dietary Inservice indicated, Explained DOT system and importance of checking dietary restrictions prior to feeding. DOT system hanging in nurses station and dayroom. Specific colored DOT placed near resident's name plate by room door. No fluids left at bedside of residents on a tube feeding and with Blue Dot. Residents requiring thickened liquids will receive tray with empty mug and coffee thickener packet. Dietary will send up carafe of hot water for staff to use to make the coffee. Demonstrated how to use Coffee thickener packets- Nectar and Honey thick. Jello and ice cream are considered thin liquids. When unsure- STOP! And ask nurse before giving anything. A further review of the CNA2's personnel file indicated that on 06/07/22, the CNA2 was terminated due to performance issues, absenteeism, and poor work quality. A review of the resident's Care Plan, revised 07/26/22, reflected a focus area for nutrition. The goal of the resident's Care Plan was that the resident would follow diet as ordered. Interventions in Resident #191's Nutrition Care Plan included; provide me my diet as ordered and provide me with my supplements as ordered. On 09/09/22 at 11:42 AM, the surveyor interviewed the facility's Registered Dietician (RD) who stated that a resident was placed on an altered diet or liquid consistency after being evaluated by the SLP. The RD stated that she observed resident's during mealtimes and if she noticed that a resident was having difficulty swallowing or suspected weight loss due to swallowing difficul[TRUNCATED]