**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review, the facility failed to provide supervision to prevent a cognitively impaired resident with a history of putting non-food items in his mouth from placing a plastic sandwich bag in his mouth for 1 of 4 residents (Resident #42) reviewed for accidents. In addition, the facility had fall interventions in place that were not effective for a resident with severly impaired cognition and poor impulse control, did not complete a root cause analysis to assist with determining new fall interventions, and did not evaluate the effectiveness of fall interventions for 1 of 3 residents (Resident #501) reviewed for falls. There was a high likelihood of Resident #42 choking on the sandwich bag resulting in serious harm, hospitalization, and/or death. Resident #501 sustained a laceration to his scalp, abrasion to his elbow, and a wound to his ear from a fall. A day later, he sustained a closed fracture of the nasal bone. Immediate Jeopardy began on 11/10/22 when Resident #42 was observed with a plastic sandwich bag in his mouth alone in his room. Resident #42 had a history of putting non-food items in his mouth. Immediate Jeopardy was removed on 11/11/22 when the facility implemented a credible allegation of Immediate Jeopardy removal. The Immediate Jeopardy was lowered in scope and severity to a G (actual harm that is not immediate jeopardy). Example #2 was cited at scope and severity of G. Findings included: 1. Resident #42 was admitted to the facility on [DATE] with diagnoses that included dementia with dysphagia. A physician's order dated 4/28/22 for remove potentially dangerous objects from resident including drinking straws every shift included directions resident puts objects in his mouth and chews on them. Resident #42's annual Minimum Data Set (MDS) dated [DATE] indicated he had severe cognitive impairment. He required extensive assistance with eating. Resident #42 did not exhibit any behaviors for the review period. A Care Plan revised 9/6/22 focused on Activities of Daily Living (ADL) care included a goal for Resident #42 to improve current level of function in ADL through the review date. Interventions included Resident #42 required assistance by 1 staff member to eat. A nursing progress note dated 8/6/22 indicated Resident #42 was found in his room chewing on his bed sheet. A nursing progress note dated 8/9/22 indicated Resident #42 was found chewing on his oxygen tubing several times. A nursing progress note dated 8/28/22 indicated Resident #42 was found in his room with a piece of plastic in his mouth. A nursing progress note dated 9/21/22 indicated Resident #42 was observed in bed chewing on his hand brace. An observation was made on 11/10/22 at 9:10 AM of Resident #42 alone in bed with his breakfast tray in front of him. He had a sandwich in his left hand and a plastic sandwich bag in his mouth with the open end out of his mouth 1 inch. The surveyor immediately went into the hall to get a staff member. The medication aide was standing in the hallway two doors down from Resident #42's room. The surveyor immediately asked for the medication aide to assist Resident #42. The medication aide put on gloves and pulled the sandwich bag from his mouth revealing 3 inches covered in chewed food particles. She threw the plastic bag and gloves in the trash can. During an interview on 11/10/22 at 9:11 AM, the Medication Aide revealed Resident #42 should not have been provided a sandwich on his diet and the sandwich bag should not have been in his room. During an interview on 11/10/22 at 9:12 AM, the Director of Nursing (DON) revealed the sandwich bag should have been removed from Resident #42's room. Resident #42 should have supervision or assistance with meals. Resident #42 usually ate in his room due to communal dining restriction due to COVID-19. During an interview on 11/10/22 at 9:15 AM, the Nurse Aide (#1) revealed the sandwich wrapped in the sandwich bag was on Resident #42's breakfast tray. She indicated she was new and was not aware Resident #42 had an order not to leave potentially dangerous items in his room. NA #1 indicated she would find this in the Care Guide on the computer kiosk on each hall. She was aware Resident #42 needed some assistance with meals but that day he was able to feed himself. She indicated she would check in throughout the meal period. During an interview on 11/10/22 at 9:16 AM, the Charge Nurse indicated Resident #42 had a history of putting things in his mouth and required supervision for this. During an interview on 11/10/22 at 10:10 AM, the Speech Language Pathologist (SLP) revealed Resident #42 was able to feed himself pureed foods, but staff should be checking in with him during the meal period. Resident #42 was at risk for choking due to his dysphagia. During an interview on 11/10/22 at 10:25 AM, the MDS Nurse indicated that Resident #42 required supervision with meals and staff should be checking on him throughout the meal period. She indicated Resident #42's behavior of putting things in his mouth was Care Planned but disappeared. The Care Plan carries over the NA Care Guide. The MDS Nurse revealed NA #1 was new and was not familiar with which residents required supervision with meals. She would find this on her Care Guide on the computer kiosk on each hallway. During an interview on 11/10/22 at 3:15 PM, the DON indicated that staff should check the tray card when they provide resident trays. Staff should provide supervision and assistance to residents as needed as indicated in the Care Plan and Care Guide. During an interview on 11/10/22 at 3:20 PM, the Administrator revealed staff should be providing supervision as indicated on the Care Plan. Staff should not have left a potentially dangerous items in Resident #42's room. The administrator was notified of the Immediate Jeopardy on 11/10/22 at 11:45 AM. The facility provided the following credible allegation with a completion date of 11/11/22: Identify those recipients who have suffered, or are likely to suffer a serious adverse outcome as a result of the noncompliance: The plastic-wrapped sandwich provided to Resident #42 at breakfast was removed from the resident's possession. The center immediately launched an investigation into the incident when notified of the incorrect diet consistency provided to Resident #42 enclosed in a sandwich bag. The Unit Manager assessed Resident #42 for possible complications of ingestion of the plastic wrapper. No adverse findings were noted upon assessment. The attending physician was notified by the Director of Nursing at 12:05pm on 11/10/22 regarding the incident. No new orders were received as a result of the notification. The resident's representative was notified of the incident at 12:15pm on 11/10/22 by the Unit Manager. The center documented the incident in the medical record. Resident #42 was immediately provided with the correct diet consistency and supervised during eating by the Certified Nurse Aide. Speech Therapy evaluated Resident #42 with no changes in diet consistency on November 10, 2022. The center's Medical Director evaluated Resident #42 on 11/10/22 with no adverse findings identified. Resident #42 remains on a Pureed Diet. Resident #42's room was evaluated by the Administrator and Director of Nursing for any other potentially hazardous item the resident could place in his mouth on 11/10/22. At the lunch and dinner meals, Resident #42 was provided the correct consistency diet and was supervised while eating by a Certified Nurse Aide to ensure the resident did not place inappropriate items that could cause choking in his mouth. As a result of the incident, root cause analysis was conducted by the center's interdisciplinary team on 11/10/22. It was identified that the NA #1 did read the tray ticket and went to the charge nurse to ask if Resident #42 was allowed to eat the sandwich on his tray. The Charge Nurse was aware of Speech Therapy doing trial mechanical soft diet and thought the resident was allowed to eat the sandwich since he witnessed him eating a sandwich with Speech Therapy supervision. The sandwich was not fully unwrapped; therefore, the resident was able to ingest part of the sandwich prior to it being identified. Resident #42's care plan was updated to include supervision at all meals, ensuring items that require unwrapping or opening have the wrapper removed, and room checks every shift and PRN to identify any items that could cause choking which may be within his/her reach. The Director of Nursing and Assistant Director of Nursing began an audit of current residents on 11/10/22 to identify those who require supervision with meals and those who have special orders for monitoring during meals. The results of the audit did not identify other residents to have special monitoring orders during meals. Those residents who need supervision with meals have been identified via the MDS and care planning is in place to meet their care needs. The center's Medical Director was notified of the Immediate Jeopardy findings at 12:05pm on 11/10/22 by the Director of Nursing. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete Resident #42 will have supervision by a Certified Nurse Aide during all meals as indicated by his/her care plan and/or physician orders to help ensure he/she does not place items in his/her mouth that could cause injury, harm, or death if ingested. The District Director of Clinical Services educated the Administrator, Director of Nursing and interdisciplinary team on 11/10/22 regarding providing appropriate levels of supervision at meal times, following diet consistency orders, and that all food items provided to the resident per their diet order are to be unwrapped/opened prior to providing them to a resident. One-to-one education was provided to the Dietary Manager on 11/10/22 by the District Director of Food Service on following resident meal tickets and the potential for injury related to inaccurate consistencies being served to residents. This Dietary Manager was in training and is no longer working in the center after 11/10/22. One-to-One education was provided to Unit Manager on 11/10/22 by the Director of Nursing related to not authorizing staff to serve a peanut butter sandwich to a resident on pureed diet, providing supervision for meals when required and/or care planned to reduce the potential for injury, and following the physician's order for removing potentially hazardous items from Resident #42's reach due to his/her tendency to place items in his/her mouth. Education for nursing staff, including full time, part time, PRN and agency licensed nurses and Certified Nurse Aides, began on 11/10/22 by the Director of Nursing and Assistant Director of Nursing regarding the provision of appropriate levels of supervision at meal times to prevent incidents and/or injuries based on physician orders and care plan interventions, following diet consistency orders, accurately reading residents' meal delivery tickets, following physician order related to removal of objects that could be considered hazardous to residents, and that all food items provided to a resident based on their ordered diet will be opened/unwrapped for resident consumption prior to providing the item to the resident. No nursing staff will be allowed to work until they have completed the education. Newly hired nursing staff will be educated on this process during orientation. Beginning 11/10/22, all meal trays will be checked for accuracy against the meal delivery card by the Dietary Manager or assigned dietary staff member prior to leaving the kitchen and then again by a Certified Nurse Aide and/or charge nurse prior to providing to residents. Certified Nurse Aides and/or licensed nurses will provide appropriate levels of supervision during meals to each resident as indicated by their care plan to reduce the potential for injury Alleged date of immediate jeopardy removal: 11/11/22. An onsite validation was completed on 11/14/22 through staff interviews, observations, and record review. Staff were interviewed to validate in-service completion of resident supervision at meals, tray card review. Observations were made of the lunch meal on all halls with no issues observed. Documentations of Care Plan and Tray Card Audits were reviewed. The facility's credible allegation of immediate jeopardy removal was validated to be completed on 11/11/22. 2. Resident #501 was admitted to the facility on [DATE] with diagnoses that inluded anxiety disorder,dementia with behavioral disturbance,osteophyte vertebrae, arthritis and cerebrovascular accident. His significant change Minimum data Set( MDS) dated [DATE] indicated his cognition was severely impaired and he required extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. His MDS indicated the resident was frequently incontinent. No behaviors were noted. Care plan initiated 02/19/2022 and updated 03/07/2022 focused on the resident had impaired cognitive function/dementia or impaired thought processes due to dementia and cognitive communication deficit. Goals included resident will improve current level of cognitive function. Interventions included engage the resident in simple, structured activities that avoid overly demanding tasks. Fall Care plan initiated 01/28/2022 indicated the resident was at risk for falls due to sick sinus syndrome, atrial fibrillation with Cardiac Pacemaker. Goals included resident risks and injury potential will be minimized. The intervention included the following: -assist to out of room activities of choice during waking hours as he will allow, -be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance updated 01/28/22 -The resident needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night, handrails on walls, personal items within reach) updated 01/28/22 -Ensure that the resident is wearing appropriate footwear or non-skid socks when ambulating or mobilizing in wheelchair. He also needs non-skid socks on when he goes to bed due to impulsiveness to stand and walk without assistance for safety updated 02/02/22 -Resident likes to get out bed early - Between 5-7 AM assist him to bathe and get dressed as he desires/will allow updated 03/10/22. Resident education to ask for assistance with care and transfers for fall prevention updated 03/16/22 -Check frequently to ensure resident's call light and urinal in within reach and encourage to use, -Ensure all frequently used items are within resident's reach updated 06/09/2022 -Ensure bed is in low position when resident is in bed updated 06/09/22 The following fall investigations from 03/27/2022 through 07/08/2022 for Resident #501 were reviewed with circumstances, and interventions: -03/27/2022- Resident #501 went in the bathroom without his walker. He was rushing and fell. The resident stated that he did not have time to wait. The report further revealed the resident had no socks or shoes on. he did not put call bell on before getting up. He had skin tear and bruise on left arm. Abrasion over right ear. It also indicated the resident landed in an almost sitting position and his briefs was wet. Treatment was provided and the physician was notified. The intervention included to remind resident to use call light and wear appropriate footwear -04/07/2022-Resident #501 attempted to transfer self to bed from wheelchair (WC) and scooted onto buttocks onto floor. No injuries noted. Resident denied pain. The physician was notified. The interventions included check frequently to ensure resident call light and urinal within reach - -05/12/2022-Resident #501 was found on his knees by his bed. He had no shoes or socks on. He said he had to use the bathroom. he did not call for help after he fell. the nurse was coming down the hall and saw him. The report indicated the resident had cognitive decline and he was non-compliant with wearing footwear and calling for help. Intervention included Sign by bed with Call for help -05/28/2022- staff Nurse Aide (NA) #2 who was also Activity Director found resident sitting on buttocks on floor. Resident #501 said that walker had gotten away from him. Body assessment did not reveal any bruising, discoloration, swelling, open areas nor any other form of distress currently. Resident #501 did state that his lower back was little sore. The physician was notified - No new interventions put in place -06/06/2022- Resident #501 found on floor in bedroom lying on left side beside wheelchair and discovered by NA#2. Resident #501 reports and confirm that he hit his head and that it hurts 8 out of a 10 on a 0-10 pain scale. The resident was sent out to the emergency room and the physician was notified- interventions put in place was assist to out of room (OOR) activities of choice during waking hours as he will allow. Review of the hospital report revealed Resident #501 was readmitted back to the facility on [DATE]. Review of Resident #501 hospital discharge record dated 06/06/2022 revealed a Computer Tomography (CT) scan was completed at the hospital. It revealed the following impression: - No acute intracranial abnormality identified. No acute intracranial hemorrhage - Mild posterior scalp soft tissue swelling and contusive changes. No underlying skull fractures. -06/08/2022- Resident #501 was found lying on the floor in his room. was sitting on his bottom, holding the walker. Resident#501 stated that he was trying to walk and fell. Received skin tear on left hand, no other injuries observed at this time. The physician was notified. Interventions put in place was ensure bed is in low position when resident is in bed. 06/10/2022- Resident #501 noted on floor beside bed. The resident indicated he was coming from the bathroom-interventions placed was -Reeducate on using call for assistance. 06/12/2022- Noted on floor in middle of room on left side-No new intervention put in place 07/02/2022- Resident #501 lost his balance and fell on his knees in the bathroom by the toilet. He has a large bruise on his right arm and has several skin tears. He had socks on with pants that were dragging the floor. First aide provided and the physician was notified. The intervention indicated was assess for possible toileting program. 07/08/2022-Resident #501 was found lying on his back on the floor under side table, 2centimenters (cm) laceration noted to right parietal scalp above right ear, 5cm skin tear to right forearm noted. The resident was assessed for injuries, first aid rendered, Emergency services was called, and the resident was transported to the Emergency department for further evaluation. The physician was notified. No new intervention put in place. Review of the emergency room (ER) report dated 07/08/2022 revealed the following diagnosis: Laceration of scalp, abrasion of right elbow, open wound of right ear. The treatment included 1 suture and 4x4 sterile gauze. Nurse note dated 07/09/2022 indicated the resident was on floor outside resident bathroom. Blood coming from nose and mouth. Dentures on floor broke in half. Called physician and obtained order to send to ER. Review of the emergency room (ER) report dated 07/09/2022 revealed the anterior maxillary sinus process or the inferior nasal spine appears fragmented baby fracture. There was a question of a non-displaced left nasal bone fracture. Soft tissue swelling overlying the nose. The impression indicated anterior maxillary sinus or anterior nasal spine appears fracture. Nondisplaced left nasal bone fracture, soft tissue swelling overlying the nasal bone. ER reported indicated the diagnosis of closed fracture of nasal bone. Observation of the resident was not completed due to the resident was no longer residing at the facility. An interview was conducted with MDS nurse #1 on 11/09/2022 at 10:20AM. MDS nurse #1 stated after the fall on 07/02/2022, they provided the resident with a highchair toilet seat to make it easier for the resident to come in and out of the bathroom. She reported the facility did not document toileting program for Resident #501. An interview was conducted with Charge Nurse (CN) #1 on 11/09/2022 at 11:51 AM. CN#1 indicated she was familiar with Resident #501 and the resident was on her regular facility assignment. CN #1 reported the resident was a challenge to care for due to his falls risk and the frequency of the resident's falls. CN 1 indicated she felt the resident needed constant supervision to ensure her safety is maintained. She stated the resident was confused and did not ask for assistant to use the bathroom even after he was reminded to ask for help. An interview was conducted with Nurse #3 on 11/09/2108 at 11:56 AM. Nurse #3 indicated she was regularly assigned to Resident #501. She indicated the Nurse Aides (NAs) observed the resident closely and attempted to toilet him every 2 hours. Nurse #3 indicated the resident was always determined to use the bathroom and did not ask for help. She indicated the resident was very confused especially during the last 2 weeks before his discharge from the facility. Nurse #3 indicated the resident did not remember to ask for help and to use the call light. An interview was conducted with the Director of Nursing (DON) on 11/10/2022 at 12:40 PM. The DON stated she was very familiar with Resident #501 and his continued falls. The DON reported the nursing staff were in serviced on falls and interventions. She stated that they did discuss resident falls in the morning meetings but currently did not have resident at risk meetings. DON added she was planning to start having resident at risk meetings soon. The DON stated the staff tried their best to prevent the resident from falls, but the resident was found on the floor frequently. She reported they did not evaluate Resident #501's fall interventions for effectiveness and moving forward the plan was for at the resident at risk meetings, they will start evaluating interventions for its effectiveness. The DON stated currently there was a daily clinical meeting, and the falls were discussed with interventions reviewed. DON stated she could not present any documentation about discussion of Resident #501's falls at the morning meetings. The DON indicated the interventions should consistently be put in place. The DON acknowledged that resident was cognitively impaired and the interventions that indicated to remind the resident to use the call light and ask to use the bathroom should not have been put in place. DON reported that she did not have documentation for the toileting program assessment for Resident #501. The DON reported the expectation was for the staff to provide adequate supervision for residents and to implement appropriate interventions. An interview was conducted with the Administrator on 11/10/2022 at 01:32 PM. The Administrator reported she was aware of Resident #501 and his continued falls. She indicated the staff made all the effort to prevent Resident #501 from falling. She indicated the expectation was to put interventions in place after each fall and to provide adequate supervision for the residents in the facility. The Administrator also indicated they will review the interventions put in place for residents at the facility to make sure they were appropriate. During a phone interview on 11/14/2022 at 1:30PM, Nursing Assistant (NA) #2 who was also the Activity Director indicated she cared for Resident #501 while he was residing at the facility. NA #2 stated she was aware of the resident's continued falls. NA # 2 indicated she observed the resident closely but sometimes she could not prevent the resident from falling because he was confused, and he tried to get to the bathroom constantly without asking for assistance.