**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. A review of the medical record revealed Resident #32 was admitted to the facility on [DATE], and her diagnoses included stroke and arthritis. A review of the census report revealed Resident #32 had resided in room [ROOM NUMBER]A since 4/26/2019. Resident #32's care plan dated 10/29/2019 indicated a risk for deterioration in activities of daily living. Interventions included use of rolling walker or wheelchair, providing set up assistance and allowing extra time to complete her activities of daily living. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was moderately cognitively impaired and independently performed all of her activities of daily living. The MDS further indicated Resident #32 was always continent of urine and stool. On 5/16/2022 at 10:00 a.m., the Assistance Maintenance Director checked hot water temperatures in bathroom sinks that were available to residents who had the ability to independently use the sink in the bathroom areas to perform self-care. The temperature of the hot water of the 200-hall bathroom registered 121.9 degrees Fahrenheit. The Assistance Maintenance Director stated the hot water temperatures were checked every Monday, Wednesday and Friday, and the acceptable range was 108-116 degrees Fahrenheit. He stated the mixing values needed adjusting, and the Administrator and nursing staff was informed by the assistance maintenance director of the hot water temperatures. On 5/16/2022 at 11:47 a.m. in an interview with Resident #32, she stated due to having no bathroom inside room [ROOM NUMBER]A she used the 200-hall bathroom located in the hallway for elimination needs. She stated the water did not feel hot when she washed her hands in the 200-hall bathroom or when staff gathered her water to bath daily. On 5/16/2022 at 4:55 p.m., Resident #32 was observed exiting the 200-hall bathroom and voiced no concerns with the hot water burning when she washed her hands. The Maintenance Director accompanied the Assistant Maintenance Director to recheck the 200-hall bathroom sink hot water temperature, and it registered 121.7 degrees Fahrenheit. The Maintenance Director stated the mixing valve had been adjusted, the facility had called a plumber, and temperatures would be monitored throughout the evening. On 5/17/2022 at 2:34 p.m. the Maintenance Director stated the plumber had found rings in the mixing valve flattened and broken. The Director stated the mixing valve was repaired but water may require 24 hours to reach even temperatures, and the temperatures were being monitored. On 5/18/2022 at 8:59 a.m., the Assistant Maintenance Director checked the 200-hallway bathroom hot water temperature. The hot water temperature registered 108.6 degrees Fahrenheit. On 5/19/2022 at 4:38 p.m. in an interview with the Administrator with the Maintenance Director present, the Administrator stated hot water temperature were to be within regulatory normal range. The Maintenance Director stated the normal range for hot water temperature was 105 to 115 degrees Fahrenheit. Based on record review, staff and Physician interviews the facility failed to provide supervision to prevent accidents when residents (Resident #369 and Resident #61) who were ordered to have nothing by mouth (NPO) and enteral feeding (nutrition delivered by a tube into the digestive system as a liquid) were served regular textured meals by Nursing Assistant (NA) #1. NA #1 fed Resident #369 a regular textured meal. Resident #369 aspirated (breathed food/liquid into the lungs) and was hospitalized for 5 days. NA #1 provided a regular textured meal tray to Resident #61. There was a high likelihood of serious harm for Resident #61. The facility also failed to maintain safe water temperatures for residents who performed activities of daily living (ADLs) independently. This was for 8 of 10 residents reviewed for supervision to prevent accident/hazards (Residents #369, #61, #47, #12, #35, #31, #171 and #32). Immediate Jeopardy for example #1 began on 5-11-22 when NA #1 fed Resident #369, who was NPO and on enteral feedings, a regular textured meal. Immediate Jeopardy for example #2 began on 5-11-22 when NA #1 provided Resident #61, who was NPO and on enteral feedings, a regular textured meal. Immediate Jeopardy was removed on 5-20-22 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of an E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education, ensure monitoring systems put into place are effective, and to implement a plan of correction for examples 3 through 10. Findings included 1.Resident #369 was admitted to the facility on [DATE] with multiple diagnoses that included gastrostomy status. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #369 was severely cognitively impaired and required total assistance with one person for feeding. The MDS also coded Resident #369 as receiving 51% or more of her calories from tube feeding and 501cc (cubic centimeters) or more water per day. The May 2022 active physician's orders included an order initiated 7-26-21 for Resident #369 to receive a fortified nutritional supplement at 55cc per hour continuously through enteral feedings. The May 2022 active physician's orders included an order initiated 8-1-21 for Resident #369 to be NPO (Nothing by mouth). Resident #369's active care plan as of 5-10-22 revealed a goal that she would remain free of complications related to the use of a feeding tube. The interventions for the goal were in part keep head of the bed elevated, observe for abdominal distention, lung sounds and check for residual. Resident #369 had a second goal that her weight would remain stable. The interventions for the goal were in part resident is NPO, diet as ordered- fortified nutritional supplement and water flushes per order. A nursing progress note dated 5-11-22 at 9:15am by Nurse #2 documented she was called into Resident #369's room by the Wound Care (WC) nurse. Nurse #2 documented she observed the resident with her eyes open, alert to tactile (physical touch) stimuli and coughing up blood-tinged fluid. The documentation indicated the Physician and family members were notified that Resident #369 was being sent to the emergency room for evaluation. The emergency room hospital records dated 5-11-22 revealed a diagnosis of aspiration of food. A CT scan (series of x-ray images) was ordered which showed Resident #369 also had pneumatosis (increased gastric pressure in the colon due to vomiting) along the right colon. The hospital records dated 5-16-22 indicated Resident #369 received intravenous fluids, intravenous antibiotics and was restarted on her enteral feedings. The resident was discharged back to the facility on 5-16-22 During a phone interview with NA #1 on 5-17-22 at 1:31pm, the NA explained 5-11-22 was her first day working at the facility. She added that it was only her 2nd time working in a long-term care facility. She discussed handing out breakfast trays on 5-11-22 and realizing Resident #369 and another resident (Resident # 61) had not received a meal tray. NA #1 stated she went to the kitchen and requested 2 meal trays (one for Resident #369 and one for Resident #61) from dietary staff. She said the dietary staff provided her 2 regular textured meal trays with eggs, French toast with apples, sausage patty and orange juice and commented the dietary staff had not mentioned to her the residents were NPO. NA #1 stated she went back to the unit, placed Resident #61's tray on the tray table and proceeded to Resident #369 where she began to feed the resident some of the eggs and orange juice. She stated Resident #369 began to turn red in the face and had trouble breathing, so she turned the resident on her side and retrieved help from a nurse that was in a meeting. She explained she did not see any nurses on the unit and had left the resident for approximately 1 minute to get help. NA #1 said she had received no orientation, training or computer access prior starting her shift. She stated she saw the enteral feeding pump for Resident #369 but did not know what it was and since she did not have access to the computer to check the resident's diet, she was unaware the resident was NPO. The WC nurse was interviewed on 5-17-22 at 2:12pm. The WC nurse discussed being in a morning meeting on 5-11-22 when NA #1 entered the meeting requesting help. She stated when she walked into Resident #369's room, she saw dark red mucous on the resident's face and sheets. The WC nurse said the resident was sitting up in the bed and NA #1 told her she had been feeding the resident breakfast when the resident became ill. Nurse #2 was interviewed on 5-17-22 at 12:39pm. The nurse explained she was called down to Resident #369's room on 5-11-22 and observed the resident sitting up in the bed, coughing with blood-tinged fluid coming out of her mouth. She further explained the WC nurse had informed her NA #1 had been trying to feed the resident a meal. She stated she called the Physician, 911 and the resident's family. The nurse stated the resident was sent to the emergency room for further evaluation. Dietary Aide #1 was interviewed on 5-17-22 at 1:20pm. The Dietary Aide stated she was working on 5-11-22 during breakfast but was assigned to the washroom and did not hand NA #1 any meal trays. She explained the Assistant Dietary Manager had spoken with and handed the meal trays to NA #1. A telephone interview occurred with the Dietary Assistant Manager on 5-17-22 at 1:56pm. The Dietary Assistant Manager stated NA #1 had come to the kitchen on 5-11-22 requesting meal trays for Resident #369 and Resident #61. He discussed checking the dietary orders for both residents and saw they were both NPO and received enteral feedings but explained he thought staff was trying to switch the residents back onto solid food, so he provided a regular meal tray for both Resident #369 and Resident #61 to NA #1. The Dietary Assistant Manager stated he could only see a resident's dietary order in the computer. He explained that sometimes the orders were not entered into the electronic medical record before trays were passed out, so he did not know if there had been an actual order to switch the residents back onto solid foods. He revealed he should have asked the Dietary Manager or the nursing staff before providing the trays to NA #1. The Medical Director was interviewed by telephone on 5-19-22 at 3:35pm. The Medical Director stated she was aware of the 5-11-22 incident for Resident #369. She indicated there was high potential for serious harm resulting from a resident aspirating. The Director of Nursing (DON) was interviewed on 5-17-22 at 2:25pm. The DON stated the accident with Resident #369 could have been avoided if NA #1 had been oriented and educated regarding the resident's care prior to receiving her assignment. 2. Resident #61 was admitted to the facility on [DATE] with multiple diagnoses that included gastrostomy status. The May 2022 active physician's orders included an order initiated 7-31-21 for Resident #61 was to be NPO. The May 2022 active physician's orders included an order initiated 1-7-22 for Resident #61 to receive a fortified nutritional supplement at 45cc (cubic centimeters) per hour continuously through enteral feedings. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #61 was severely cognitively impaired and required total assistance with one person for eating. Resident #61 was also coded for tube feeding acquiring 51% or more of her calories per day with 501cc (cubic centimeter) or more of water per day. Resident #61's active care plan as of 5-10-22 revealed a goal that she would not exhibit overt signs and symptoms of complications related to her feeding tube. The interventions for the goal were in part administer feedings as ordered, resident is NPO (nothing by mouth) and elevate the head of the bed 30-35 degrees while feeding. During a phone interview with NA #1 on 5-17-22 at 1:31pm, the NA explained 5-11-22 was her first day working at the facility. She added that it was only her 2nd time working in a long-term care facility. She discussed handing out breakfast trays on 5-11-22 and realizing Resident #61 and another resident (Resident # 369) had not received a meal tray. NA #1 stated she went to the kitchen and requested 2 meal trays (one for Resident #61 and one for Resident #369) from dietary staff. She said the dietary staff provided her 2 regular textured meal trays with eggs, French toast with apples, sausage patty and orange juice and commented the dietary staff had not mentioned to her the residents were NPO. NA #1 stated she went back to the unit, placed Resident #61's tray on the tray table next to the residents bed. She commented Resident #61 would not have been able to reach the tray then stated she proceeded to Resident #369's room. NA #1 stated she had not fed Resident #61 but said another staff could have tried to feed Resident #61 since she left the meal tray in the room. NA #1 said she had received no orientation, training or computer access prior starting her shift. She stated since she did not have access to the computer to check the resident's diet and she was unaware the resident was NPO. A telephone interview occurred with the Dietary Assistant Manager on 5-17-22 at 1:56pm. The Dietary Assistant Manager stated NA #1 had come to the kitchen on 5-11-22 requesting meal trays for Resident #61 and Resident #369. He discussed checking the dietary orders for both residents and saw they were both NPO and received enteral feedings but explained he thought staff was trying to switch the residents back onto solid food, so he provided a regular meal tray for both Resident #61 and Resident #369 to NA #1. The Dietary Assistant Manager stated he could only see a resident's dietary order in the computer. He explained that sometimes the orders were not entered into the electronic medical record before trays were passed out, so he did not know if there had been an actual order to switch the residents back onto solid foods. He revealed he should have asked the Dietary Manager or the nursing staff before providing the trays to NA #1. The Medical Director was interviewed by telephone on 5-19-22 at 3:35pm. The Medical Director stated she was aware of the incident on 5-11-22. She indicated there was high potential for serious harm from a resident who was NPO and fed solid foods to aspirate. The Director of Nursing (DON) was interviewed on 5-17-22 at 2:25pm. The DON stated the potential accident with Resident #61 could have been avoided if NA #1 had been oriented and educated regarding the resident's care prior to receiving her assignment. The Administrator was notified of Immediate Jeopardy on 5-17-22 at 6:05pm. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident #369's diet order: NPO Resident #61's diet order: NPO Nurse Aide #1, an agency staff, began working at the facility on 5/11/22 at approximately 7:00 AM. On 5/11/2022 during breakfast meal tray delivery Nurse Aide #1 recognized that Residents #369 and #61 had not received meal trays. She went to the kitchen and requested meal trays for both residents and was provided trays with regular textured meals from the Dietary Assistant Manager. At approximately 8:40 am, Nurse Aide #1 delivered a breakfast tray to Resident #369's room and the breakfast tray was placed on the bedside table of Resident #61 (out of residents' reach). Resident #369's tray consisted of scrambled eggs, sausage patty, French toast, apples, and orange juice. Both residents had the same items on the trays. Nurse Aide #1 sat down to feed Resident #369. Shortly thereafter, resident appeared to have some difficulty and Nurse Aide #1 gave her orange juice. Resident's color appeared red. Nurse Aide #1 turned resident on her side and called out for nursing assistance. Arriving nurse reported resident began to vomit bloody emesis (vomit). Staff called MD and 911 and the resident was sent to the hospital at approximately 9:40 am, while alert and oriented, for further evaluation and treatment. At no time did Resident #369 stop breathing or lose consciousness during event. A staff member (unknown) immediately removed the meal tray from Resident #61's room when staff became aware of the concern with Resident #369. Resident #61 was not fed the regular textured tray. Post event: - Medical director notified, and in-depth ad hoc Quality Assurance & Performance Improvement (QAPI) meeting for this event held 5/11/2022, with the Interdisciplinary Team, Medical Director and Regional Nurse Consultant. The QAPI committee consists of the Administrator, Director of Nursing (DON), Staff Development Coordinator (SDC), Minimum Data Set (MDS) Coordinator, the Medical Director, Regional Nurse Consultant, Special Projects DON, and the Unit Manager. - Plan developed. Root cause was determined to be the following: Nurse Aide #1's first day working at the facility was 5/11/2022 and she received no orientation or training prior to working on the floor. She had no long-term care experience and the failure to orient prior to working on the floor contributed to the deficiency. In addition, the facility failed to validate Nurse Aide #1's access to the electronic medical record. She had no access to the physician's orders or care plans to see what the diet orders were. Nurse Aide #1 failed to validate residents' diet with charge nurse prior to requesting a meal tray from dietary. The Dietary Assistant Manager failed to follow the policy to validate the tray card system and consult with the dietary manager and/or a licensed nurse to determine if there was a change in the residents' diet order prior to fixing a meal tray for two residents (Residents #369 and #61). - Nurse Aide #1 no longer works at the facility. Her last day was 5/11/2022. Nurse Aide #1 did not return to the floor after the incident. - Dietary Assistant Manager was suspended on 5/11/2022. He remains on suspension, but termination was recommended on 5/17/2022. - This event was submitted to the state as a reportable on 5/11/2022. The allegation of neglect was substantiated, and the final investigative summary was submitted on 5/18/2022. All residents are at risk for the current deficient practice. Plan developed: - Diets of all current residents will be reviewed for physician's diet order, diet care plans to match, and dietary tray cards to match; this will be completed by 05/13/2022 by the Interim DON, Unit Managers, or Dietary Director. There were three resident diets corrected. - All resident care plans and CNA care guides will be reviewed for matching level of meal assistance (set-up; supervision; encourage/cue; dependent on staff); this will be completed 05/16/2022 by the Interim DON, Unit Managers, or Minimum Data Set (MDS) Nurse. No discrepancy noted. - Audit of past 30 days of grievances, events, and progress notes will be reviewed by the interim administrator and/or Regional Nurse Consultant by 05/13/2022, for purposes of assessing other events during resident meals and/or residents receiving improper diets/meal trays, to ensure appropriate steps. One grievance was identified related to the way the diet was ordered to ensure the correct meal consistency was provided to the resident. Diet has been corrected and clarified. There was no harm to the resident affected. - Resident council meeting will be held by 5/17/2022 for any additional concerns meal/dietary concerns. Residents had no concerns regarding their food. - Clinical licensed and unlicensed and dietary staff will be reeducated by the DON and/or SDC on (i) locating and verifying resident diet information if in question, (ii)proper set-up of resident meal trays: proper positioning of residents at mealtime (whether in dining room, resident room, wheelchair, and in bed), (ii) proper consistency of diets and liquids (e.g., regular, mechanical soft, pureed, nectar/pudding/honey thickened liquid), and (iii) checking resident tray cards when setting up resident meal tray to ensure matching. Reeducation will be completed by the IDT by 05/18/2022. No staff including agency staff will work on the floor after 5/18/22 until education has been received. Education provided by the DON and/or SDC on the facility's Assistant with Meals policy, ensuring residents are served the correct meal as ordered by validation of residents' diets using the CNA care guides, what NPO means, and how giving a resident the wrong diet could cause choking episodes, aspiration into the lungs, or subsequent death of the resident. - The facility staff development coordinator immediately educated all staff on the need to provide a diet as ordered and the serious adverse outcomes that could result from providing an incorrect diet. This education was initiated on 5/17/2022 and completed on 5/19/2022. Education was also provided by the DON and/or SDC to agency staff and a post-test provided to validate understanding starting on 5/17/2022 and completed on 5/19/2022. All staff will complete and score 100% on the written post-test. This written test was completed on 5/18/2022 and included validation of the diet report, notification of the dietary manager if unsure of a diet request, training on diet textures including NPO diet, and reviewing all diet orders for accuracy in the meal tracking system. No staff including agency staff will work on the floor after 5/17/2022 until education has been received. - The dietary staff were re-educated on the protocol in place to ensure meal trays are not provided to NPO residents unless ordered by the physician. A list of resident diets is printed and posted as a second reference for the dietary staff to validate a residents' diet. This education was provided by the Regional Dietary Manager on 5/18/2022. The list of resident diets was posted on the bulletin board in the kitchen. The dietary manager will keep the posting updated if changes are made. - Additional education was provided to Dietary staff by the Director of Nursing that providing a diet not ordered for a resident could result in serious adverse outcomes. Re-education and a verbal re-test completed on 5/18/2022. Dietary staff required to attain a 100% by 5/18/2022 or they will not be allowed to work. - Facility Staff Development Coordinator, Wound Nurse and/or Regional Nurse Consultant will ensure all staff have access to the electronic medical records system prior to the beginning of their first assigned work shift as of 5/16/2022. The on- call clinical team member or weekend manager will be responsible for the EMR access validation as stated above for the agency orientation process. No nursing staff will work on the floor after 5/16/2022 without access to the electronic medical records system. Orientation on the electronic medical record will be completed with the agency staff by the facility wound nurse, staff development coordinator, and/or the regional nurse consultant. The Agency Orientation Checklist includes education on how to use the medical records system. In addition, the Clinical Team Member or Weekend Manager are responsible to audit agency staff and validating staff are accessing the electronic medical record for resident care needs. The agency staff are also instructed on the use of the care delivery guides for information on each resident's care needs prior to working on the floor. - The facility has provided the staffing agencies a copy of the agency orientation guide on 5/12/22. Agency staff will present to the facility with a signed orientation packet. Agency staff will not be permitted to work until this agency orientation material has been completed. The number to the on-call phone has been posted at each nurse's station for agency staff to receive this education over the phone and complete agency orientation guides have been placed at each nurse's station for reference. A Clinical Team Member rotation, consisting of either the Director of Nursing, Wound Care Nurse, or Staff Development Coordinator, will have the on-call phone on off hours and weekends and will be available to staff to conduct training and other assistance as needed. Should the agency staff arrive to the facility without the orientation packet completed, the agency staff will be directed to contact the on-call phone/Clinical team member for the orientation process to be completed prior to beginning their assignment. The on-call clinical team member will be responsible to be in the facility at the beginning of day shift and available on off hours and will be responsible to collect the agency staff orientation paperwork at the start of the shift or assist with the orientation process. In the afternoon hours of weekend days, approximately 2:45 pm - 7:00 pm, the Manager on Duty will be responsible to collect the agency staff orientation paperwork at the start of the afternoon shift, as previously established, or assist the agency staff in contacting the on-call clinical team member to complete the orientation process. The Clinical Team will be responsible to review the schedule daily, specifically on the weekend days, to determine who will be an agency staff person working at the facility for the first time and who will need to have validation of the orientation packet being completed prior to their arrival, or if it must be done on site prior to beginning their job duties. Education will also include information on residents who are NPO and/or fed by a tube. Additional education was provided by the Director of Nurses and Unit Manager for the nursing staff, going over the list of residents who are NPO, and adding list to the CNA care guide notebook located at each nurse's station. Centralized scheduling has been educated by Clinical Information Technology Nurse Technologist on providing agency staff access to the electronic medical record prior to arrival to the facility. If the access is not obtained prior to arrival, the agency staff will call the on-call phone number and access will be provided along with steps to access the system. Validation will be completed that electronic medical record access is successful prior to the staff working their shift. The on- call clinical team member or weekend manager will be responsible for the EMR access validation as stated above for the agency orientation process. This was implemented on 5/18/2022. Any staff, to include agency staff, who were not educated by 5/18/2022 will receive education prior to working on the floor. Alleged date of IJ removal: 5/20/2022. The facility's credible allegation of Immediate Jeopardy was validated onsite on 5-24-22 through interviews with facility staff including nursing staff and dietary staff as well as the Regional Consultant. The nursing staff verbalized receipt of education prior to starting their shift in the facility. The staff education documentation, audits and monitoring were reviewed. Nursing staff education included completing the orientation checklist and obtaining access to the facility's electronic medical record system prior to providing resident care, and the use of the resident care guides to locate resident care information including diets. Nurse aides were observed using resident care guides, located at the nursing station, to confirm resident's diets and stated resident diets were verified with nursing staff before requesting a diet tray from the kitchen. Dietary staff education included use of resident diet list to confirm a resident's diet and to clarify resident diets with the dietary manager or nurse as needed. Dietary staff stated resident dietary list was printed daily and used as a reference when nursing staff requested diet trays for residents, and a list of residents with nothing by mouth (NPO) diets and the resident diet list was posted in the kitchen. All resident diets were audited for accuracy, and daily meal audits indicated no issues with residents receiving the correct diets. Signage with contact information was posted at the time clock and both nursing stations reminding agency nursing staff not to provide resident care until obtaining access to the facility's electronic medical record and receiving the Orientation Checklist. Interviews with the nursing staff and a review of staffing audits revealed new agency staff were receiving access to the facility's electronic medical record and the orientation checklist information prior to or on the first day working in the facility and providing resident care. The facility's date of immediate jeopardy removal of 5-20-22 was validated. 3. A review of the medical record revealed Resident #47 was admitted on [DATE]. The Annual Minimum Data Set (MDS) dated [DATE] noted Resident #47 was cognitively intact and needed extensive to total assistance for all daily care with the help of one person. Resident #47 could feed himself with altered utensils. Resident was in a motorized wheelchair when out of bed and could propel himself throughout the facility. The care plan dated 4/29/22 noted a focus of Activities of Daily Living (ADL) function with interventions of: Resident has preferred routine of bath and out of bed by 7 AM. Provide assistance for toileting and hygiene. On 5/16/22 at 10:30 AM, the Assistant Maintenance Director took hot water temperatures in bathroom sinks available to residents who had the ability to use the sink in the bathroom areas to perform self-care. There were residents in these rooms that were unable to perform self-care. On 5/16/22 at 10:30 AM, accompanied by the Assistant Maintenance Director, the temperature in the bathroom area of Resident #47's room registered 118.9. The Assistant stated that was too high, and the mixing valve needed to be adjusted. Resident #47 was in the room and was asked if he went into the bathroom area to wash his hands and he stated yes, I can take my chair in the bathroom and wash my hands. The Resident was encouraged by the Assistant Maintenance Director to turn on the cold water first with the hot water so he would not burn his hands. At 4:55 PM on 5/16/22, Resident #47's sink hot water temperature was 121.5. The Assistant Director of Maintenance stated the mixing valve had been adjusted, the plumber was in the facility and the temperatures would be monitored throughout the evening. On 5/17/22 at 2:00 PM, the Maintenance Director stated the plumber came, found rings in the mixing valve were flat and broken. The Director stated the mixing valve was repaired but water may require 24 hours to reach even temperatures, and the temperatures were being monitored. On 5/18/22 at 9:20 AM, the temperature of the hot water in the bathroom area of Resident #47's room was 107.2. 4. A review of the medical record revealed Resident #12 was admitted on [DATE] with diagnoses of Diabetes Mellitus, debility, pain. The Annual Minimum Data Set (MDS) dated [DATE] noted Resident #12 was cognitively intact and needed supervision to extensive assistance for all daily care with the help of one person. The MDS indicated Resident #12 could feed herself independently after tray set up. The care plan dated 2/15/22 noted a focus of Activities of Daily Living (ADL) with an intervention of only do what is needed so resident can maintain ability. On 5/16/22 at 10:30 AM, hot water temperatures were taken in bathroom sinks available to residents who had the ability to use the sink in the bathroom areas to perform self-care. On 5/16/22 at 10:35 AM, accompanied by the Assistant Maintenance Director, who took the temperatures, the temperature of the hot water in the bathroom area sink was 119.9. The Assistant Maintenance Director stated the mixing valve needed to be adjusted. On 5/16/22 at 4:55 PM, hot water temperatures were rechecked. Resident #12's bathroom sink r[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and Physician interview, the facility failed to train and orient new agency nursing staff and verify competency to deliver care in accordance with the resident's assessed care needs. Nursing Assistant (NA) #1 was not oriented to the protocol for determining residents' dietary orders resulting in the NA feeding a regular textured meal on 5-11-22 to a resident (Resident #369) who had enteral feedings (nutrition delivered by a tube into the digestive system as a liquid) and a physician's order to be nothing by mouth (NPO). Resident #369 aspirated and was hospitalized for 5 days. NA #1 also provided a regular textured meal tray to another resident (Resident #61) who had enteral feedings and a physician's order to be NPO creating a high likelihood of serious harm. This occurred for 2 of 2 residents (Resident #369 and Resident #61) reviewed for enteral feedings. Immediate Jeopardy for example #1 began on 5-11-22 when NA #1 fed Resident #369, who was NPO and on enteral feedings, a regular textured meal. Immediate Jeopardy for example #2 began on 5-11-22 when NA #1 provided Resident #61, who was NPO and on enteral feedings, a regular textured meal. Immediate Jeopardy was removed on 5-19-22 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of a D (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) to complete education and ensure monitoring systems put into place are effective. Findings included: a. Resident #369 was admitted to the facility on [DATE] with multiple diagnoses that included gastrostomy status The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #369 was severely cognitively impaired and required total assistance with one person for feeding. The MDS also coded Resident #369 as receiving 51% or more of her calories from tube feeding and 501 cubic centimeters (cc) or more water per day. The May 2022 active physician's orders included an order for Resident #369 to be NPO and to receive a fortified nutritional supplement at 55cc per hour continuously through enteral feedings. Resident #369's active care plan as of 5-10-22 revealed a goal that she would remain free of complications related to the use of a feeding tube. The interventions for the goal were in part keep head of the bed elevated, observe for abdominal distention, lung sounds and check for residual. Resident #369 had a second goal that her weight would remain stable. The interventions for the goal were in part resident is NPO, diet as ordered- fortified nutritional supplement and water flushes per order. A nursing progress note dated 5-11-22 at 9:15am by Nurse #2 documented she was called into Resident #369's room by the Wound Care (WC) nurse. Nurse #2 documented she observed the resident with her eyes open, alert to tactile (physical touch) stimuli and coughing up blood-tinged fluid. The documentation indicated the Physician and family members were notified that Resident #369 was being sent to the emergency room for evaluation. The emergency room hospital records dated 5-11-22 revealed a diagnosis of aspiration of food. A CT scan (series of x-ray images) was ordered which showed Resident #369 also had pneumatosis (increased gastric pressure in the colon due to vomiting) along the right colon. The hospital records dated 5-16-22 indicated Resident #369 received intravenous fluids, intravenous antibiotics and was restarted on her enteral feedings. The resident was discharged back to the facility on 5-16-22. b. Resident #61 was admitted to the facility on [DATE] with multiple diagnoses that included gastrostomy status. The May 2022 active physician's orders indicated Resident #61 was to be NPO and was to receive a fortified nutritional supplement at 45 cubic centimeter (cc) per hour continuously through enteral feedings. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #61 was severely cognitively impaired and required total assistance with one person for eating. Resident #61 was also coded for tube feeding acquiring 51% or more of her calories per day with 501cc or more of water per day. Resident #61's active care plan as of 5-10-22 revealed a goal that she would not exhibit overt signs and symptoms of complications related to her feeding tube. The interventions for the goal were in part administer feedings as ordered, resident is NPO and elevate the head of the bed 30-35 degrees while feeding. During a phone interview with NA #1 on 5-17-22 at 1:31pm, the NA explained 5-11-22 was her first day working at the facility. She added that it was only her 2nd time working in a long-term care facility. She discussed handing out breakfast trays on 5-11-22 and realizing Resident #369 and Resident #61 had not received a meal tray. NA #1 stated she went to the kitchen and requested 2 meal trays (one for Resident #369 and one for Resident #61) from dietary staff. She said the dietary staff provided her 2 regular textured meal trays with eggs, French toast with apples, sausage patty and orange juice. NA #1 stated she went back to the unit, placed Resident #61's tray on the tray table and proceeded to Resident #369 where she began to feed Resident #369 some of the eggs and orange juice. She stated Resident #369 began to turn red in the face and had trouble breathing, so she turned the resident on her side and retrieved help from a nurse that was in a meeting. She explained she did not see any nurses on the unit and had left the resident for approximately 1 minute to get help. NA #1 said she had received no orientation, training or computer access prior starting her shift. She stated she saw the enteral feeding pump for Resident #369 but did not know what it was and since she did not have access to the computer to check the resident's diet, she was unaware the resident was NPO. She added that she did not feed Resident #61 but said another staff member could have tried to feed the resident since she left the meal tray in the resident's room. The Director of Nursing (DON) was interviewed on 5-17-22 at 2:25pm. The DON stated she was not aware if NA #1 had received training/orientation prior to accepting her work assignment. The DON explained the Staff Development Coordinator would have provided the education. During an interview with the Staff Development Coordinator (SDC) on 5-18-22 at 9:56am, the SDC confirmed she was responsible for the orientation/training of NA #1 on her first day working at the facility (5-11-22). The SDC revealed she had not provided NA #1 any education/orientation or computer access until after the incident with Resident #369. She explained NA #1 started her shift at 7:00am on 5-11-22 and she did not arrive to work until later and she did not want to pull NA #1 off the floor to provide the orientation/education and computer access. The SDC stated she was unaware NA #1 did not have long term care experience. She indicated NA #1 would not have been able to know what her assigned residents' diet orders were or what their care needs were without having orientation. The SDC also discussed new agency staff scheduled off hours and weekends did not receive training/orientation prior to starting their assignment. She added she was concerned for the residents' well-being but did not know how to correct the problem. She also said this was only a problem for agency staff as facility staff received scheduled orientation prior to beginning their first shift. The Medical Director was interviewed by telephone on 5-19-22 at 3:35pm. The Medical Director stated she was not involved in the training or orientation of staff but expected staff to have the education to care for the residents in the facility. The Administrator was interviewed on 5-19-22 at 5:35pm. The Administrator stated he expected all staff to be educated and oriented in the care needs of the residents. The Administrator was notified of Immediate Jeopardy on 5-18-22 at 12:56pm. Resident #369's diet order: NPO Resident #61's diet order: NPO On 5/11/2022 during breakfast meal tray delivery Nurse Aide #1 recognized that Residents #369 and #61 had not received meal trays. She went to the kitchen and requested meal trays for both residents and was provided trays with regular textured meals from the Dietary Assistant Manager. At approximately 8:40 am, Nurse Aide #1 delivered a breakfast tray to Resident #369's room. Nurse Aide #1 sat down to feed Resident #369. Shortly thereafter, resident appeared to have some difficulty and Nurse Aide #1 gave her orange juice. Resident's color appeared red. Nurse Aide #1 turned resident on her side and called out for nursing assistance. Arriving nurse reported resident began to vomit bloody emesis (vomit). Staff called MD and 911 and the resident was sent to the hospital at approximately 9:40 am, while alert and oriented, for further evaluation and treatment. At no time did Resident #369 stop breathing or lose consciousness during event. Resident #61 was provided a meal tray. Resident #61 was not fed, and the meal tray was left on the bedside table. The meal tray was not accessible to Resident #61. The meal tray was removed from Resident #61's room as soon as staff were aware Nurse Aide #1 had placed a tray in the room. Upon review of this event, administrative staff immediately implemented the process of dietary staff not issuing a food tray without the resident name being listed on the census diet report audit sheet to prevent a serious adverse outcome from occurring or recurring. Additionally, dietary staff are to consult with the dietary manager and/or the licensed nurse if additional diet clarification is needed. The licensed nurse will validate the correct diet by using the electronic medical record. The dietary manager will validate the correct diet by using the electronic meal tracking system. Post event: 1) Medical director notified, and in-depth ad hoc Quality Assurance & Performance Improvement (QAPI) meeting for this event held 5/11/2022, with the Interdisciplinary Team, Medical Director and Regional Nurse Consultant. The QAPI committee consists of the Administrator, the Medical Director, Director of Nursing (DON), Staff Development Coordinator (SDC), Special Projects DON, Interim Unit Manager, and Regional Nurse Consultant. 2) Plan developed. Root cause was determined to be the following: Nurse Aide #1's first day working at the facility was 5/11/2022 and she received no orientation or training prior to working on the floor. She had no long-term care experience and the failure to orient prior to working on the floor contributed to the deficiency. In addition, the facility failed to validate Nurse Aide #1's access to the electronic medical record. She had no access to the physician's orders or care plans to see what the diet orders were. Nurse Aide #1 failed to validate residents' diet with charge nurse prior to requesting a meal tray from dietary. The Dietary Assistant Manager failed to follow the policy to validate the tray card system, and to consult with the dietary manager and/or a licensed nurse to determine if there was a change in the residents' diet order prior to fixing a meal tray for two residents (Residents #369 and #61). 3) Nurse Aide #1 was provided agency orientation immediately after the incident by the Staff Development Coordinator. 4) Nurse Aide #1 no longer works at the facility. Nurse Aide #1's last day was 5/11/2022. Nurse Aide #1 did not return to the floor after the incident. 5) This event was submitted to the state as a reportable on 5/11/2022. The allegation of neglect was substantiated, and the final investigative summary was submitted on 5/18/2022. All residents are at risk for the current deficient practice. Plan developed: 1) The facility has provided the staffing agencies a copy of the agency orientation guide on 5/12/22. Agency staff will present to the facility with a signed orientation packet. Agency staff will not be permitted to work until this agency orientation material has been completed. The number to the on-call phone has been posted at each nurse's station for agency staff to receive this education over the phone and complete agency orientation guides have been placed at each nurse's station for reference. A Clinical Team Member rotation, consisting of either the Director of Nursing, Wound Care Nurse, or Staff Development Coordinator, will have the on-call phone on off hours and weekends and will be available to staff to conduct training and other assistance as needed. Should the agency staff arrive to the facility without the orientation packet completed, the agency staff will be directed to contact the on-call phone/Clinical team member for the orientation process to be completed prior to beginning their assignment. The on-call clinical team member will be responsible to be in the facility at the beginning of day shift and available on off hours and will be responsible to collect the agency staff orientation paperwork at the start of the shift or assist with the orientation process. In the afternoon hours of weekend days, approximately 2:45 pm - 7:00 pm, the Manager on Duty will be responsible to collect the agency staff orientation paperwork at the start of the afternoon shift, as previously established, or assist the agency staff in contacting the on-call clinical team member to complete the orientation process. The Clinical Team will be responsible to review the schedule daily, specifically on the weekend days, to determine who will be an agency staff person working at the facility for the first time and who will need to have validation of the orientation packet being completed prior to their arrival, or if it must be done on site prior to beginning their job duties. Education will also include information on residents who are NPO and/or fed by a tube. Additional education was provided by the Director of Nurses and Unit Manager for the nursing staff, going over the list of residents who are NPO, and adding list to the CNA care guide notebook located at each nurse's station. Centralized scheduling has been educated by Clinical Information Technology Nurse Technologist on providing agency staff access to the electronic medical record prior to arrival to the facility. If the access is not obtained prior to arrival, the agency staff will call the on-call phone number and access will be provided along with steps to access the system. Validation will be completed that electronic medical record access is successful prior to the staff working their shift. The on- call clinical team member or weekend manager will be responsible for the EMR access validation as stated above for the agency orientation process. This was implemented on 5/18/2022. Any staff, to include agency staff, who were not educated by 5/18/2022 will receive education prior to working on the floor. 2) Facility Staff Development Coordinator, Wound Nurse and/or Regional Nurse Consultant will ensure all staff have access to the electronic medical records system prior to the beginning of their first assigned work shift as of 5/16/2022. The on- call clinical team member or weekend manager will be responsible for the EMR access validation as stated above for the agency orientation process. No nursing staff will work on the floor after 5/16/2022 without access to the electronic medical records system. Orientation on the electronic medical record will be completed with the agency staff by the facility wound nurse, staff development coordinator, and/or the regional nurse consultant. The Agency Orientation Checklist includes education on how to use the medical records system. In addition, the Clinical Team Member or Weekend Manager are responsible to audit agency staff and validating staff are accessing the electronic medical record for resident care needs. The agency staff are also instructed on the use of the care delivery guides for information on each resident's care needs prior to working on the floor. 3) The Agency Orientation Checklist has been reviewed by the Regional Nurse Consultant on 5/18/22 and approved for education purposes for agency staff and is designed to be completed at the start of the shift for new agency staff. The orientation checklist covers nursing processes, as well as emergency preparation for newcomers to the facility. 4) Additional education provided by the Director of Nursing and Unit Manager on the CNA care guide located at each nurse's station which contains resident diet orders. Any staff, to include agency staff, who were not educated by 5/18/2022 will receive education prior to working on the floor. 5) Agency orientation guides have been placed at each nurse's station as an additional resource. The guides were placed at the nurses on 5/17/2022. The staff have been re-educated by the Regional Nurse Consultant and Director of Nurse on the placement of the agency orientation guides at each nurses' station as an accessible resource. Any staff, to include agency staff, who were not educated by 5/18/2022 will receive education prior to working on the floor. 6) Agency staff will be educated on the CNA care report cards located at each nurse's station to include the residents' current diet orders and the definition of NPO (nothing by mouth) by the Director of Nursing, Staff Development Coordinator, and the Regional Nurse Consultant beginning 5/17/2022. No staff including agency staff will work on the floor after 5/17/2022 until education has been received. 7) Staff were provided education on the severity of what could happen to a resident if they were provided a diet that was not ordered by the physician and could result in serious adverse outcomes by the Director of Nursing and the Staff Development Coordinator. No staff including agency staff will work on the floor after 5/17/2022 until education has been received. Alleged date of IJ removal: 5/19/2022. The facility's credible allegation of Immediate Jeopardy was validated onsite on 5-24-22 through interviews with facility staff including nursing staff as well as the Regional Consultant. The staff verbalized receipt of education prior to starting their shift in the facility. The staff education documentation, audits and monitoring were reviewed. Nursing staff education included completing the orientation checklist and obtaining access to the facility's electronic medical records system prior to providing resident care, and the use of the resident care guides to locate resident care information including diets. Nurse aides were observed using resident care guides, located at the nursing station, to confirm resident's diets and stated resident diets were verified with nursing staff before requesting a diet tray from the kitchen. Meal audits indicated no issues with residents receiving the correct diets. Signage with contact information was posted at the time clock and both nursing stations reminding nursing staff not to provide resident care until obtaining access to the facility's electronic medical record system and receiving the Orientation Checklist. Interviews with the nursing staff and a review of staffing audits revealed new agency staff were receiving access to the facility's electronic medical records and the orientation checklist information prior to or on the first day working in the facility and providing resident care. The facility's date of immediate jeopardy removal of 5-19-22 was validated.

Based on record review and staff interviews the facility failed ensure that dietary staff were competent to carry out the functions of the food and nutrition service in accordance with residents' dietary orders. The Dietary Assistant Manager provided Nursing Assistant (NA) #1 with a regular textured meal for 2 residents (Resident #369 and #61) who were ordered nothing by mouth (NPO) and on enteral feedings (nutrition delivered by a tube into the digestive system as a liquid) continuously resulting in Resident #369 aspirating and being hospitalized . Immediate Jeopardy began on 5-11-22 when the Dietary Assistant Manager provided regular meal trays for 2 residents (Resident #369 and Resident #61) who were NPO and on continuous enteral feedings. The Immediate jeopardy was removed on 5-19-22 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope/severity of a D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to competent dietary staff. Findings included: a. The May 2022 active physician's orders included an order for Resident #369 to be NPO and to receive a fortified nutritional supplement at 55 cubic centimeter (cc) per hour continuously through enteral feedings. b. The May 2022 active physician's orders indicated Resident #61 was to be NPO and was to receive a fortified nutritional supplement at 45 cubic centimeter (cc) per hour continuously through enteral feedings. During a phone interview with NA #1 on 5-17-22 at 1:31pm, the NA discussed handing out breakfast trays on 5-11-22 and realized Resident #369 and Resident # 61 had not received a meal tray. The NA stated she went to the kitchen and requested 2 meal trays for Resident #369 and Resident #61 from dietary staff. She said the dietary staff provided her 2 regular meal trays with eggs, French toast with apples, sausage patty and orange juice and commented the dietary staff had not mentioned to her the residents were NPO. She stated she saw the enteral feeding pump but did not know what it was and since she did not have access to the computer to check the resident's diet, she was unaware the residents were NPO. She added that she did not feed Resident #61 but said another staff member could have tried to feed the resident since she left the meal tray in the resident's room. During the interview, the NA explained on 5-11-22 she fed Resident #369 eggs and orange juice. The NA stated Resident #369 began to turn red in the face and had trouble breathing, so she turned the resident on her side and retrieved help from a nurse that was in a meeting. Resident #369 was sent to the emergency room and hospitalized for 5 days. A telephone interview occurred with the Dietary Assistant Manager on 5-17-22 at 1:56pm. The Dietary Assistant Manager explained he had been working at the facility for a few weeks but had received the new employee training that included the tray card print outs and how to verify orders in the computer. He stated Nursing Assistant (NA) #1 came to the kitchen on 5-11-22 during the breakfast meal and requested meal trays for Resident #369 and Resident #61. He discussed checking the dietary orders in the electronic medical record for both residents and saw they were both NPO and received enteral feedings but thought staff was trying to switch the residents back onto solid food, so he provided a regular meal tray consisting of eggs, French toast with apples, sausage patty and orange juice for both Resident #369 and Resident #61 to the NA. The Dietary Assistant Manager stated he could only see a resident's dietary order in the computer. He explained that sometimes the orders were not entered into the electronic medical record before trays were passed out, so he did not know if there had been an actual order to switch the residents back onto solid foods and should have asked the Dietary Manager or the nursing staff before providing the trays. The Dietary Manager (DM) was interviewed on 5-19-22 at 11:47am. The DM explained he was not in the kitchen when NA #1 requested 2 meal trays for Resident #369 and Resident #61 on 5-11-22. He stated the Dietary Assistant Manager was a new employee but received new employee training/orientation on the tray card print outs and how to verify diet orders in the computer. He said the Dietary Assistant Manager should have found him or clarified the order with the nurse prior to giving the trays to the NA. The Administrator was interviewed on 5-19-22 at 5:35pm. The Administrator stated he expected dietary staff to follow dietary orders and seek clarification from management if there are any questions before providing a meal tray to any resident. The Administrator was notified of Immediate Jeopardy on 5-18-22 at 1:55pm. Resident #369's diet order: NPO Resident #61's diet order: NPO On 5/11/2022 during breakfast meal tray delivery Nurse Aide #1 recognized that Residents #369 and #61 had not received meal trays. She went to the kitchen and requested meal trays for both residents and was provided trays with regular textured meals from the Dietary Assistant Manager. At approximately 8:40 am, Nurse Aide #1 delivered a breakfast tray to Resident #369's room. Nurse Aide #1 sat down to feed Resident #369. Shortly thereafter, resident appeared to have some difficulty and Nurse Aide #1 gave her orange juice. Resident's color appeared red. Nurse Aide #1 turned resident on her side and called out for nursing assistance. Arriving nurse reported resident began to vomit bloody emesis (vomit). Staff called MD and 911 and the resident was sent to the hospital at approximately 9:40 am, while alert and oriented, for further evaluation and treatment. At no time did Resident #369 stop breathing or lose consciousness during event. Resident #61 was provided a meal tray. Resident #61 was not fed, and the meal tray was left on the bedside table. The meal tray was not accessible to Resident #61. The meal tray was removed from Resident #61's room as soon as staff were aware Nurse Aide #1 had placed a tray in the room. Post event: - Medical director notified, and in-depth ad hoc Quality Assurance & Performance Improvement (QAPI) meeting for this event held 5/11/2022, with the Interdisciplinary Team, Medical Director and Regional Nurse Consultant. The QAPI committee consists of the Administrator, the Medical Director, Director of Nursing (DON), Staff Development Coordinator (SDC), Special Projects DON, Interim Unit Manager, and Regional Nurse Consultant. - Plan developed. Root cause was determined to be the following: Nurse Aide #1's first day working at the facility was 5/11/2022 and she received no orientation or training prior to working on the floor. She had no long-term care experience and the failure to orient prior to working on the floor contributed to the deficiency. In addition, the facility failed to validate Nurse Aide #1's access to the electronic medical record. She had no access to the physician's orders or care plans to see what the diet orders were. Nurse Aide #1 failed to validate residents' diet with charge nurse prior to requesting a meal tray from dietary. The Dietary Assistant Manager failed to follow the policy to validate the tray card system, and to consult with the dietary manager and/or a licensed nurse to determine if there was a change in the residents' diet order prior to fixing a meal tray for two residents (Residents #369 and #61). - Dietary Assistant Manager was suspended on 5/11/2022. He remains on suspension, but termination has been recommended on 5/17/2022. - This event was submitted to the state as a reportable on 5/11/2022. This event was submitted to the state as a reportable on 5/11/2022. The allegation of neglect was substantiated, and the final investigative summary was submitted on 5/18/2022. All residents are at risk for the current deficient practice. Plan developed: - Dietary staff educated that providing a diet not ordered for a resident could result in serious adverse outcomes by the Director of Nursing and the Regional Dietary Manager on 5/18/2022. No dietary staff will work after 5/18/2022 until education has been completed. - Dietary manager reviewed the census diet report (a roster of residents and diet orders) with the dietary staff and re-education provided on the validation process to follow prior to giving out any food/drinks on 5/17/2022. The dietary staff will refer to the census dietary report prior to issuing a meal tray to a resident. No dietary staff will work after 5/18/2022 until education has been completed. - Dietary manager will provide validation with dietary staff to ensure understanding resident diets, texture, and restrictions. Dietary staff will be able to state the process to follow if they are unsure about a residents' diet. A copy of the facility's dietary provider's Diet Cross Walk (dietary conversion list provided a comparable diet or meal plan), and the National Dysphagia diet level and Consistency modified diet control panel will be posted as a dietary staff resource. This validation was started and completed on 5/17/2022. The information was posted on the board in the kitchen for staff review on 5/17/2022. No dietary staff will work after 5/17/2022 until validation has been completed. - Dietary staff will not issue a food tray without the resident name being listed on the census diet report audit sheet. Dietary staff has been educated by the Regional Dietary Manager to consult with the dietary manager and/or the licensed nurse if additional diet clarification is warranted. The licensed nurse will validate the correct diet by using the electronic medical record. The dietary manager will validate the correct diet by using the electronic meal tracking system. This action was completed 5/18/2022. Alleged date of IJ removal: 5/19/2022. The facility's credible allegation of Immediate Jeopardy was validated onsite on 5-24-22 through interviews with facility staff including dietary staff. The dietary staff verbalized receipt of education including the importance of providing resident with the correct diet as ordered. The staff education documentation, audits and monitoring were reviewed. All resident diets were audited for accuracy, and daily meal audits indicated no issues with residents receiving the correct diets. Dietary staff education included the use of resident diet list to confirm a resident's diet and to clarify resident diets with the dietary manager or nurse as needed. Dietary staff stated resident dietary list was printed daily and referenced to when nursing staff requested diet trays for residents, and a list of residents with nothing by mouth (NPO) diets, resident diet list, diet terminology conversion list and national dysphagia diet levels were posted in the kitchen to reference for diet information. Daily meal audits indicated no issues with residents receiving the correct diets. The facility's date of immediate jeopardy removal of 5-19-22 was validated.

Based on record review and staff interviews the facility failed to provide leadership and oversight to ensure effective systems were in place for training, orienting, and verifying competencies for new agency staff which resulted in Nursing Assistant (NA) #1 providing a regular meal tray to two residents (Resident #369 and Resident #61) who were to receive nothing by mouth (NPO) and received continuous enteral feedings (nutrition delivered by a tube into the digestive system as a liquid). Immediate Jeopardy began on 5-11-22 when the facility failed to ensure NA #1 was trained, oriented and competent to care for residents who were NPO and on enteral feedings. Immediate Jeopardy was removed on 5-19-22 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope/severity of an D (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) to complete education and ensure monitoring systems put into place are effective. Findings included: This tag is cross referenced to: F726 Based on record review, staff interviews, and Physician interview, the facility failed to train and orient new agency nursing staff and verify competency to deliver care in accordance with the resident's assessed care needs. Nursing Assistant (NA) #1 was not oriented to the protocol for determining residents' dietary orders resulting in the NA feeding a regular textured meal on 5-11-22 to a resident (Resident #369) who had enteral feedings (nutrition delivered by a tube into the digestive system as a liquid) and a physician's order to be nothing by mouth (NPO). Resident #369 aspirated and was hospitalized for 5 days. NA #1 also provided a regular textured meal tray to another resident (Resident #61) who had enteral feedings and a physician's order to be NPO creating a high likelihood of serious harm. This occurred for 2 of 2 residents (Resident #369 and Resident #61) reviewed for enteral feedings. The Administrator was interviewed on 5-19-22 at 5:35pm. The Administrator discussed it was the Staff Development Coordinators (SDC) position to ensure all agency staff were trained and oriented prior to starting their shift and the Director of Nursing (DON) was to oversee the training and orientation was complete as well as being available for any questions the agency staff may have. The Administrator stated the management in the facility were agency/contract staff which led to a lack of consistency and poor communication. The Administrator was notified of Immediate Jeopardy on 5-18-22 at 2:51pm. Resident #369's diet order: NPO Resident #61's diet order: NPO On 5/11/2022 during breakfast meal tray delivery Nurse Aide #1 recognized that Residents #369 and #61 had not received meal trays. She went to the kitchen and requested meal trays for both residents and was provided trays with regular textured meals from the Dietary Assistant Manager. At approximately 8:40 am, Nurse Aide #1 delivered a breakfast tray to Resident #369's room. Nurse Aide #1 sat down to feed Resident #369. Shortly thereafter, resident appeared to have some difficulty and Nurse Aide #1 gave her orange juice. Resident's color appeared red. Nurse Aide #1 turned resident on her side and called out for nursing assistance. Arriving nurse reported resident began to vomit bloody emesis (vomit). Staff called MD and 911 and the resident was sent to the hospital at approximately 9:40 am, while alert and oriented, for further evaluation and treatment. At no time did Resident #369 stop breathing or lose consciousness during event. Resident #61 was provided a meal tray. Resident #61 was not fed, and the meal tray was left on the bedside table. The meal tray was not accessible to Resident #61. The meal tray was removed from Resident #61's room as soon as staff were aware Nurse Aide #1 had placed a tray in the room. Post event: - Medical director notified, and in-depth ad hoc Quality Assurance & Performance Improvement (QAPI) meeting for this event held 5/11/2022, with the Interdisciplinary Team, Medical Director and Regional Nurse Consultant. The QAPI committee consists of the Administrator, the Medical Director, Director of Nursing (DON), Staff Development Coordinator (SDC), Special Projects DON, Interim Unit Manager, and Regional Nurse Consultant. - Plan developed. Root cause was determined to be the following: Nurse Aide #1's first day working at the facility was 5/11/2022 and she received no orientation or training prior to working on the floor. She had no long-term care experience and the failure to orient prior to working on the floor contributed to the deficiency. In addition, the facility failed to validate Nurse Aide #1's access to the electronic medical record. She had no access to the physician's orders or care plans to see what the diet orders were. Nurse Aide #1 failed to validate residents' diet with charge nurse prior to requesting a meal tray from dietary. The Dietary Assistant Manager failed to follow the policy to validate the tray card system, and to consult with the dietary manager and/or a licensed nurse to determine if there was a change in the residents' diet order prior to fixing a meal tray for two residents (Residents #369 and #61). All residents are at risk for the current deficient practice. - Administration staff, consisting of the Administrator, Director of Nursing, Staff Development Director, and Regional Nurse Consultant, immediately reviewed the facility's protocol for orienting, training, and verifying competencies of new staff prior to allowing the staff to work on the floor. Root Cause Analysis review completed and determined staff were not consistent in completing new agency staff orientation at the start of their shift, leaving the potential for significant issues to arise with resident care. Based on this review, it was determined additional oversite was required with completing the first-time agency staff orientation to remove the potential for significant issues with resident care. The administrative team is ultimately responsible to attain and maintain the implementation of the revised plan to ensure orientation is completed and competencies verified at the time of agency staff's initial shift in the building prior to the staff working on the floor. The revised plan was fully implemented on 5/18/22. - Education was provided on 5/18/22 by the Regional Nurse Consultant to the administrator reviewing thoroughly F835 at §483.70 Administration from Appendix PP of the State Operations Manual. This education focused on the regulatory requirement that a facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Alleged date of IJ removal: 5/19/2022. The facility's credible allegation of immediate jeopardy removal was validated onsite on 5-24-22 through interviews with facility staff including nursing staff and dietary staff as well as the Regional Consultant. The staff verbalized receipt of education prior to starting their shift in the facility. The staff education documentation, audits and monitoring were reviewed. The dietary manager education dated 5/11/2022 included different types of diets, nothing by mouth (NPO) and the importance of the accuracy of resident diets, and these topics were included in the re-education of the dietary staff. Dietary staff education also included use of resident diet list to validate resident's diet and confirmation with dietary manager or nurse as needed. Assistance with meals education conducted on 5/11/2022 to the nursing staff included checking meal tray card for correct resident and diet and verifying physician diet order with nurse. The administrative team education dated 5/18/2022 included administration regulation, ensuring expected practices were followed and overseeing as necessary on the floor to assist staff in resident care. Nursing education also included providing resident care before receiving access to the facility's electronic resident record and the orientation checklist information. Staffing audits and interviews revealed centralized scheduling or management staff were providing the orientation checklist and access to the facility's electronic medical record prior to the agency staff reporting to work and prior to providing resident care. Nursing staff were using resident care guides for resident care information including diet orders and were verifying resident diets with the assigned nurse before requesting a diet tray from the kitchen, and dietary staff used the daily printed resident diet list, NPO list, dietary manager and nurse to confirm resident's diet. Daily meal audits indicated residents were receiving diets as ordered. The facility's date of immediate jeopardy removal of 5-19-22 was validated.