**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, staff interviews, interviews with family, family friend, and home health aide, review of Emergency Medical Services (EMS) run report and call transcripts, review of the facility's Self-Reported Incident (SRI) and investigation, and review of facility policies, the facility failed to prevent an incident of neglect involving Resident #87. This resulted in Immediate Jeopardy, actual harm and death beginning on [DATE] at 11:30 P.M. when Resident #87 complained of chest pain to Certified Nursing Assistant (CNA) #609 who reported the change to Registered Nurse (RN) #422. RN #422 then failed to timely identify and obtain treatment for Resident #87 following an acute change in condition. In addition, the facility failed to ensure cardiopulmonary resuscitation (CPR) was initiated timely at the time Resident #87 was found unresponsive (without vital signs). On [DATE] at 2:50 A.M., Resident #87 expired with cause of death as cardiopulmonary and pulseless electrical activity with onset of 15 minutes prior to death. This affected one (#87) of three residents reviewed for hospitalization. The facility census was 81. On [DATE] at 10:13 A.M., Regional Director of Clinical Operations (RDCO) #417, the Administrator, the Director of Nursing (DON), and Assistant Director of Nursing (ADON) #813 were notified Immediate Jeopardy began on [DATE] at 11:30 P.M. when Resident # 87, who had advance directives for a full code complained of chest pain. CNA #609 reported the residents' complaint to RN #422. However, RN #422 failed to complete a comprehensive assessment or timely transfer the resident to the hospital for evaluation/medical intervention. The resident was subsequently found unresponsive (no time documented), with bluish-purple lips and fingertips. There was no evidence to support staff immediately initiated cardiopulmonary resuscitation (CPR). The facility failed to conduct a thorough investigation to determine the circumstances of the incident. However, interviews conducted by the State Survey Agency revealed staff did not initiate CPR for approximately seven to twenty minutes per seven staff (two nurses and five CNAs). As a result of Resident #87 not being assessed timely, a code not being called, and CPR not being initiated timely, Resident #87 passed away on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 2:50 P.M., Resident #87 passed away in the facility. On [DATE] at 9:30 A.M., clinical staff reviewing documentation during morning clinical meeting found no documentation of an occurrence with Resident #87. RN #422 was contacted and was instructed to come in and complete documentation immediately. On [DATE] at 11:12 A.M., RN #422 completed a late-entry progress note. From [DATE] to [DATE] staff interviews and statements were obtained by the Administrator, ADON #813 and Acting DON #424 regarding occurrence with Resident #87. On [DATE], Acting DON #424 educated all licensed nurses on clinical documentation standards, notification of change of condition, CPR/Ohio Do Not Resuscitate (DNR) comfort care (CC) and DNR CC Arrest policies- with emphasis on immediately initiating CPR after verification of a CPR code status, and wound care. All new hire nurses will be educated during the new hire orientation process by DON/designee. All borrowed nurses from sister facilities will be educated prior to shift start by DON/designee. Ongoing education will be completed during quarterly all-staff meetings by Director of Nursing/designee. On [DATE], Acting DON #424 educated CNAs on documentation and CPR with emphasis on their supportive role by the direction of the nurse. On [DATE], Acting DON #424 reviewed all resident's nursing notes for the last 30 days that had a change in condition to validate timely and correct treatment. Timely and correct treatment was based on nursing standards for the specific situation. On [DATE], Acting DON #424 completed whole-house code status audit to ensure orders and care plans were updated and current. All resident code statuses are current and can be found in the resident header of the electronic medical record (EMR). Starting [DATE], DON/designee completed ongoing audit of nurses notes to be reviewed daily (five days per week) during daily clinical meeting to monitor for change of condition, and appropriate assessment/treatment completed, up to and including CPR. Any concerns noted will be addressed immediately. Results will be reviewed at monthly Quality Assurance Performance Improvement (QAPI) meetings. On [DATE], Licensed Practical Nurse (LPN) #503 completed a mock code blue drill which included four other staff during the day shift. On [DATE], RN #422 was terminated for performance and policy violations. Upon investigation, it was determined RN #422 was uncooperative during the investigation process. RN #422 failed to provide an accurate description of what occurred and failed to follow the facility's policies and procedures regarding documentation. On [DATE] at 9:57 A.M., an interview with the Administrator stated the facility had no additional information related to their investigation into Resident #87's change in condition and his death to provide for State Survey Agency review. The facility did not provide any documentation of corrective actions completed by facility after their investigation. On [DATE] an ad hoc QAPI was held to discuss the incident with Resident #87 and reviewed plan for education and ongoing monitoring. Members in attendance included the Administrator, the DON, ADON #813, LPN #410, LPN #503, Social Service Director (SSD) #920, RDCO #417 and Medical Director #435. This will be reviewed at monthly QA meeting for the next six months. By [DATE], the DON educated all licensed nurses on completion and documentation of assessments with emphasis on obtaining current vital signs when assessing resident, CPR policy with emphasis on identifying code status, CPR/Ohio DNR comfort care and DNR CC Arrest policies with emphasis on immediately initiating CPR after verification of a CPR code status, and overhead announcement of code. All new hire nurses will be educated during the new hire orientation process by DON/designee. All borrowed nurses from sister facilities will be educated prior to shift start by DON/designee. Ongoing education will be completed during quarterly all-staff meetings by DON/designee. Starting on [DATE], DON/designee will complete mock code blue audits, three times a week for four weeks across various shifts. Concerns will be addressed in real time and discussed at monthly QA meetings. Starting on [DATE], DON/designee will review three assessments per week for four weeks across various shifts to validate assessment accuracy and completion of vital signs. Starting [DATE], DON/designee will continue ongoing audit of at least five residents' nurse's notes to be reviewed daily for five days/week for 12 weeks during daily clinical meetings to monitor for change of condition, and appropriate assessment/treatment completed, up to and including CPR. Any concerns noted will be addressed immediately. Results will be reviewed at monthly QA meetings. Starting [DATE], when the initiation of CPR is required, a Code Event Minutes form will be completed by a designated scribe with time resident is found and time CPR is initiated. These minutes will be reviewed by DON/designee after the Code Event Minutes form is completed, and any concerns will be addressed as appropriate. Although the Immediate Jeopardy was removed, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #87's closed medical record revealed an admission date of [DATE] and diagnoses included obstructive sleep apnea, hyperlipidemia, weakness, non-pressure chronic ulcer of other part of left lower leg with other specified severity, peripheral vascular disease, chronic kidney disease stage three, chronic obstructive pulmonary disease (COPD), edema and other acute osteomyelitis to bilateral ankles and feet. Review of Resident #87's plan of care for COPD dated [DATE] revealed Resident #87 had shortness of breath while lying flat. An intervention dated [DATE] included the following: staff were to monitor vital signs, report abnormal findings to medical provider, resident/resident representative, staff were to observe for signs and symptoms of COPD: increased shortness of breath, frequent coughing with and without mucus, wheezing, tightness in the chest and anxiety. Report any abnormal findings to medical provider, resident/resident representative. Resident #87 had a physician order dated [DATE] for an advance directive of CPR (Full Code). Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #87 was cognitively intact and had no behaviors during the review period. Resident #87 utilized a walker for mobility. Resident #87 required substantial/maximum assistance with toileting, partial/moderate assistance with upper body dressing, substantial/maximum assistance from sitting to standing, and partial/moderate assistance for chair to bed and toilet transfers. The discharge MDS assessment dated [DATE] revealed Resident #87 died in the facility. Review of Resident #87's medical record revealed he had wounds to left gluteal fold, left lower extremity, left lateral foot, sacrum/bilateral buttocks and right lateral foot with dressing changes to be done every day and night shift and as needed. Resident #87 received hydrocodone-acetaminophen 5-325 milligrams (mg) every four hours as needed (PRN) for severe pain greater than seven (a pain scale from zero to no pain to 10 the most severe pain). Resident #87 received this pain medication on [DATE] at 8:09 A.M. for a pain level of seven; on [DATE] at 12:32 P.M. for a pain level of eight and on [DATE] at 5:25 P.M. for a pain level of eight. Resident #87did not receive this medication the rest of the night. No administration of hydrocodone-acetaminophen was documented on [DATE]. Resident #87 was not documented as having behaviors during his admission to the facility. Review of Resident #87's vital signs in the medical record revealed the last complete set of vital signs was collected on [DATE] at 8:08 A.M. The following were recorded at 8:08 A.M.: pain at zero; pulse of 79 beats per minute (bpm) (normal resting heart rate); temperature of 97.4 degrees Fahrenheit (F); and blood pressure of 123/67 millimeters of mercury. Review of the skilled assessment dated [DATE] at 8:25 A.M. and authored by LPN #811 revealed no changes since the previous evaluation and indicated Resident #87 was alert and oriented times three. Subsequent vital signs recorded revealed on [DATE] at 8:28 P.M. respirations at 18 breaths per minute (normal resting range for an adult); on [DATE] at 10:59 P.M. oxygen saturation via nasal cannula at 94% (normal range); and on [DATE] at 11:52 P.M. blood glucose at 287 milligrams/deciliter (mg/dL) (blood sugar high (normal range 99 mg/dL or below). Review of an EMS telephone call on [DATE] at 11:49 P.M. revealed Resident #87 stated, I need assistance, I can't stand up. The resident explained he was at the facility and provided his room number and stated he needed lift assistance. The resident explained his former nursing aide for a year and a half came to the facility to change his bandage. When she came and was changing them, the nurse threw her out because she was not an employee. He identified himself as Resident #87. He stated they way he was sitting, it was killing his buttocks, and he can't [unable to determine the rest of what Resident #87 said]. There was no documentation in the resident's medical record this visitor was changing the resident's bandage and was thrown out of the facility. The EMS run sheet dated [DATE] at 11:50 P.M. revealed they were dispatched to the facility for a resident (Resident #87) who cannot stand up. While en route, dispatch updated EMS that a call was placed by the resident, and they will contact the facility to speak with staff. Upon arrival, the scene was determined safe. EMS staff entered the building and met a nurse (not able to be identified) at the front desk who stated the resident does not need to go to the emergency room (ER) and the resident just doesn't want to be here. (This behavior of not wanting to be in the facility was not documented in the medical record and interviews with staff could not corroborate this statement.) The nurse stated Resident #87 had no complaints and they were unaware Resident #87 had called EMS. EMS staff explained to the nurse that this was not an appropriate reason to go to the ER. The nurse agreed and stated she would speak with Resident #87. Resident to be left in care of staff. There was no documentation in Resident #87's medical record of EMS arriving at facility and no nursing assessment including vital signs obtained at this time. Review of a call from Berea Police and Fire Department to the facility on [DATE] at 11:54 P.M. revealed dispatch had gotten a call from Resident #87 for a 911 call from his room. Resident #87 stated he fell and needed assistance getting up, and they do have paramedics en route. LPN #423 answered the facility's telephone and stated she would check to find out what was going on. There was no documentation in the resident's medical record of a nursing assessment including vital signs obtained at this time and the telephone call received by the local police department was not documented in the medical record. Review of an EMS telephone call on [DATE] at 12:02 A.M. revealed Resident #87 called 911 back, the nurse just came in and said he sent 911 away. Dispatch told Resident #87 that staff told EMS they were not needed. Resident #87 stated he had been sitting there for six hours, no pain medications, and the nurse refused to do his bandaging on his feet. A telephone call was then placed to the facility and LPN #423 answered. Dispatch stated Resident #87 called 911 again and was on the other telephone line. LPN #423 stated EMS just left and said they were not going to take him; if they had known he had called they would never have come out. LPN #423 reported that Resident #87 did not fall, he was sitting in a chair, and she was not sure what they could do in that moment. EMS said they would not take him. Dispatch said Resident #87 was on the other line advising he could not stand up for hours. LPN #423 stated Resident #87's nurse [RN #422] was to be in his room with him to do a dressing change. Dispatch said they would talk to Resident #87. Resident #87 stated no nurse was in the room with him. Dispatch stated a male nurse was on his way to him. Resident #87 stated RN #422 has refused to bandage his legs for six hours and now he was gathering supplies, and the resident didn't know how long that takes. Dispatch stated the paramedics were there and staff were advising EMS that Resident #87 did not need transported to the hospital and she called and spoke with staff again. Resident #87 reported no one else was in his room. Dispatch asked to speak to whoever was in the room and RN #422 got on the line and identified himself as Resident #87's nurse [RN #422]. Dispatch told RN #422 that Resident #87 kept calling and he replied, yeah, there was not an emergency. Resident #87 yelled in the background, yes, there is. RN #422 then stated yeah, there's not an emergency, it would be a waste to send people and dispatch indicated EMS just got back in the station. Dispatch stated to advise Resident #87, if he keeps calling, they must send somebody out. RN #422 stated he would try; there was only so much that RN #422 can do and was not able to take Resident #87's telephone (which he implied he could not remove the resident's access to telephone). Dispatch stated at some point they would have to send somebody like police out; they would have to send someone. Resident #87 can be heard in the background saying, if you would do your job. Dispatch started to say, If he is being unreasonable. RN #422 then stated, Well I did not commit a crime. and dispatch indicated per protocol, they would have to send someone out to do a welfare check and she did not indicate anything had been done wrong. There was no evidence this EMS call was documented in Resident #87's medical record. The EMS run sheet dated [DATE] revealed a call received at 1:58 A.M. for a cardiac arrest for Resident #87. EMS was on the scene at 2:05 A.M. Resident #87 was unconscious, drooling, not breathing and had delayed skin capillary refill with pale, cyanotic skin. No blood pressure or pulse could be found. Upon arrival at the scene, Resident #87 was supine on the floor receiving CPR from nursing home staff. Staff stated Resident #87 fell from chair while being changed by nurse and when nurse left to get help to lift him, Resident #87 was found unresponsive and not breathing. No palpable pulse could be felt. Approximate arrest time was 1:55 A.M. Manual CPR was taken over by EMS with ventilations given via bag valve mask ventilation (BVM). Resident #87 was intubated and the cardiac monitor showed asystole (cardiac flatline), then pulseless electrical activity (PEA), then ventricular fibrillation (VFIB) then PEA. Resident #87 was taken to the hospital. Disposition of the call was identified as dead after arrival, resident dead at scene-resuscitation attempted with transport. Review of an EMS call dated [DATE] at 1:58 A.M. revealed a female voice (CNA #620 upon review of the facility's telephone list) was at the facility and they had a resident (Resident #87) that was not responsive and had no pulse or anything and provided the room number. Dispatch asked if a nurse was in there with the resident and CNA #620 indicated RN #422 was in with the resident. Dispatch asked if they were doing CPR. CNA #620 stated yes, they were trying to do CPR now and it looked like the resident fell out of a chair and his back was against the chair, they were trying to lay him down flat on the floor and do CPR. Dispatch stated medics were going to be dispatched and told the caller whoever was performing CPR to keep doing so until the medics got there and to have someone meet the medics at the door. Review of the change in condition evaluation dated [DATE] at 2:40 A.M. and authored by RN #422 revealed Resident #87 was unresponsive and it began this morning [[DATE]]. The assessment stated there were no vital signs obtained after the change in condition occurred, and listed vital signs obtained on [DATE] at 8:08 A.M. which included blood pressure, pulse, heart rate, respirations and temperature. Resident #87's advance directive was listed as CPR and respiratory assessment indicated Resident #87 had apnea (temporary cessation of breathing, preventing the body from getting enough oxygen). The progress note and eInteract Situation, Background, Assessment and Recommendation (SBAR) dated [DATE] at 2:40 A.M. and authored by RN #422 revealed Resident #87 was unresponsive and listed vital signs collected on [DATE] at 8:08 A.M. (blood pressure, pulse, respirations, and temperature), at 8:28 P.M. (blood glucose), at 11:52 P.M. (pulse oximetry). The eInteract transfer to hospital evaluation dated [DATE] at 2:41 A.M. and authored by RN #422 revealed Resident #87 was sent to the hospital at 2:30 A.M. due to unresponsive status. Vital signs (no time listed) were blood pressure at 129/73 mmHg; temperature at 98.7 degrees F; pulse was 68 bpm; respirations were 14 breaths per minute; and oxygen saturation 95%. Review of a death certificate revealed Resident #87's time of death was on [DATE] at 2:50 A.M. with cause of death as cardiopulmonary and pulseless electrical activity with onset of 15 minutes prior to death. No autopsy was performed, and the manner of death was listed as natural. The progress note dated [DATE] at 11:12 A.M. and authored by RN #422 revealed the nurse was performing a dressing change on Resident #87 and needed assistance transferring Resident #87. This writer left the room to get assistance and upon returning, found Resident #87 unresponsive. After a quick assessment, this writer began CPR and instructed nearby personnel to get an automated external defibrillator (AED) and call EMS. EMS arrived and continued CPR and transferred the resident to the emergency room (ER). Family arrived at the scene shortly after. DON and Administrator notified. Review of an e-mail witness statement dated [DATE] at 8:47 A.M. and authored by RN #422 revealed while caring for Resident #87, a CNA began a dressing change without communicating to RN #422 (time not given). At the time, RN #422 was completely unaware of who she was or what her level of licensure was. She repeatedly refused to clarify her identity and level of licensure while making threats to both RN #422 and the facility. Her behavior was extremely aggressive and unprofessional and may even be classified as abuse. Eventually, she explained who she was and her licensure. Upon finally being made aware of her licensure, RN #422 explained how many aspects of the dressing change cannot be performed by CNAs as they were beyond her scope of practice. Namely wound assessment: all assessments cannot be delegated and must be performed by nurses and nurses only. Furthermore, the aspects of the dressing change with which she completed, the dressings were completed incorrectly, putting the resident at risk as well. When explaining the process of a dressing change, the CNA displayed a gross lack of understanding that RN #422, using his clinical judgement, considered unacceptable for practice. Simply put she described a dressing change as ‘just following directions,' when there was such a deeper level of knowledge required. In regard to Resident #87's EMS calls, there were two. During the first EMS call, Resident #87 stated he fell. RN #422 entered Resident #87's room, found him in his chair and asked if he fell. Resident #87 stated he never fell. EMS refused to admit him as an emergency situation was not occurring. EMS was called a second time (time not given) by Resident #87 and refused to travel to the facility. Then RN #422 completed Resident #87's dressing change (time not given). Following the dressing change, RN #422 required assistance with transferring Resident #87 (time not given). RN #422 left the room to get assistance. When RN #422 arrived at Resident #87's room, he was unresponsive (time not given). After a quick assessment (not documented, no time given) RN #422 began CPR and instructed nearby healthcare personnel to get an AED and call EMS. EMS transported Resident #87 to the emergency department (ED). Review of a typed witness statement dated [DATE] for RN #422 revealed on [DATE] (no time given), RN #422 was doing a dressing change to Resident #87's buttocks while he was positioned on walker in front of chair. Resident #87 became weak, and RN #422 had to lower Resident #87 to the floor. RN #422 went to get assistance from other nursing staff (no time given, no staff identified). Resident #87 was responsive at the time (not given) and RN #422 went to get help. Upon arrival at the room with staff assistance (no time given, no staff identified), RN #422 attempted to transfer Resident #87 into bed, he became unresponsive, so the resident was lowered to the floor and CPR was initiated (time not given).Review of RN #422's written witness statement dated [DATE] revealed Resident #87 used his call light and entered the room (time not given). Resident #87 requested to have his dressings changed and RN #422 informed him that RN #422 would gather supplies and change his dressing shortly. Upon re-entering the room (time not given), RN #422 found a home health aide performing his dressing change. RN #422 stopped this home health aide and asked who she was. The home health aide refused multiple times to identify herself, her behavior was very aggressive and unprofessional. Home health aide left with the dressing change incomplete. Resident #87 then called the police stating he fell. EMS arrived and refused to admit him because he was in stable condition. When EMS arrived, Resident #87 stated he did not fall. Resident #87 repeatedly called EMS (times not given) until RN #422 began his dressing change. RN #422 completed the dressing change. After RN #422 completed the dressing change, RN #422 and [Resident #87] were having issues operating his chair (time not given). RN #422 and Resident #87 were unable to bring his chair to a working height, so RN #422 left the room to get assistance transferring Resident #87. When RN #422 looked for help, all the CNAs were not on the floor, and RN #422 was not notified of the CNAs leaving. RN #422 ran to the other side to get CNA #509 (time not given). Resident #87 was not responding to words or stimuli. RN #422 performed an assessment and felt a weak thready pulse (vitals not recorded) and apnea. RN #422 and CNA #509 lowered Resident #87 to the ground and began CPR, called EMS, and instructed a (unidentified) CNA and to get an AED (times not given). No shocks were advised by the AED. EMS arrived and transported Resident #87. Review of CNA #509's typed witness statement dated [DATE] revealed RN #422 came to request her help with Resident #87. When CNA #509 came to the front hall (time not given), Resident #87 was sitting on the floor with his back resting on the chair, unresponsive. Both RN #422 and CNA #509 attempted to arm and arm, two-person assist the resident into the chair. When unsuccessful, RN #422 and CNA #509 went to get a lift sling in attempt to mechanically lift Resident #87 into the chair. Female nurse (not identified) came in to assist (time not given) and observed Resident #87 lying on the floor on lift sling. Female nurse (not identified) questioned RN #422 regarding Resident #87's pulse. CPR initiated (time not given), aide (not identified) was instructed to call 911 by female nurse (not identified) and EMS came in to continue CPR. Review of LPN #423's typed witness statement dated [DATE] revealed Resident #87 had called police/EMS three times that night. First time, EMS stated Resident #87 had fallen. LPN #423 ran to verify Resident #87 was ok and observed him sitting in his recliner chair. LPN #423 advised RN #422 that EMS was called. RN #422 then went to Resident #87's room to observe him in his chair, asked Resident #87 if he had fallen and if he was ok. Once EMS arrived and entered the facility, staff let EMS know Resident #87 had not fallen and he was ok. EMS did not assess or observe Resident #87 and left the scene. RN #422 then advised Resident #87 he was going to dress his wounds. LPN #423 went back to her work area, shortly after she reported back to her own work area, there was a telephone call from EMS a second time. Between 2:00 A.M. and 3:00 A.M., LPN #423 saw RN #422 come to the back for a nasal cannula then go back towards the front. About 20 minutes later, LPN #423 saw RN #422 come to the back of the facility and ask for help because Resident #87 had fallen. CNA #509 went to assist RN #422. Another nurse on shift (not identified) was also prompted to help. Once at Resident #87's room, LPN #423 observed Resident #87 lying on floor on Hoyer (mechanical lift) pad. LPN #423 asked RN #422 if Resident #87 had a pulse. RN #422 stated he checked the pulse (time not given), and a pulse was present (vital signs not recorded); after rechecking the pulse, RN #422 stated no pulse was present, so CPR was initiated (no time given). Review of CNA #620's typed witness statement dated [DATE] revealed on or after 2:00 A.M., CNA #620 was doing rounds. CNA #620 came out of a nearby resident's room and noticed CNA #509 standing by Resident #87's door and he motioned for CNA #509 to come help. CNA #509 asked where RN #422 was, CNA #509 mentioned RN #422 went to get another nurse for help. When LPN #905 and LPN #423 arrived (time not given), CNA #620 and CNA #509 were instructed to clear the room. EMS was called and compressions were started (time not given). Review of LPN #905's witness statement dated [DATE] revealed LPN #905 did not recall much from that night but did remember someone had called the police. LPN #905 ran to the front to observe if Resident #87 was on the floor (time not given). Once LPN #905 noted Resident #87 was not on the floor, she went back to report findings to EMS. LPN #905 stated EMS arrived and stated they could not take Resident #87 if there was nothing reported. EMS never entered Resident #87's room. As the night progressed (time not given), RN #422 stated Resident #87 called the police on him again. When LPN #905 entered the building (time not given), everyone was running towards Resident #87's room and was asking for her help. When LPN #905 ran to Resident #87's room, LPN #905 saw Resident #87 on the floor, his arms were above his head, and he had on a nasal cannula. LPN #905 observed the crash cart outside the door and chest compressions were being performed (staff not identified). After a while EMS ran in (time not given) to continue to assist with CPR. Review of CNA #609's typed witness statement dated [DATE] revealed Resident #87 called EMS around 12:00 A.M. and did not see him go out with EMS upon arrival. CNA #609 asked Resident #87 why he did not go to the hospital, and he responded he did not want to. Later on, that night (no time given), RN #422 informed CNA #609 that Resident #87 was down on the floor. When CNA #609 went into the room to assist, Resident #87 was positioned on the floor with his back against his chair. LPN #905 and LPN #423 arrived (time not given), and CNA #609 got the crash cart to assist. Review of an undated and unauthored document regarding Resident #87 revealed the following information: - On [DATE] (no time listed) RN #422 reported doing a dressing change for Resident #87, went to get assistance and when he returned, Resident #87 was unresponsive. CPR was initiated and continued until EMS arrived and took over CPR. Resident #87 was sent to the ER. - On [DATE] (no time listed) Resident #54 (Resident #87 was his former roommate) said he wanted to talk with the Administrator and the DON. Resident #54 had monitored the care of Resident #87 and reported the approximate time of Resident #87 requesting and receiving pain medications. Resident #54 also believed EMS had been called on two different occasions but believed they had been turned away as they never came into the room. This was concerning to Resident #54, but the concerns reported did not rise to the level of abuse/neglect without further investigation. RN #422 was suspended pending investigation. - No date listed. An investigation was initiated, other residents were assessed with no concerns, staff statements were obtained, and the facility requested the EMS run report.- On [DATE], Admissions #705 called Family Member (FM) #425 to offer condolences. No questions, concerns or requests were made at this time.- From [DATE] to [DATE] (inaccurate dates) it was determined from statements collected that RN #422 stated EMS arrived at the facility because Resident #87 had called them, stating he had fallen. RN #422 had gone to Resident #87's room and talked with Resident #87 who had not fallen and went back to the desk to report this information to EMS. EMS left the facility. Later that night (no time listed) EMS called the facility and stated they received a call from Resident #87; RN #422 talked to EMS and told them Resident #87 was okay. Later than night (no time listed) RN #422 was completing a treatment on Resident #87 when he went unresponsive and was lowered to the floor. RN #422 alerted staff (not specified, no time listed) for additional assistance. At that time (not listed) Resident #87 had a pulse. At some point while trying to place Resident #87 in the bed, he lost his pulse and respirations, and EMS was called, and CPR was initiated. EMS arrived, continued CPR and took Resident #87 to the hospital. A discrepancy was identified regarding RN #[TRUNCA

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, closed medical record review, review of an emergency medical services run report, review of facility witness statements, review of the diet guide sheet and recipes, review of the facility's diet manual, review of employee disciplinary action and interviews, the facility failed to ensure residents with physician orders for mechanically altered diets were provided the correct texture food items to prevent choking and to meet their individual needs. This resulted in Immediate Jeopardy and actual harm/death on 04/23/24 during the dinner meal when Resident #91, who was ordered a Dysphagia Advanced diet, was edentulous and care planned for oral problems, was served a broccoli salad; the resident was subsequently found unconscious, required cardiopulmonary resuscitation (CPR) and when Emergency Medical Services (EMS) arrived, intubation was initially unsuccessful due to a piece of broccoli being found in the resident's airway. Resident #91 was pronounced deceased as a result of the incident. This affected one resident (#91) and had the potential to affect 15 additional residents (#3, #16, #19, #20, #21, #22, #24, #27, #31, #37, #38, #56, #57, #59 and #61) who the facility identified as being on a Dysphagia Advanced diet ordered by their physician or other delegated provider. The facility census was 90. On 05/06/24 at 11:28 A.M., the Administrator, Director of Nursing (DON) and Regional Director of Clinical Operations (RDCO) #8 were notified Immediate Jeopardy began on 04/23/24 at approximately 5:10 P.M. when Resident #91 was served a meal tray with a broccoli salad cut into bite size pieces in his room while sitting on the edge of his bed. At approximately 5:50 P.M., Resident #91 was found unconscious and not breathing, slumped over with his face on his dinner tray and CPR was started by facility staff. EMS was notified and arrived at the facility at 6:00 P.M. Initially, intubation was unsuccessful and [NAME] forceps were used to remove a piece of broccoli from the airway. Resident #91 expired at the facility. According to the EMS run report, the presumed cardiac arrest etiology was possible obstructed airway (broccoli removed). The Immediate Jeopardy was removed on 05/06/24 when the facility implemented the following corrective actions: • On 04/23/24 at 6:25 P.M., Physician #17 was notified of Resident #91's death by Registered Nurse (RN) #9. At 6:39 P.M., Resident #91's daughter was notified of Resident #91's death by Licensed Practical Nurse (LPN) #10. • On 04/23/24 by 7:00 P.M., LPN/Unit Manager #2 interviewed all residents with Dysphagia Advanced diet orders about their meal consistency for the dinner meal on 04/23/24 with no additional concerns identified. • On 04/23/2024 at 7:00 P.M., the DON and LPN/Unit Manager #2 initiated a house audit to identify any residents on Dysphagia Advanced diet. In addition, Regional Director of Operations Registered Dietitian (RDORD) #13 and RN #1 audited validation diet orders in the electronic medical record to ensure the meal tickets matched. • On 04/23/24, the DON began conducting interviews and obtained witness statements from nursing staff working the time of the event involving Resident #91. All the interviews/witness statements were completed on 04/24/24 at 4:30 P.M. • On 04/23/24, the DON initiated education with facility staff on Dysphagia Advanced diet, the difference between diets/food textures/thickened liquids/obstructed airway care and meal service policy. Education included dietary staff to serve food consistencies as ordered and nursing staff to validate meal being served to resident matches meal ticket prior to serving to residents. The education was completed on 04/24/24 at 4:30 P.M. • On 4/24/2024 at 7:30 A.M., the DON audited the breakfast meal to ensure Dysphagia Advanced diets were prepared appropriately with no concerns identified. • On 04/24/2024 at 12:30 P.M., the Administrator and DON reviewed all notes from Speech Language Pathologist (SLP) #15 and interviewed SLP #15 with no concerns identified. • On 04/24/2024 at 1:00 P.M., RDORD #13 reviewed Resident #91's meal ticket and dietary profile. • On 04/24/2024 at 1:30 P.M., RDORD #13 audited all diets in the electronic medical record and from the dietary meal tracker master list. Three (Residents #31, #20 and #12) residents' diet orders were fixed due to duplicate orders in the electronic medical record. • On 04/24/24 at 2:00 P.M., the Administrator gave a verbal warning and suspended [NAME] #5 pending investigation in an effort to investigate the event prior to [NAME] #5 returning to work. • On 04/24/24 at 2:00 P.M., the DON requested the EMS run report from the City Fire Department. • On 04/24/2024 at 5:30 P.M., RN #18 educated all residents/responsible parties with Dysphagia Advanced diets that refused to eat in dining room for potential risks of unsupervised dining. Education record assessment completed, and care plans were updated. • On 04/28/24 at 11:00 A.M., Dietary Manager (DM) #4 educated [NAME] #5 on preparing a Dysphagia Advanced diet with a return demonstration completed successfully. • On 05/06/24 at 11:50 A.M., the DON conducted an audit of all residents in house to identify residents ordered Dysphagia Advanced diet. The DON assessed all residents ordered a Dysphagia Advanced diet with no concerns identified. • On 05/06/24 at 2:48 P.M., RDORD #19 in collaboration with Regional Speech Therapy Director #20 updated the Dysphagia Advanced diet policy/manual to define the appropriate size of chopped vegetables to be approximately 0.5 inches. There were no food exclusions outside what was listed on the Dysphagia Advanced policy as long as the food items met the size requirement. • On 05/06/24 at 3:08 P.M., the DON conducted education with facility staff related to the updated Dysphagia Advanced policy/manual with the adjusted size of chopped vegetables to be approximately 0.5 inches via electronic communication to be completed on 05/07/24 by 12:00 P.M. Any staff not able to be educated by that time would be educated prior to the start of their next scheduled shift. • On 05/06/24, DM #4 initiated education with all Cooks related to preparing Dysphagia Advanced diet, including a return demonstration. All additional Cooks would be trained prior to the start of their next scheduled shift. • Beginning on 05/06/24, the Administrator/DON/Designee with support of interdisciplinary team bean audits which will be scheduled to be conducted on meal trays at different mealtimes to ensure correct meal consistencies were being served as ordered. Auditing would occur five times a week for two weeks, then three times a week for two weeks. Results of the audits will be reviewed with the Quality Assurance Performance Improvement (QAPI) committee with additional recommendations as warranted. • Beginning on 05/06/24, Director of Therapy #21 conducted an audit of residents ordered a Dysphagia Advanced diet to identify date of last therapy screen. For any resident not screened in the last 90 days or that have not received speech therapy in the last 90 days, a screen would be completed by 05/07/24. Although the Immediate Jeopardy was removed on 05/06/24, the deficiency remained at Severity Level II (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action and monitoring for effectiveness and on-going compliance. Findings include: Review of the closed medical record for Resident #91 revealed an admission date of 10/13/22 and discharge date of 04/23/24. Resident #91 had diagnoses including memory deficit following cerebral infarction, diabetes, peripheral vascular disease, hypertensive heart disease, hepatitis C, and hyperlipidemia. Review of the oral/dental care plan dated 10/19/22 revealed Resident #91 had oral/dental problems related to (being) edentulous (lacking teeth) and did not wear dentures with an intervention that included provide a mechanically altered diet. Review of the Speech Therapy (ST) evaluation dated 06/14/23 revealed Resident #91 was referred to ST due to exacerbation of decreased safety awareness during oral intake, increased signs and symptoms of dysphagia (difficulty swallowing) and risk for aspiration (when food or liquid enters the airway and eventually the lungs by accident). Review of the ST Discharge summary dated [DATE] revealed Resident #91 had met short- and long-term goals and reached maximum potential with skilled services. Resident #91 was safely consuming the least restrictive diet consistency without overt signs and symptoms of difficulty/aspiration. Resident #91's recommended discharge diet order was mechanical soft textures (Dysphagia Advanced). Review of the MDS 3.0 quarterly assessment dated [DATE] revealed Resident #91 was severely cognitively impaired and was independent with eating. Review of the nutritional assessment dated [DATE] revealed Resident #91 was ordered a Dysphagia Advanced texture diet with good appetite and oral intake. Review of the April 2024 physician orders revealed Resident #91 was ordered a Dysphagia Advanced texture diet and could have regular ground beef (hamburger on bun, patty, meatballs, meatloaf and regular fish). The order had been in place since 02/22/23. Review of the nurse's note dated 04/23/24 timed 6:39 P.M. revealed Resident #91 was noted to be without vital signs, CPR started and 911 (EMS) and Power of Attorney (POA) notified. Continued CPR until EMS arrived and took over care of resident. EMS notified hospital emergency department and physician called time of death 6:19 P.M. Review of the Prehospital Care Report Summary (EMS run report) dated 04/23/24 revealed dispatch requested a squad for [AGE] year-old male not breathing at [address and name of facility]. Staff performing CPR and respirations on pulseless and apneic (not breathing) patient. Staff stated patient was last known well at 5:45 P.M. while eating dinner. Patient found unresponsive at approximately 5:52 P.M. at which time a Code was called by nurse supervisor. EMS crew took over manual CPR. Attempted intubation - no success. During resuscitation attempt, a piece of broccoli was removed from patient's airway with [NAME] forceps. Patient remained in asystole (without heartbeat) during code. Resuscitation attempt terminated per [name of physician]. Time of death was 6:19 P.M. Presumed cardiac arrest etiology: possible obstructed airway (broccoli removed). Review of a facility witness statement dated 04/24/24 authored by RN #9 revealed, I was passing dinner trays on [Front North]. I went into [Resident #91's room] and announced that I was bringing in dinner. [Resident #100] (Resident #91's wife/roommate) was sitting on her bed. [Resident #91] was lying down .[Resident #91] sat up and was sitting on the side of his bed like he always does to eat. He was acting his norm. I served [Resident #91] his tray. His tray was consistent with his diet order. Review of a facility witness statement dated 04/23/24 authored by State Tested Nurse Aide (STNA) #15 revealed, I started collecting trays and when I got to [Resident #91's] room, found [Resident #91] slumped over his tray. I yelled for the nurse and the nursing staff came when it was called Code Blue. Review of a facility witness statement dated 04/23/24 authored by STNA #14 revealed, At approximately 5:50 P.M., I other aides and I went down the hall to collect trays. Upon entering the room, we found resident faced down in his food tray. At that point, we all screamed for help down the nurses station. Review of a facility witness statement dated 04/23/24 authored by LPN #10 revealed, I was at the nurses' cart charting, when aide called, and I ran down to patients room. Patient was face down in dinner tray. This nurse pushed and assisted patient back on bed to obtain vitals and start CPR . Review of the Diet Guide Sheet for Dinner Day 3, Week 1 on Tuesday revealed ½ cup of broccoli salad, chop for resident's ordered a Dysphagia Advanced diet. Review of the recipe for Broccoli (floret) Salad revealed steam or boil broccoli, cook until tender, drain off excess liquid and chop or slice into pieces. For Dysphagia Advanced: chop to small, appropriate small. Review of the facility's 2019 Diet and Nutrition Care Manual for Dysphagia Advanced diets revealed this diet was used for individuals with mild oral and/or pharyngeal phase dysphagia. Foods that were difficult to chew were chopped, ground, shredded, cooked, or altered to make them easier to chew and swallow. Foods to avoid included cooked rubbery or non-tender cooked vegetables. There was no definition of what the measurement was for small, appropriate size. Review of the Employee Corrective Action Form dated 04/24/24 revealed [NAME] #5 was given a verbal warning and suspended pending investigation due to incident that occurred on 04/23/24. Review of the Teachable Moment form dated 04/24/24 revealed RN #9 was educated related to diet consistency and texture types and validating that meal matched diet type prior to serving residents. Interview on 04/29/24 at 8:05 A.M. with Dietary Manager (DM) #4 revealed broccoli salad was on the menu for dinner on 04/23/24 and the salad was served cold. DM #4 had observed [NAME] #5 steam and chop the broccoli; however, DM #4 was not at the facility when dinner was served. DM #4 was told that Resident #91 had received a piece or a couple of pieces of broccoli that were not properly chopped, the resident choked and passed away. Interview on 04/29/24 at 10:50 A.M. with RN #9 revealed she served Resident #91 his dinner on 04/23/24 while the resident was sitting on the edge of his bed. RN #9 placed a fork into the broccoli salad and the broccoli was chopped and soft. RN #9 felt the dinner served was consistent with his diet order. RN #9 stated after CPR was completed and EMS called Resident #91's time of death, a paramedic told RN #9 that, we did pull a piece of broccoli out of his airway. Interview on 04/29/24 at 11:40 A.M. with [NAME] #5 revealed for dinner on 04/23/24, he cooked the broccoli in the steamer for approximately 25 minutes, ran the broccoli under cool water to cool it off, then cut up the broccoli in to bite size pieces using a chef's knife. [NAME] #5 stated if the broccoli salad was served to residents on a Dysphagia Advanced diet, he would have had to chop the broccoli into finer/smaller pieces rather than bite size pieces. During the interview, [NAME] #5 could not recall if he made a separate broccoli salad for residents on a Dysphagia Advanced diet. [NAME] #5 did not respond when asked if he referenced the broccoli recipe while preparing the broccoli salad. Observation of the lunch tray line on 04/29/24 at 12:00 P.M. revealed [NAME] #6 was serving lunch which included Capri Vegetable Blend which contained cooked, diced carrots. [NAME] #6 served the Carpi Vegetable Blend to the meal tray intended for Residents #31 and #21 who were ordered a Dysphagia Advanced diet. The diced carrots were approximately the size of a half dollar-sized coin. Interview, during the observation, with DM #4 revealed she trained the cooks to chop food items into ½ inch pieces for a Dysphagia Advanced diet. Review of the recipe for Capri Vegetable Blend revealed Capri Blend included 35% Julienne cut carrots strips, 27% bias cut green beans, 23% half round yellow squash, and 15% crinkle cut zucchini. Steam or boil vegetables until tender, toss lightly with margarine. For Dysphagia Advanced: chop to small, approximate size. Interview on 04/29/24 at 1:45 P.M. with DM #4, (Dietary District Manager (DDM) #11 and the Administrator were present) verified the Capri Vegetable Blend recipe called for Julienne cut carrots rather than diced carrots and verified the diced carrots in the Capri Vegetable Blend were larger than ½ inch. Interview on 04/29/24 at 2:20 P.M. with RDORD #13 verified there was no definition for small, appropriate size in the diet manual for a Dysphagia Advanced diet. Interview on 04/29/24 at 3:05 P.M. with STNA #15 revealed Resident #91 was a good eater and normally cleaned his plate. On 04/23/24, STNA #15 was assisting STNA #14 with collecting meal trays and STNA #15 began collecting trays from the back of the hallway. STNA #15 arrived at Residents #100 and #91's room, and STNA #15 began to collect Resident #100's tray (Resident #100 was not in the room) when STNA #15 looked up and observed Resident #91 slumped over his overbed table with his face down on his plate. STNA #15 rubbed Resident #91's head stating Resident #91's name. STNA #15 began yelling for LPN #10. Interview on 04/29/24 at 4:00 P.M. with the Administrator revealed the facility conducted an investigation after Resident #91 expired and the investigation concluded that Resident #91 had choked. Interview on 04/29/24 at 4:25 P.M. with Speech Language Pathologist (SLP) #16 revealed she worked with Resident #91 in June/July 2023 to determine his diet order. Resident #91 was edentulous. SLP #15 would expect that broccoli be served in ½ inch chopped, soft pieces and soft enough to mash with a fork for resident's ordered a Dysphagia Advanced diet. SLP #15 revealed broccoli stems were not able to be mashed. Interview on 04/30/24 at 10:15 A.M. with LPN #10 revealed she was Resident #91's nurse on 04/23/24. That evening, LPN #10 was passing medications while three STNAs and one nurse passed meal trays to the residents on the hall. At approximately 5:20 P.M. or 5:30 P.M., LPN #10 administered medications to Resident #100 (Resident #91's roommate) in the hallway. At that time, LPN #10 observed Resident #91 sitting on the edge of his bed feeding himself without any concerns. LPN #10 returned to the nursing station and was standing at the medication cart when STNAs alerted the nurses to come to Resident #91's room. LPN #10 ran down the hallway into Resident #91's room and the resident's face was in his tray. A follow-up interview on 05/06/24 at 2:25 P.M. with SLP #16 revealed she had not screened Resident #91 for swallowing since October 2023 and a therapy screening list including Resident #91 should have been provided to the therapy department in March 2024 but that did not occur. The facility identified 15 additional residents, Resident #3, #16, #19, #20, #21, #22, #24, #27, #31, #37, #38, #56, #57, #59 and #61 who required a Dysphagia Advanced diet ordered by their physician or other delegated provider. The facility's failure to ensure food items were properly prepared and/or served at an appropriate size during the dinner meal on 04//23/24 and lunch meal on 04/29/24 placed these additional residents at risk for choking and/or adverse outcomes. Review of the facility's Meal Distribution policy revised September 2017 revealed all meals would be assembled in accordance with the individualized diet order, plan of care and preferences. The nursing staff would be responsible for verifying meal accuracy and timely delivery of meals to residents/patients. For point-of-service dining, the Dining Services department staff, under the supervision of the licensed nurse, would assemble the meal in accordance with the individual meal card and present it to the resident/patient or care staff for delivery to the resident/patient. This deficiency represents non-compliance investigated under Complaint Number OH00153286 and OH00153283.