Based on review of facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for two of four residents reviewed (Residents 1, 2), resulting in Immediate Jeopardy to the resident's physical/mental health and safety. This deficiency was cited as past non-compliance. Findings include: The facility's abuse policy, dated March 22, 2023, revealed that the facility shall provide a safe environment where residents are not subject to mental, physical, sexual, and verbal abuse or neglect by staff, residents, volunteers, consultants, contractors, and other caregivers, visitors or family members. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 29, 2023, revealed that the resident was sometimes understood, could sometimes understand, required extensive assistance with her daily care tasks including with eating, was totally dependent on staff for her transfers, and had diagnoses that included dementia and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). An incident note for Resident 1, dated October 28, 2023, at 2:30 p.m. revealed that Nurse Aide 3 notified the Registered Nurse Supervisor about witnessing physical abuse to Resident 1 during lunch at 12:30 p.m. However; Nurse Aide 3 did not report the abuse to her supervisor at that time. Resident 1 was sleeping in the Atrium at dinner and it was witnessed that Nurse Aide 2 slapped the resident on the left cheek and told her to wake the f**k up multiple times. The resident was unable to be aroused enough to answer any questions. The Registered Nurse Supervisor immediately assessed Resident 1 and no injuries were noted to the resident. Nurse Aide 2 was escorted out of the facility. Staff was re-educated on abuse and reporting, and no staff were allowed to work without receiving the re-education. All of the residents were interviewed, and skin assessments were performed. The physician and the resident's power of attorney (POA - a person who is legally authorized to make decisions for a person who can no longer make them) were notified. A quarterly MDS assessment for Resident 2, dated September 8, 2023, revealed that the resident was confused, required extensive assistance from staff for his daily care tasks, and had a diagnosis which included Alzheimer's disease and dementia. A nursing note for Resident 2, dated October 28, 2023, revealed that the nurse aide reported an allegation of abuse by another staff member to the Registered Nurse Supervisor. The resident was calling the nurse aide a whore and the nurse aide slapped him in the face, hitting his nose. She continued providing care to him and he told her to touch his Jimmy John and she replied, No, you're a dirty black man, you're a faggot that touches little boys. She smacked him on the top of his head. The nurse aide who was assisting told her she should not do that, and Nurse Aide 2 said she did not give a f**k. An Investigative Interview statement from Nurse Aide 5, dated October 28, 2023, revealed that at around 1:15 p.m. she and Nurse Aide 2 went into Resident 2's room to change the resident. The resident called Nurse Aide 2 a whore and she smacked him in the mouth. Nurse Aide 5 told Nurse Aide 2 that she should not do that and she said, Where I'm from I smack residents around. When they were putting a new brief on the resident he asked her if she wanted to touch his Jimmy John. She smacked him on the nose and told the resident that he was a dirty black man who loves little boys and was a faggot. They pulled him up in bed and he said she was in the KKK and she smacked him on top of his head. They covered him up and left the room. An Investigative Interview statement from Nurse Aide 1, dated October 28, 2023, revealed that at 12:30 p.m. during lunch in the Atrium she witnessed Nurse Aide 2 smack Resident 1 on the left cheek and say, wake the f**k up. She did this several times. An Investigative Interview statement from Nurse Aide 3, dated October 28, 2023, revealed that at 12:30 p.m. in the Atrium she witnessed Nurse Aide 2 smack Resident 1 on her left cheek multiple times and told her to wake the f**k up. An Investigative Interview statement from Registered Nurse 4, dated October 28, 2023, at 3:27 p.m. revealed that Nurse Aide 5 told Registered Nurse 4 that she needed to talk to her in private. As they entered the nursing station on 3 East, she led her to the bathroom then told her that Nurse Aide 2 hit Resident 2 and called him names while they were changing him. She told Nurse Aide 2 she should not do that, and Nurse Aide 2 stated, I'll do what I want. Nurse Aide 5 said that Nurse Aide 2 had also hit Resident 1 earlier and told her to wake the f**k up, and that Nurse Aide 3 saw it. An Investigative Interview statement from Licensed Practical Nurse 7, dated October 28, 2023, revealed that at 1:30 p.m. Nurse Aide 5 reported to her that she witnessed another nurse aide smacking a resident in the mouth, on the nose, and called him a dirty black man who loves little boys and was a faggot. The resident said she was in the KKK so she smacked him on the head. Nurse Aide 5 indicated that she wrote a report and turned it in to Registered Nurse 4 Following the incident with Resident 2 on October 28, 2023, the facility's corrective actions included: Nurse Aide 2 was escorted out of the facility, and after the investigation her employment with the facility was terminated. An audit of current residents was started. Re-education regarding abuse to staff, and staff were not allowed to work until re-education had been completed. Ongoing random audits of residents were being completed. The audits were to be reviewed at Quality Assurance Performance Improvement (QAPI) meetings. On November 7, 2023, at 5:30 p.m. the Nursing Home Administrator was given the required Immediate Jeopardy Template and informed that the physical/mental health and safety of Residents 1 and 2 had been placed in Immediate Jeopardy due to the failure of the facility to ensure that Residents 1 and 2 were not subjected to physical/mental abuse by Nurse Aide 2, who physically/mentally abused the residents. On November 8, 2023, at 11:01 a.m. the facility submitted an immediate action plan that included: The nurse aide was suspended at the time of the reported abuse, and is no longer employed at the facility. An in-house audit was performed on all residents at the time of the incident, and assessments were completed along with interviews to confirm no other residents were identified. In-house re-education was provided to staff on abuse and reporting of abuse. The facility will not allow an employee to work unless education has been completed prior to returning to work. Ongoing random audits of care and interviews continue to ensure that no residents have been affected. The audits are going to be reviewed at QAPI. Facility staff were interviewed on November 8, 2023 and were knowledgeable of the facility's policy on abuse. The facility alleged compliance on November 2, 2023. The Immediate Jeopardy was lifted on November 8, 2023, at 11:25 a.m. when it was confirmed that the corrective action plans developed on October 28, 2023, were completed by November 2, 2023, and that Residents 1 and 2 and any other current residents were not physically/mentally abused since November 2, 2023. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(j) Resident rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to complete a Nurse Aide Registry verification for one of five nurse aides reviewed upon hire (Nurse Aide 2) and staff failed to report physical abuse of one resident (Resident 1) in a timely manner which allowed a second resident to be physically abused (Resident 2) putting all of the residents in danger of being abused, resulting in Immediate Jeopardy to their physical safety. Findings include: The facility's abuse policy, dated March 22, 2023, revealed that the facility shall provide a safe environment where residents are not subject to mental, physical, sexual, and verbal abuse or neglect by staff, residents, volunteers, consultants, contractors, and other caregivers, visitors, or family members. All allegations of abuse should be reported immediately to the charge nurse, Director of Nursing, Nursing Home Administrator, and the resident's physician for investigation into the circumstances of the incident. The staff member who discovers the incident, suspected abuse situation, or has the initial knowledge of such incidents will be responsible for immediately notifying his or her supervisor. The supervisor who becomes aware of such incidents must immediately report to the Nursing Home Administrator and the Director of Nursing in person or by telephone. An incident note for Resident 1, dated October 28, 2023, at 2:30 p.m. revealed that Nurse Aide 3 notified the Registered Nurse Supervisor about witnessing physical abuse to Resident 1 at 12:30 p.m. during lunch. The resident was sleeping in the Atrium at dinner and it was witnessed that Nurse Aide 2 slapped the resident on the left cheek and told her to wake the f**k up multiple times. The resident was unable to be aroused enough to answer any questions. The Registered Nurse Supervisor immediately assessed the resident and then escorted Nurse Aide 2 out of the facility. No injuries were noted to the resident. There was no documented evidence that the physical abuse of Resident 1 by Nurse Aide 2 was reported to the Registered Nurse Supervisor immediately when it happened. A nursing note for Resident 2, dated October 28, 2023, revealed that a nurse aide reported an allegation of abuse by another staff member to the Registered Nurse Supervisor. At approximately 1:15 p.m. Resident 2 was calling Nurse Aide 2 a whore and Nurse Aide 2 slapped him in the face, hitting his nose. She continued providing care to him and he told her to touch his Jimmy [NAME] and she replied, No, you're a dirty black man, you're a faggot that touches little boys. She smacked him on top of his head. The nurse aide who was assisting told her she should not do that and Nurse Aide 2 said she did not give a f**k. An Investigative Interview statement from Licensed Practical Nurse 7, dated October 28, 2023, revealed that at 1:30 p.m. Nurse Aide 5 reported to her that she witnessed Nurse Aide 2's physical abuse of Resident 2. Nurse Aide 5 indicated that she had not reported the incident yet; then wrote a report and turned it into the Registered Nurse 4. An Investigative Interview statement from Licensed Practical Nurse 6, dated October 28, 2023, revealed that at 1:30 p.m. Nurse Aide 7 reported to her that she witnessed Nurse Aide 2's physical abuse of Resident 2. Nurse Aide 7 indicated that she had not reported the incident yet; then wrote a report, and turned it into the Registered Nurse 4. An Investigative Interview statement from Registered Nurse 4, dated October 28, 2023, at 3:27 p.m. revealed that Nurse Aide 5 told Registered Nurse 4 that she needed to talk to her in private. As they entered the nursing station on 3 East, she led her to the bathroom then told her that Nurse Aide 2 hit Resident 2 and called him names while they were changing him. She told Nurse Aide 2 that she should not do that, and Nurse Aide 2 stated, I'll do what I want. The nurse aide said Nurse Aide 2 also hit Resident 1 and told her to wake the f**k up and that Nurse Aide 3 saw it. An Investigative Interview statement from Nurse Aide 3, dated October 28, 2023, revealed that at 12:30 p.m. in the Atrium she witnessed Nurse Aide 2 smack Resident 1 on her left cheek multiple times and told her to wake the f**k up. An Investigative Interview statement from Nurse Aide 5, dated October 28, 2023, revealed that at around 1:15 p.m. she and Nurse Aide 2 went into Resident 2's room to change the resident. The resident called Nurse Aide 2 a whore and she smacked him in the mouth. Nurse Aide 5 told Nurse Aide 2 that she should not do that and she said, I'm from another facility and I smack residents around. When they were putting a new brief on the resident he asked her if she wanted to touch his Jimmy [NAME], she then smacked him on the nose, and told the resident that he was a dirty black man who loves little boys and was a faggot. They pulled him up in bed and he said she was in the KKK and she smacked him on top of his head. They covered him up and left the room. Interview with the Nursing Home Administrator on November 7, 2023, at 1:50 p.m. confirmed that Nurse Aide 5 failed to report the abuse timely, so she was suspended, then given re-education regarding the reporting of abuse, then given a final written warning, and placed on a 90-day probation. Nurse Aide 3 was terminated because she did not report the witnessed abuse to Resident 1 until they were interviewing her about the abuse toward Resident 2. Following the incident with Resident 2 on October 28, 2023, the facility's corrective actions included: Nurse Aide 2 was escorted out of the facility, and after the investigation her employment with the facility was terminated. An audit of current residents was started. Re-education regarding abuse and reporting abuse to staff, and staff were not allowed to work until re-education had been completed. Ongoing random audits of residents were being completed. The audits were to be reviewed at Quality Assurance Performance Improvement (QAPI) meetings. The facility's abuse policy, dated March 22, 2023, revealed that nurse aides who are currently on the registry will have their registry checked for past incidences of abuse, neglect, mistreatment of residents, and misappropriation of resident property prior to hiring for employment. The prevention of resident abuse and neglect is accomplished by the completion of pre-employment screening of potential employee registries, completion of a criminal record check of all employees, and per-employment reference checks of potential hires. The personnel file for Nurse Aide 5 revealed that she was hired July 7, 2023. She was provided education on abuse, neglect, and exploitation on July 8, 2023. She successfully completed her nurse aide training program on June 22, 2023, and received her Pennsylvania Nurse Aide Registry on September 18, 2023. The personnel file for Nurse Aide 2 revealed that she was hired on March 29, 2023. However, there was no documented evidence until November 7, 2023, at 8:41 a.m. that the nurse aide's standing on the Pennsylvania Nurse Aide Registry was verified. She was provided education on abuse, neglect, and exploitation on April 12, 2023. Nurse Aide 2's time record, dated October 28, 2023, revealed that she punched in for duty at 12:06 p.m. and punched out at 2:25 p.m. Interview with the Nursing Home Administrator on November 7, 2023, at 2:23 p.m. confirmed that the Nurse Aide Registry check for Nurse Aide 2 was not completed as required. On November 7, 2023, at 5:30 p.m. the Nursing Home Administrator was given the required Immediate Jeopardy Template and informed that the physical/mental health and safety of Resident 2 had been placed in Immediate Jeopardy due to the failure of the facility to ensure that Nurse Aide 5 immediately reported the witnessed abuse to Resident 1 by Nurse Aide 2 to their supervisor as per the facility's policy. On November 8, 2023, at 11:01 a.m. the facility submitted and implemented an immediate action plan that included: The reporting of abuse was not immediate. Notification of the abuse was made in two hours. Re-education was given to staff on the importance of reporting abuse immediately along with the facility abuse policy/procedure. Employees were not permitted to work before receiving re-education. Upon notification, the nurse aide (perpetrator) was escorted out of the facility immediately. The perpetrator was terminated following the conclusion of the investigation. The facility conducted audits of the residents for signs of abuse. No additional residents were identified from the audit. Ongoing random audits of residents are being completed weekly. The audits are going to be reviewed at QAPI. The facility acknowledged compliance on November 2, 2023. Nurse Aide Registry verifications were obtained on the nurse aide identified as not having the registry verifications completed prior to hire. Certifications are current and active. In-house audit of employee files have been completed on November 7, 2023. All employees with licenses or certifications have been validated as being current and active. Re-education will be given to the Human Resources Director on ensuring that pre-employment verifications and checks are completed before employees start. The Nursing Home Administrator or designee will be auditing new employee charts as new employees are hired to ensure that the process is completed prior to them starting on the floor. Employees not having all the required pre-employment items and supporting documentation will not be permitted to work until all items are received. Review of those audits will be taken to QAPI for continuation or resolution of audit. The facility acknowledged compliance on November 8, 2023. The Immediate Jeopardy was lifted on November 8, 2023, at 11:25 a.m. when it was confirmed that the corrective action plans developed on October 28, 2023, and November 8, 2023, were implemented. It was confirmed that Residents 1 and 2 and any other current residents were not physically/mentally abused. The majority of staff were educated, and a plan for remaining staff to receive the education prior to the start of their next work shift was developed and implemented. All employees with licenses or certifications have been validated as being current and active. Re-education had been given to the Human Resources Director on ensuring that pre-employment verifications and checks are completed before employees start. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on a review of facility policies, clinical records, and facility reports, as well as staff interviews, it was determined that the facility failed to ensure that supervision and adequate interventions were in place to prevent a resident from receiving food items from other residents outside of their ordered diet restrictions for one of six residents reviewed (Resident 2), and failed to ensure that supervision and adequate interventions were in place to prevent a resident from giving other residents food items outside of their ordered diet restrictions for one of six residents reviewed (Resident 1). The facility's failure created a situation in which Resident 2 obtained a food item outside of his ordered diet restriction causing him to accidentally choke to death. The facility's failure also placed the current residents with diet restrictions in Immediate Jeopardy of the likelihood of serious bodily injury, harm, or death. The facility also failed to ensure that supervision and adequate interventions were in place to prevent a resident from assisting other residents in their wheelchairs without leg rests for one of six residents reviewed (Resident 1). Findings include: The facility's behavior policy, dated March 22, 2023, indicated that should a resident's behavior become abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his or her safety or the safety of others, the nurse supervisor/charge nurse must immediately implement the policy and procedure for unmanageable residents. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 28, 2023, indicated that the resident was moderately cognitively impaired, was independent with transfers and ambulation (walking), had no behaviors, and had diagnoses that included dementia, anxiety, and depression. A quarterly MDS assessment for Resident 2, dated May 10, 2023, revealed that the resident was sometimes understood, sometimes understands with a Brief Interview for Mental Status (BIMS) score of 09, indicating that the resident was moderately impaired with his attention, orientation, and ability to register and recall new information; required supervision of one-person physical assist with eating; required extensive assistance from staff with his daily care tasks; was totally dependent on staff for his transfers; and had a diagnosis of dementia. The resident experienced holding of food in his mouth/cheeks or residual food in his mouth after meals and experienced coughing or choking during meals or when swallowing medications during the review period. The resident was on a mechanically-altered diet that required a change in the texture of food or liquids. A significant change in status MDS assessment for Resident 2, dated July 14, 2023, revealed that the resident was usually understood, could usually understand, had severe cognitive impairment, was independent with eating after set-up, required extensive assistance from staff for his daily care tasks, was totally dependent on staff for his transfers, had a diagnosis of dementia and was on a mechanically-altered diet that required a change in the texture of food or liquids. A care plan for Resident 2, dated October 6, 2023, revealed that the resident was at risk for aspiration (when something you swallow goes down the wrong way and enters your airway or lungs) complications related to coughing and impulsiveness at mealtimes. Staff was to ensure that the resident's diet and liquid consistency was followed as ordered. A nursing note for Resident 2, dated May 2, 2023, at 5:41 p.m. revealed that the resident experienced a coughing episode during the dinner meal on a mechanical soft diet. The resident was eating too fast and not chewing his food well. The resident was also not drinking his honey thick fluids and was coughing after consuming the fluids. The resident was assessed by the registered nurse. A nursing note at 5:44 p.m. revealed that the physician was made aware that the resident was eating dinner very fast and aspirated on his food. A new order for a chest x-ray to rule out aspiration was received. A speech language pathologist (SLP) evaluation for Resident 2, dated May 4, 2023, revealed that the resident was referred because the resident had a coughing event on May 2, 2023, and now presents with wheezing. SLP services warranted to determine safest diet level. Physician's orders for Resident 2, dated May 5, 2023, and discontinued on July 10, 2023, included an order for the resident to receive a Carbohydrate Controlled Diet (CCD) pureed (food that has been ground, pressed, and/or strained to a soft, smooth consistency, like a pudding) texture, with honey (slightly thicker, similar to honey or a milkshake) consistency liquids, and no regular creamer. An incident note for Resident 2, dated May 6, 2023, at 6:58 p.m. revealed that the resident was given iced tea by his roommate. The roommate thought he was dry and thought he would give him a drink. The resident coughed on the drink. Education was provided to the roommate that he is not to give other resident's drinks due to special ordered diets and liquid consistency. A SLP discharge summary for Resident 2, dated May 10, 2023, revealed that the resident has a good prognosis to maintain his current level of function with consistent staff follow through and her discharge recommendations were for a pureed consistency diet with honey thick liquids, to encourage slow intake with small bites in an upright position along with encouraging consumption. Staff was to provide verbal cues to decrease rate and size as needed along with distant supervision. A nursing note for Resident 2, dated May 28, 2023, at 8:54 a.m. revealed that he was yelling out to another resident in hallway to come to his room. The resident then motioned to that resident that he was hungry by drawing his hand up to his mouth. As the writer approached the residents, the other resident gave Resident 2 an oatmeal cream pie. The resident consumed some of the oatmeal cream pie, until she was able to educate him and the other resident that his diet is pureed and honey thick and it is not okay to have anything other than pureed food and honey thick liquids unless therapy okays it in the future. The resident became mad and yelled, I hate you! and I'm mad!. The resident then stormed back into his room in his wheelchair. A nursing note for Resident 1, dated May 28, 2023, at 9:07 a.m. revealed that the resident was educated by the Director of Nursing that he could not be offering other residents food because he was not aware of their diets. Resident 1 was noted to be giving a resident, who was ordered a pureed diet, mechanical soft food in the hallway. Resident 1 stated that he was sorry, and he did not want to get anyone in trouble or hurt anyone. Education was effective. A nursing note for Resident 2, dated May 31, 2023, at 9:26 a.m. revealed that the resident is at baseline for behaviors at this time. The resident does not like his diet and will eat items not on his diet if given the opportunity. The resident does not take redirection or education well. A nursing note for Resident 2, dated June 1, 2023, at 10:06 a.m. revealed that the nurse aide notified the writer that another male resident was seen coming out of the resident's room. Upon approaching the resident, he wiped small crumbs of peanut butter crackers off his shirt. The writer tried to educate resident again and he just shook his head and laughed. The education was not successful. Physician's orders for Resident 2, dated July 10, 2023, and discontinued on September 21, 2023, included an order for the resident to receive a CCD pureed texture diet, with honey consistency liquids, no regular creamer, extra sauce and gravy, and food in bowls. A nursing note for Resident 2, dated July 14, 2023, at 9:13 p.m. revealed that staff reported to the writer that the resident was eating a cheese cracker and drinking thin consistency soda in his room. Upon entering the resident's room, the resident was no longer eating or drinking. Surroundings were assessed and there were cracker crumbs on his wheelchair and on the floor next to him. When asked if he was eating the crackers and drinking the soda he replied with a nod of his head. It was explained to him the risks of not following the appropriately prescribed diet including choking, aspiration, respiratory infection, and even death. The resident's response was to shrug his shoulders. The physican was made aware of the resident not following his prescribed diet, and no new orders were received. The resident's representative was updated and gave permission for the resident's room to be searched periodically for food and drink items. A nursing note for Resident 1, dated August 9, 2023, at 12:56 p.m. revealed that Licensed Practical Nurse 1 was walking in the hallway when she turned the corner and saw Resident 1 hand Resident 2 a hard candy, which Resident 2 ate. Resident 1 was educated that per Resident 2's diet, it was not safe for him to have hard candy, as he could choke. Resident 1 was asked if he heard her to ensure that the education was understood and he stated, It melts, it's fine, he won't choke. She told him that it was not safe for Resident 2 and he was to refrain from sharing food that was not pureed due to safety. At 1:17 p.m. Resident 1 told Licensed Practical Nurse 1 the only way Resident 2 was going to learn how to eat was if he was taught. She told Resident 1 that was not how it worked and if that was part of his care plan, they would take care of it. Resident 1 stated that she was not the boss of him, and he would do what he wanted and stated, You know nothing, I know what I'm doing. Licensed Practical Nurse 1 told him that if something would happen to Resident 2, once he knowingly gave him food that was unsafe for him, that he could be responsible, and that it was all about safety. The situation was reported to the Director of Nursing. A nursing note for Resident 2, dated August 9, 2023, at 12:59 p.m. revealed that the nurse was walking in the hallway when she turned the corner and happened to see Resident 1 hand the resident a hard candy, which the resident then proceeded to swallow once he saw the nurse. The nurse then educated the resident that he cannot have hard candy with his diet. The nurse also let Resident 1 know that it is not safe for resident to have hard candy. Neither of the residents seemed receptive to the education. Physician's orders for Resident 2, dated September 21, 2023, and discontinued October 5, 2023, included an order for the resident to receive a CCD mechanical soft (designed for people who have trouble chewing and swallowing. Chopped, ground and pureed foods are included in this diet, as well as foods that break apart without a knife) texture diet, with thin liquids, extra sauce and gravy, may have regular creamer, and food in bowls. Physician's orders for Resident 2, dated October 5, 2023, included an order for the resident to receive a CCD mechanical soft texture diet, with honey consistency liquids, extra sauce and gravy, and food in bowls. A nursing note for Resident 2, dated October 11, 2023, at 2:04 p.m. revealed that the writer was notified by a nurse aide at 1:00 p.m. that the resident was not breathing. Upon entering the resident's room, the resident was found with his head hanging forward toward his chest. The resident did not respond to verbal stimuli. The resident's head was lifted, the carotid pulse (pulse in the neck) was checked and was absent. There was no breathing noted. The resident had cracker crumbs on his chest. The nurse aides used a mechanical lift to return resident to bed while the licensed practical nurse and the writer confirmed the resident's code status from his chart. The resident was confirmed to be a Do Not Resuscitate (DNR). Upon return to the resident's room and due to a lack of a pulse and absence of breath, he was pronounced at 1:05 p.m. The Nursing Home Administrator and Assistant Director of Nursing were notified of the resident's change in status. The Death Certificate for Resident 2, dated October 11, 2023, revealed that accidental choking led to asphyxia (a condition arising when the body is deprived of oxygen, causing unconsciousness or death). A witness statement completed by Registered Nurse 4, dated October 11, 2023, revealed that Nurse Aide 5 came and got the nurse to look at Resident 2. She stated, don't think he is breathing. The nurse ran to his room. Resident 1 did not have a carotid pulse and was not breathing. The nurse noticed orange cracker crumbs on his chest. The licensed practical nurse and the nurse went to confirm his code status while the aides put him to bed in case they needed to start Cardiopulmonary Resuscitation (CPR). The aides stated that they cleaned his face. The nurse also noted cracker crumbs on the floor of his room. A witness statement completed by Nurse Aide 5, dated October 11, 2023, revealed that at 1:00 p.m. her and Nurse Aide 6 started to lay people down after lunch. They started with Resident 2. As soon as she walked into the room, she noticed that the resident was not breathing. She ran over to the East Hall and got the registered nurse. They both ran to Resident 2's room. Nurse Aide 5 and Nurse Aide 6 laid him down with the lift. There were orange cracker crumbs all over his shirt, lift pad, and wheelchair. While cleaning him up he had crackers in his mouth and coming out his nose. A witness statement completed by Nurse Aide 6, undated, revealed that around 1:00 p.m. in the afternoon her and Nurse Aide 5 went into Resident 2's room to change him. His head was down. They lifted his head up and it fell back down. His eyes were open, and food was in his mouth and nose. Nurse Aide 5 went to get help and Nurse Aide 6 stayed in the room, wiped off his face, and tried a sternal rub. Food was all over his shirt. The charge nurse came in the room and said to go ahead and lay him down. When they got him in bed there were cracker crumbs all through the sling and on the dura pad that they had wiped off. Interview with Resident 1 by the Nursing Home Administrator, dated October 11, 2023, revealed that he had asked the resident if he shared any of his snacks with any other residents and his reply was no. He then asked the resident where he got his snacks, and he said that his brother brought them in for him. Information provided by the facility revealed that the type of cracker in Resident 2's possession was not a brand or type of cracker ordered or supplied by the facility. Resident 2 had no other snacks in his room that were inconsistent with his current ordered diet. A full house audit was conducted to determine if any other residents had the same orange crackers in their possession. Resident 1, who lives a few doors down from Resident 2, had the same small packs of orange crackers. Upon review of Resident 1's record, he has been observed in the past sharing his snacks with other residents. Education was provided at that time on not offering or sharing food or snacks with other residents for their safety. Interview with Speech Language Pathologist on October 19, 2023, at 12:40 p.m. revealed that she had worked with Resident 2 in the past and had recommended a diet downgrade to pureed diet with honey consistency liquids due to his impulsive eating. She indicated that the resident's sister wanted his diet upgraded due to not liking the pureed diet and experiencing weight loss, so his diet was upgraded to a mechanical soft diet. She indicated that she follows dietary's list of foods that are approved for a mechanical diet. She indicated that as a SLP standpoint she uses any food that can be cut easily with a fork, then she would consider that food to be a mechanical soft food. She indicated that she would not consider a peanut butter cracker a mechanical soft food item unless it was softened with a liquid. She indicated that the resident was very difficult to work with because he was such an impulsive eater. You could not get him to slow down when eating even with cueing and education. She indicated that he was not on her radar to see about advancing his diet because of his impulsive eating. She indicated that the resident would not be safe to eat peanut butter crackers or to be given peanut butter crackers from another resident. Interview with the Dietician on October 19, 2023, at 1:04 p.m. revealed that that dry cheese crackers would not be considered a mechanical soft food unless it was softened with a liquid. A review of Resident 1's clinical record revealed that there was no documented evidence that new interventions were put into place to monitor and prevent Resident 1 from giving food to other residents that were on restricted diets. A nursing note, dated October 13, 2023, at 12:32 p.m. revealed that Resident 1 was presented with education regarding resident diet/snacks and he verbalized understanding of the education that was given. It was stressed the adverse effects that could occur with giving residents food outside of their prescribed diet. Resident 1 stated, I have always been a giver and I like to share things, but I guess I can't. It was explained that it was a kind gesture, but it could cause harm to other residents and snacks should not be shared. He was agreeable and stated that he would not share snacks with other residents. A nursing note, dated October 16, 2023, at 5:28 p.m. revealed that Resident 1 was seen getting off the elevator by the East nurse's station with multiple bags of snacks and candy. He was re-educated on not sharing snacks with any other resident. He was not receptive to the education and yelled, Don't tell me that! I don't do that! Interview with the Nursing Home Administrator on October 19, 2023, at 2:45 p.m. revealed that there was no documented evidence that any interventions, other than education, were put into place to prevent Resident 1 from giving food to other residents. Interview with Nurse Aide 5 on October 19, 2023, at 2:45 p.m. revealed that she had previously seen cracker crumbs on the Resident 1's floor and in his wheelchair before. As of October 6, 2023, there was no documented evidence that the facility developed and/or implemented any new interventions and/or supervision to prevent Resident 2 from obtaining food items outside of his ordered diet. Following the incident on October 11, 2023, the facility's corrective actions included: On October 11, 2023, a whole house audit for snacks in resident rooms was completed. If snacks were found, education was provided to the resident and/or the resident's responsible party. They were asked if the snack that was not in line with the resident's current diet order could be removed. If the resident and/or the resident's responsible party was in agreement with the removal of the snack, the snack was then removed from the resident's room. On October 11, 2023, a current in-house resident audit of diet order/tray ticket information/care plan was completed. On October 12, 2023, a call was placed to the residents' family/representative regarding the facility's meal and snack safety protocol. October 12, 2023, education to staff regarding meal and snack safety was started. On October 13, 2023, a resident council meeting was held to discuss snack and food protocol. On October 16, 2023, daily audits started for snacks in rooms/sharing was started. On October 19, 2023, at 3:15 p.m. the Executive [NAME] President of Operations and the Nursing Home Administrator were informed that the health and safety of Resident 2 and the health and safety of current residents were in Immediate Jeopardy due to the failure to ensure that supervision and adequate interventions were in place to prevent Resident 1 and/or other identified residents from giving other residents food items outside of their ordered diet restrictions. The facility submitted and implemented an immediate action plan that included placing Resident 1 in a private room, install a motion detector alarm on Resident 1's door to alert staff that he is outside of his private room, and the resident will be provided one-on-one supervision while outside his room or when other residents enter his room. The education included ensuring that staff administer appropriate snacks and to also monitor any residents that were sharing snacks with other residents that are against their diet order and notify nursing immediately so appropriate intervention and action can be taken, families and resident representatives were educated on ensuring they are providing the appropriate snacks that are consistent with the residents' current physician-ordered diet, future admissions will be provided education on the facility's meal and snack safety protocol upon admission to the facility. Audits will be completed by the Director of Nursing and/or designee to ensure that staff are following the process. Audit information would be reviewed and discussed during QA meetings for recommendations or resolution to improve the process. The Immediate Jeopardy was lifted on October 20, 2023, at 3:35 p.m. when it was confirmed that the facility had placed Resident 1 in a private room with a motion detector and secured his snacks in a location outside of his room. The majority of staff were educated, and a plan for remaining staff to receive the education prior to the start of their next work shift was developed and implemented. A nursing note, dated January 22, 2023, at 8:54 a.m. revealed that Licensed Practical Nurse 2 was called to talk to Resident 1 about why he should not push other residents in the hallways. Resident 1 stated that he liked helping out because it kept him healthy. He was educated that pushing other residents was not allowed for him for their safety. A nursing note, dated March 22, 2023, at 5:57 p.m. revealed that Resident 1 entered the dining room during the evening meal and proceeded to push another resident back to the resident's room. Resident 1's education to not push other residents was ineffective. A nursing note, dated March 23, 2023, at 9:17 a.m. revealed Resident 1 was trying to escort a female resident to her room. He was educated that he was not allowed to push other residents around the facility because it was a safety issue. The resident in the wheelchair was capable of using her wheelchair to get back and forth to the dining room without assistance. Resident 1 was being defiant and his behaviors actually increased since being educated. A nursing note, dated April 24,2023, at 4:48 p.m. revealed that Resident 1 was educated that he was not to be pushing other residents to the dining room due to safety for him and the resident, and he acknowledged the education. A nursing note, dated April 27, 2023, at 1:01 p.m. revealed that Resident 1 had not learned form previous education that pushing other residents may potentially cause harm to him or the other resident. Resident 1 was found pushing another male resident from the dining room towards his room. The resident was removed from Resident 1's possession and he was educated that it was not his responsibility to push other residents and that if residents needed assistance from staff, staff needed to provide the assistance for safety reasons. A nursing note, dated October 19, 2023, at 9:15 a.m. revealed that the Director of Nursing witnessed Resident 1 pushing Resident 4 in her wheelchair without leg rests. Staff immediately intervened and provided education to Resident 1. He was not receptive to the education, although he did stop pushing the wheelchair. As she continued down the hallway and around the corner she witnessed Resident 1 again pushing Resident 4 without leg rests. She attempted to intervene again but was ignored by Resident 1, at which time the physical therapist stepped in and intervened. However, as of October 20, 2023, there was no documented evidence that the facility developed and/or implemented any new interventions and/or supervision to prevent Resident 1 from assisting other residents in their wheelchairs without leg rests. Interview with Licensed Practical Nurse 3 on October 20, 2023, at 1:51 p.m. revealed that she had seen Resident 1 push other residents before while they were in their wheelchairs and he was told to stop at that time. Interview with the Director of Nursing on October 20, 2023, at 1:37 p.m. confirmed that she observed Resident 1 push Resident 4 in her wheelchair without leg rests and then push her again after he was educated not to. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing services.