**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, record review, and interview, the facility failed to provide life saving practices in a timely manner for 1 of 1 residents. Specifically, R1 was found in the dining room unresponsive after R1 consumed an egg salad croissant that did not meet R1's therapeutic diet. On 10/06/23 at 2:55 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 10/06/23 at 2:55 PM, the Administrator and the Director of Nursing (DON) were notified that the failure to provide life-saving practices in a timely manner constituted Immediate Jeopardy (IJ) at F684. On 10/06/23 at 2:55 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 09/18/23. The IJ was related to 42 CFR 483.25 - Quality of Care. On 10/06/23 at 9:18 PM, the facility provided an acceptable IJ Removal Plan. On 10/09/23 at 10:00 AM, the survey team validated the facility's corrective actions and removed the IJ as of 10/06/23. The facility remained out of compliance at F684 at a lower scope and severity of D. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F684 constituting substandard quality of care. Findings include: Review of the facility policy titled Emergency Procedure-Chocking revised on August 2018, states, Trained staff will assist those who are choking by attempting to expel the foreign body from the airway. Unconscious Resident-Lying Down (or when Unable to Reach Around the Resident) 1. Ease the resident as gently as possible to the floor. 2. Call for help if assistance is not already present but do not leave the resident unattended. 3. Position the resident on his or her back with arms at his or her side. 4. Perform abdominal thrust as follows a. Facing the resident, kneel and straddle the resident's upper thigh with your body. b. Place the heel of one hand on the resident's upper mid-abdomen, below the rib cage, and above the navel with fingers pointed toward the resident's chest. c. Place the other hand directly over the positioned hand. d. Bring your shoulders forward over your hands. e. Use your body weight to press your hands into the resident's upper abdomen with a quick upward thrust. 5. Perform the finger sweep maneuver to check for a foreign body as follows: a. Keep the residents face up. b. Perform the tongue-jaw lift to open the resident's mouth. (Note: Moving the lower jaw moves the tongue off the throat and opens the airway. c. Perform the finger sweep using your index finger as a hook. 1. Insert your index finger into the resident's mouth alongside the cheek and across the base of the tongue 2. Try to remove any foreign objects. 3. Avoid pushing foreign objects deeper into the throat. 4. Turn the resident's head to one side if needed to sweep an object from the mouth. Under the documentation section states, The person performing this procedure should record the following information in the resident's medical record. 1. The date and time the procedure was performed. 2. The name and title of the individual (s) who performed the procedure. 3. The exact time the choking began. 4. The exact time of any unconsciousness. 5. All assessment data obtained during the procedure. 6. The time the procedure was started and stopped. 7. The resident's response to the procedure. 8. The signature and title of the person recording the data. Review of the facility policy titled Emergency Procedure - Cardiopulmonary Resuscitation with a revised date of February 2018, states, Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS) . General Guidelines states, 4. The chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR . Emergency Procedure - Cardiopulmonary Resuscitation states, 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing . Review of R1's Face Sheet revealed, R1 was admitted to the facility on [DATE] with a re-admission date of 12/07/21, and diagnoses including but not limited to; Parkinson's disease, diabetes mellitus, dementia, Schizoaffective Disorder, bipolar disorder and dysphagia. Further review of R1's Face Sheet indicated R1 was a full code. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 09/07/23 revealed R1 had a Brief Interview of Mental Status (BIMS) score of 7 out of 15 which indicated R1 was severely cognitively impaired. Further review of the MDS revealed R1 requires supervision and set up help only while eating. Review of R1's Physician Orders revealed an active order for, Dysphagia Mechanical Texture Soft Diet. Review of R1's Progress Note dated 9/18/23 at 5:45 PM, revealed, Note Text: Resident at supper in the dining room. Passed by res and noted res not moving and not responding to any type of stimuli. Took res to room and noted pulse. Requested assist from other nurses; res placed on bed w large amt of food removed from the throat. Call to EMS. Res was given CPR at 17:54 as EMS was entering the building. EMS began CPR.DON was contacted. Review of R1's Hospital Emergency Department Encounter Note dated 09/18/23 revealed, . by EMS from her SNF after reported aspiration event which resulted in her going into cardiac arrest. Patient was intubated by EMS and received 3 rounds of epinephrine prior to receiving ROSC . Upon arrival to the ED, patient obtunded, unresponsive, GCS 3 T, tachycardic, hypotensive, coarse breath sounds that are worse in the right lung field. Further review of the Encounter Note revealed, Independent interpretation of chest x-ray demonstrates right upper lobe opacities consistent with aspiration . Case discussed with critical care team who agrees to evaluate the patient for admission due to cardiac arrest likely secondary to acute hypoxic respiratory failure from aspiration. Hospital Course, 1. S/P out of hospital cardiac arrest on 9/18 - at least 16 min downtime. Suspected to be secondary to aspiration event - continue supportive care. During an interview on 10/03/23 at 1:29 PM, R1's son stated, Everybody knows on the second floor, that my mom is on a puree diet which is like baby food. What idiot gave my mom a croissant sandwich and walked off, which is on the hospital report, she was left unattended for 20 minutes with no oxygen going to the brain, and when she got to the hospital, the hospital staff suctioned the food from her throat. Doctors told me that she was brain-dead because of the aspiration. My mom can't walk, she has Dementia, my mom can't even feed herself due to constant shaking due to Parkinson's. I trusted the facility to give my mom the care I could not give her, and she died on Sunday 10/01 from the aspiration that occurred on 09/18. During an interview on 10/04/23 at 12:43 PM, Certified Nursing Assistant (CNA)1 revealed that she was passing out trays on station 1, with the help of another CNA. As CNA1 was passing out trays, R1 grabbed an egg salad croissant sandwich from another resident's tray and took multiple bites of it. CNA1 then provided R1 with her meal tray. CNA1 stated that she noticed that the sandwich that was on R1's tray was the same as the sandwich R1 took from the other resident. The only difference was that R1 had 2 sandwiches on her tray, the egg salad croissant, and an egg salad sandwich on regular bread. CNA1 stated she gave the other resident R1's egg salad croissant to replace the sandwich that R1 took. CNA 1 stated she observed R1 eat the rest of her food while talking and with a mouth full of food and CNA1 told her to chew her food and slow down while eating. CNA1 stated that she continued to pass out trays to other residents. CNA1 further stated approximately 5 minutes later, Licensed Practical Nurse (LPN)1 asked CNA1 and another CNA to transfer R1 to her room because she was unresponsive. Review of LPN1's witness statement dated 09/18/23 revealed, At 5:45 PM on 09/18/2023, I was assisting with supper in the dining room and noticed that [R1] was quiet which is unlike her. The resident checked the pulse present, but the resident was unresponsive. Egg salad was noted on the face. I sent [CNA1] upstairs to get help. [LPN2] and [LPN3] arrived. Took the resident to her room, and she was still unresponsive. at 5:54 PM, [R1] lost her pulse. CPR was initiated and 911 was called. EMS arrived within minutes and took over the code. Called resident RP, after EMS arrived. During an interview on 10/06/23 at 10:56 AM, LPN1 stated that she was in the station 1 dining room, R1 was found unresponsive with a faint pulse, quiet, and not responding to verbal commands or physical touch. R1's head was down. LPN1 stated that she didn't know how long the resident was unresponsive before she saw her. LPN1 stated that she noticed R1 had egg salad on her face and was not aware of what R1's meal was that day and stated R1 was on a puree diet with thickened liquids. LPN1 further stated that the Heimlich maneuver was not done because R1 was already unresponsive and CPR was not done in the dining room due to the resident having a faint pulse. LPN1 stated that she sent CNA1, and another CNA to grab help for R1. Once helped arrived, LPN1 stated that she wheeled R1 to her room, layed R1 on her side, and cleared her throat while waiting for other staff to get to the room before calling 911. LPN1 further stated finger sweeps were not done until R1 was wheeled to her room and placed on the bed. LPN1 stated that the crash cart is in station 1 dining room, left of the piano, where R1 was located and does not remember if the crash cart was used. LPN1 stated the AED pads were not used while performing CPR, and she did compressions while LPN2 was doing breaths. LPN1 stated she did 1 set of 20 compressions, and EMS took over. On 10/06/23 the facility presented an acceptable removal plan, which included: Actions Taken: Facility leadership interviewed facility staff working on 9/18/2023 Facility initiated education for facility staff related to identifying the need for and providing basic life-saving measures on 9/19/2023 Facility initiated education for facility staff on facility's choking policy 10/6/2023 Facility initiated skills checks for Licensed Nurses related to providing CPR, the Heimlich maneuver, and finger sweeps on 10/6/2023 Facility to monitor staff's response to emergency situations by performing mock code drills 1 time per shift per month for 3 months - 9/26/2023 Facility to continue daily audits on crash carts on the presence and availability of supplies - ongoing Facility reviewed emergency procedure - choking policy on 10/6/2023 Date of compliance: 10/6/2023

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure Resident (R)1 received proper supervision to prevent asphyxiation. Specifically, R1 was found in the dining room unresponsive after R1 consumed an egg salad croissant that did not meet R1's therapeutic diet. On 10/06/23 at 2:55 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 10/06/23 at 2:55 PM, the Administrator and the Director of Nursing (DON) were notified that the failure to provide proper supervision to prevent asphyxiation constituted Immediate Jeopardy (IJ) at F689. On 10/06/23 at 2:55 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 09/18/23. The IJ was related to 42 CFR 483.25 - Quality of Care. On 10/06/23 at 9:18 PM, the facility provided an acceptable IJ Removal Plan. On 10/09/23 at 10:00 AM, the survey team validated the facility's corrective actions and removed the IJ as of 10/06/23. The facility remained out of compliance at F689 at a lower scope and severity of D. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings include: Review of R1's Face Sheet revealed, R1 was admitted to the facility on [DATE] with a re-admission date of 12/07/21, and diagnoses including but not limited to; Parkinson's disease, diabetes mellitus, dementia, Schizoaffective Disorder, bipolar disorder and dysphagia. Further review of R1's Face Sheet indicated R1 was a full code. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 09/07/23 revealed R1 had a Brief Interview of Mental Status (BIMS) score of 7 out of 15 which indicated R1 was severely cognitively impaired. Further review of the MDS revealed R1 requires supervision and set up help only while eating. Review of R1's Physician Orders revealed an active order for, Dysphagia Mechanical Texture Soft Diet. Review of R1's Hospital Emergency Department Encounter Note dated 09/18/23 revealed, . by EMS from her SNF after reported aspiration event which resulted in her going into cardiac arrest. Patient was intubated by EMS and received 3 rounds of epinephrine prior to receiving ROSC . Upon arrival to the ED, patient obtunded, unresponsive, GCS 3 T, tachycardic, hypotensive, coarse breath sounds that are worse in the right lung field. Further review of the Encounter Note revealed, Independent interpretation of chest x-ray demonstrates right upper lobe opacities consistent with aspiration . Case discussed with critical care team who agrees to evaluate the patient for admission due to cardiac arrest likely secondary to acute hypoxic respiratory failure from aspiration. Hospital Course, 1. S/P out of hospital cardiac arrest on 9/18 - at least 16 min downtime. Suspected to be secondary to aspiration event - continue supportive care. Review of R1's Care Plan with a revision date of 06/07/22 revealed, I have the potential for alteration in cardiac function/output dx htn and hyperlipidemia. The goal with a target date of 09/18/23 revealed, Risk for complications of cardiac problems through the next 90 day review period. the interventions/tasks with a revision date of 03/22/21 revealed, provide my diet as ordered. Further review of R1's Care Plan with an initiated date of of 10/14/16 revealed, Altered diet r/t decrease with chewing, dx dysphagia, Vit D-defiency, gerd. The goal with a revision date of 03/17/23 revealed, I will have decreased risk for s/s of aspiration through next 90 day review period. The interventions/tasks with an revision date of 02/10/17 revealed, Provide diet as ordered. Review of R1's Progress Note dated 09/18/23 at 5:45 PM, revealed, Note Text: Resident at supper in the dining room. Passed by res and noted res not moving and not responding to any type of stimuli. Took res to room and noted pulse. Requested assist from other nurses; res placed on bed w large amt of food removed from the throat. Call to EMS. Res was given CPR at 17:54 as EMS was entering the building. EMS began CPR. DON was contacted. During an interview on 10/03/23 at 1:29 PM, R1's son stated, Everybody knows on the second floor, that my mom is on a puree diet which is like baby food. What idiot gave my mom a croissant sandwich and walked off, which is on the hospital report, she was left unattended for 20 minutes with no oxygen going to the brain, and when she got to the hospital, the hospital staff suctioned the food from her throat. Doctors told me that she was brain-dead because of the aspiration. My mom can't walk, she has Dementia, my mom can't even feed herself due to constant shaking due to Parkinson's. I trusted the facility to give my mom the care I could not give her, and she died on Sunday 10/01 from the aspiration that occurred on 09/18. During an interview on 10/04/23 at 12:43 PM, Certified Nursing Assistant (CNA)1 revealed that she was passing out trays on station 1, with the help of another CNA. As CNA1 was passing out trays, R1 grabbed an egg salad croissant sandwich from another resident's tray and took multiple bites of it. CNA1 then provided R1 with her meal tray, which contained an egg salad croissant. CNA1 stated she observed R1 eat the rest of her food while talking with a mouth full of food and CNA1 told R1 to chew her food and slow down while eating. CNA1 stated that she continued to pass out trays to other residents. CNA1 further stated approximately 5 minutes later, Licensed Practical Nurse (LPN)1 asked CNA1 and another CNA to transfer R1 to her room because she was unresponsive. Review of LPN1's witness statement dated 09/18/23 revealed, At 5:45 PM on 09/18/2023, I was assisting with supper in the dining room and noticed that [R1] was quiet which is unlike her. The resident checked the pulse present, but the resident was unresponsive. Egg salad was noted on the face. I sent [CNA1] upstairs to get help. [LPN2] and [LPN3] arrived. Took the resident to her room, and she was still unresponsive. at 5:54 PM, [R1] lost her pulse. CPR was initiated and 911 was called. EMS arrived within minutes and took over the code. Called resident RP, after EMS arrived. During an interview on 10/06/23 at 10:56 AM, LPN1 stated that she was in the station 1 dining room, R1 was found unresponsive with a faint pulse, quiet, and not responding to verbal commands or physical touch. R1's head was down. LPN1 stated that she didn't know how long the resident was unresponsive before she saw her. LPN1 stated that she noticed R1 had egg salad on her face and was not aware of what R1's meal was that day and stated R1 was on a puree diet with thickened liquids. On 10/06/23 the facility presented an acceptable removal plan which included: Actions Taken: Facility leadership interviewed facility staff working on 9/18/2023 DON/Designee initiated dining observation audits on 9/19/2023 Facility initiated education for facility staff related to providing adequate supervision during meal service including safe eating practices and appropriate time of cleaning trays on 10/6/2023 Facility initiated education for direct care staff on utilization of the Nursing Observation for Therapy Screening form on 9/19/2023 Facility implemented therapeutic diet binder on each nurse's station to include resident photos for residents receiving a therapeutic diet on 10/6/2023 Facility initiated education for facility staff on therapeutic binder as it relates to residents that may require increased monitoring during meals on 10/6/2023 Facility to implement monitoring process for any residents who receive an upgraded diet daily for 10 days, weekly for 4 weeks, and monthly for 2 months for meal safety on 10/6/2023 Date of compliance: 10/6/2023

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, record review and interview, the facility failed to provide Resident (R)1 with a therapeutic diet as prescribed by the physician. Specifically, R1 had a physician order for Dysphagia Mechanical Texture Soft Diet and on 09/18/23 R1's meal did not reflect the prescribed diet orders resulting in R1 suffering asphyxiation requiring Cardiopulmonary Resuscitation (CPR) and being sent to a local hospital. On 10/06/23 at 2:55 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 10/06/23 at 2:55 PM, the Administrator and the Director of Nursing (DON) were notified that the failure to provide R1 with a prescribed therapeutic diet constituted Immediate Jeopardy (IJ) at F808. On 10/06/23 at 2:55 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 09/18/23. The IJ was related to 42 CFR 483.60 - Food and Nutrition Services. On 10/06/23 at 9:18 PM, the facility provided an acceptable IJ Removal Plan. On 10/09/23 at 10:00 AM, the survey team validated the facility's corrective actions and removed the IJ as of 10/06/23. The facility remained out of compliance at F808 at a lower scope and severity of D. Findings include: Review of the facility's policy titled Therapeutic Diet with a revised date of 10/2017 states, Policy Interpretation and Implementation 1. Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. Diagnosis alone will not determine whether the resident is prescribed a therapeutic diet. 2. A therapeutic diet is considered a diet ordered by a physician, practitioner, or dietician as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet . 4. If a mechanically altered diet is ordered, the provider will specify the texture modification. 6. The dietician, nursing staff, and attending physician will regularly review the need for, and resident acceptance of, prescribed therapeutic diets. Review of the undated Texture Modification Inservice provided by the facility states, Purpose: to educate all new hires and current employees on the importance of and guidelines for proper texture modification. Importance of texture Modification Some residents have problems chewing or use multiple swallows to swallow one bite . Proper preparation and delivery of texture modified diets is critical for resident safety and wellness. Dysphagia Mech Soft Consistency requires meat to be ground and moistened. Bread items are pureed to a smooth mousse-like texture. Items may be served as pureed for this consistency if they are not inherently fork-mashable or soft. Review of R1's Face Sheet revealed, R1 was admitted to the facility on [DATE] with a re-admission date of 12/07/21, and diagnoses including but not limited to; Parkinson's disease, diabetes mellitus, dementia, Schizoaffective Disorder, bipolar disorder and dysphagia. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 09/07/23 revealed R1 had a Brief Interview of Mental Status (BIMS) score of 7 out of 15 which indicated R1 was severely cognitively impaired. Further review of the MDS revealed R1 requires supervision and set up help only while eating. Review of R1's physician orders revealed an active order for Dysphagia Mechanical Texture Soft Diet with a start date of 07/03/23. Review of R1's meal ticket dated 09/18/23 revealed, Regular - Dys Adv. Nectar, double portions with meals, and no salt packets. Marinated green bean Salad- 1/2 Cup, Chocolate cake w/ Peanut Butter Frosting- 1 square. Nectar Tea -4 Oz, Nectar Thick, Nectar water- 4 Oz, Nectar Thick, Creamy Dill Macaroni Salad (no raw veg)- 1/2 cup, Egg Salad for sandwich - 1/2 cup, Savory Summer Soup - 6 Oz, Nectar Thick. Double portions w/All meals. Ground Meats w/gravy, Puree all other food, Puree dessert. Review of R1's Speech Therapy Discharge Summary revealed R1 was discharged from speech therapy due to highest Practical Level Achieved. The patient was seen for 2 days during the 6/24/2023-06/28/2023 progress period. Discontinued on 06/28/2023. The patient safely consumes mechanical soft consistency while facilitating safe swallow strategies exhibiting modified independence. R1's discharge status and recommendations state, Solids=Mechanical soft/chopped textures. Review of R1's Care Plan with a revision date of 06/07/22 revealed, I have the potential for alteration in cardiac function/output dx htn and hyperlipidemia. The goal with a target date of 09/18/23 revealed, Risk for complications of cardiac problems through the next 90 day review period. the interventions/tasks with a revision date of 03/22/21 revealed, provide my diet as ordered. Further review of R1's Care Plan with an initiated date of of 10/14/16 revealed, Altered diet r/t decrease with chewing, dx dysphagia, Vit D-defiency, gerd. The goal with a revision date of 03/17/23 revealed, I will have decreased risk for s/s of aspiration through next 90 day review period. The interventions/tasks with an revision date of 02/10/17 revealed, Provide diet as ordered. Review of R1's Hospital Emergency Department Encounter Note dated 09/18/23 revealed, . by EMS from her SNF after reported aspiration event which resulted in her going into cardiac arrest. Patient was intubated by EMS and received 3 rounds of epinephrine prior to receiving ROSC . Upon arrival to the ED, patient obtunded, unresponsive, GCS 3 T, tachycardic, hypotensive, coarse breath sounds that are worse in the right lung field. Further review of the Encounter Note revealed, Independent interpretation of chest x-ray demonstrates right upper lobe opacities consistent with aspiration . Case discussed with critical care team who agrees to evaluate the patient for admission due to cardiac arrest likely secondary to acute hypoxic respiratory failure from aspiration. Hospital Course, 1. S/P out of hospital cardiac arrest on 9/18 - at least 16 min downtime. Suspected to be secondary to aspiration event - continue supportive care. During an interview on 10/03/23 at 1:29 PM, R1's son stated, Everybody knows on the second floor, that my mom is on a puree diet which is like baby food. What idiot gave my mom a croissant sandwich and walked off, which is on the hospital report, she was left unattended for 20 minutes with no oxygen going to the brain, and when she got to the hospital, the hospital staff suctioned the food from her throat. Doctors told me that she was brain-dead because of the aspiration. My mom can't walk, she has Dementia, my mom can't even feed herself due to constant shaking due to Parkinson's. I trusted the facility to give my mom the care I could not give her, and she died on Sunday 10/01 from the aspiration that occurred on 09/18. During an interview on 10/03/23 at approximately 4:41 PM, the Dietary Aide (DA) stated that his duties are dishes and the tray line. The DA further stated by looking at R1's meal ticket from 09/18/23, the vegetables would have been pureed, and the egg salad sandwich would have been given to her as a regular sandwich, with the croissant cut open and egg salad stuffed in the croissant and would have been given thicken liquids as well per meal ticket. Furthermore, the DA stated that if R1 had puree beside the egg salad sandwich, as noted on her meal ticket, then it would have been chopped up and served in a cup. During an interview on 10/04/23 at 12:10 PM, the District Kitchen Manager (DKM) revealed that looking at R1's meal ticket dated 09/18/23, R1 is advanced dysphagia mechanical soft which is one above a puree diet. The DKM states residents with a mechanical soft diet would be required to eat soft bread such as a croissant and by looking at the meal ticket R1 received a regular egg salad croissant sandwich. DKM states vegetables would be cooked down until soft, however not pureed, along with thickened liquids. During an interview on 10/04/23 at 12:43 PM, Certified Nursing Assistant (CNA)1 revealed that she was passing out trays on station 1, with the help of another CNA. As CNA1 was passing out trays, R1 grabbed an egg salad croissant sandwich from another resident's tray and took multiple bites of it. CNA1 then provided R1 with her meal tray. CNA1 stated that she noticed that the sandwich that was on R1's tray was the same as the sandwich R1 took from the other resident. The only difference was that R1 had 2 sandwiches on her tray, the egg salad croissant, and an egg salad sandwich on regular bread. CNA1 stated she gave the other resident R1's egg salad croissant to replace the sandwich that R1 took. CNA1 stated she observed R1 eat the rest of her food while talking and with a mouth full of food and CNA1 told her to chew her food and slow down while eating. CNA1 stated that she continued to pass out trays to other residents. CNA1 further stated approximately 5 minutes later, Licensed Practical Nurse (LPN)1 asked CNA1 and another CNA to transfer R1 to her room because she was unresponsive. On 10/06/23 the facility presented an acceptable removal plan which included: Actions Taken by Facility: Facility leadership interviewed facility staff working on 9/18/2023 Facility reviewed policies on Therapeutic Diets on 9/19/2023 Facility updated policy on Meal Ticket Process to include the process by which meal tickets are updated when a new diet order is entered for a resident on 10/6/2023 DON/Designee audited all residents on therapeutic diets to ensure meal tickets match the residents' diets on 10/5/2023 Dietary Manager and/or designee to monitor each meal tray for accuracy with meal ticket for all meals for 10 days, all meal trays for one meal per week for 4 weeks, and all meal trays for one meal per month for 2 months. Initiated facility staff education on therapeutic diets including what textures each diet consists of on 10/6/2023 Initiated facility staff education on reviewing meal tickets for accuracy with the prescribed diet on 10/6/2023 Date of Compliance: 10/6/2023